America the Beautiful: Rediscovering What Made This Nation Great (20 page)

Our founding fathers felt that everyone had a right to life, liberty, and the pursuit of happiness — but does everyone have a right to health care? The Bible tells us that almost every time Jesus arrived in a new area, he first healed the sick. These acts of his provided goodwill and credibility, making it much easier for him to talk about the weightier matters of life. Perhaps the lesson for us is to make sure that the basic needs of the most helpless among us are taken care of. Maybe the real question is not whether health care should be available to everyone in our society, but rather how can we provide universal health care in an efficient and cost-effective way.

I have to chuckle when politicians talk about ways to acquire more money to fund solutions to our health care, for we already spend close to twice as much money per capita on health care as the next closest nation in the world. The problem is not
allocation
of money, but rather how it is
spent
. If other nations can spend half as much or less and still achieve good basic health care for every one of their citizens, our system must be filled with waste and abuse. Perhaps it was the recognition of this fact that led to massive attempts to reform health care in this nation by the Obama administration. I’m very happy that our politicians are paying attention to this overwhelming problem, but I am less happy about the solutions that have been forced upon the populace. Perhaps well-meaning individuals temporarily forgot that we live in a nation where the majority does not impose its will on the minority simply because it can. Perhaps the better approach is to take a step back and analyze our health-care situation, then apply logic.

In having an appendectomy in Detroit versus having one in, say, Miami versus having one in New York City, you will find there are myriad different ways that your health-care provider must submit your bill and collect payment. Unfortunately, our health-care insurance system has become so complex that virtually all medical offices and larger practices need billing specialists just to navigate its intricacies. All of this variation and complexity produces mountains of paperwork and requires armies of people to push it around. Funding all these workers causes a larger portion of your health-care dollars to go toward paying administrative costs than the portion that goes to pay the actual professional fees; in fact, about twice as much goes to paper pushers. Imagine how much money we could save if we had a consistent and simplified system for medical billing and collections. Interestingly, every single medical diagnosis carries a designation known as the ICD — 9 code, and every single medical procedure has a designation known as a CPT code. If we created uniform payments for the codes, all bills could be submitted very easily electronically into one common computer system, with virtually instant payment from the insurance companies.

Of course there are always special-interest groups that fight simplification of anything because they benefit from the complexities. In this case, the insurance companies would almost certainly object to such a system, arguing that some unscrupulous doctors would simply submit “evidence” that they had done two appendectomies instead of one and instantly receive payment for two. The insurance companies would claim that, without layers
of oversight, the potential for massive fraud would be enormous. Another special-interest group that would likely resist would consist of doctors living in areas where reimbursement is traditionally higher than in the rest of the country. They would certainly not be eager to relinquish their financial advantage.

First of all, as someone who has been in the field of medicine my entire professional life, I can tell you with great certainty that there are very few physicians who would engage in that type of fraud, but there certainly are some. However, the solution for dealing with those few is not to create a gigantic and expensive bureaucracy as we have done, but rather to apply what I term the “Saudi Arabian solution.” Why don’t people steal very often in Saudi Arabia? Obviously because the punishment is the amputation of one or more fingers. I would not advocate chopping off people’s limbs, but there would be some very stiff penalties for this kind of fraud, such as loss of one’s medical license for life, no less than ten years in prison, and loss of all of one’s personal possessions. Not only would this be a gigantic deterrent to fraud, but to protect themselves every physician in practice would check every single bill quite thoroughly before submitting it, which would not be that difficult to do and document.

As for the physicians who live in areas where they are more highly compensated, they would simply have to adjust just like everyone else in society has to during lean times. If there was no difference in payments based on location, you would see specialists disperse from those highly paid areas to other areas throughout the country, which would be wonderful for the nation in terms of access to quality care. This migration of top specialists to other areas of the country is unlikely to affect the quality of care in the large metropolises and would probably even be beneficial because there would be less competition for patients and fewer unnecessary procedures being done in order to stay busy.

When there are too many specialists in one region, it is not uncommon for diseases to be overtreated by those specialists, who all like to be kept busy. The same thing occurs when there are too many medical centers. Everyone wants to be seen as the premier medical center, offering all the latest treatments and technologies. Thus you have massive duplication of medical services, again with an intense desire for all of them to be maximally utilized. It makes a great deal more sense to have each of the medical centers in the same region designated to specialize in only certain areas, with the others taking up the slack. For example, one could serve as the cardiac center, while another serves as the neuroscience center, and yet another could be the renal center.

In order to make a system like this work, reasonable, consistent, and timely payment must be a given. Compensation has to be fair given the investment of time and money necessary to acquire the skills to render good medical care. Compensation cannot be determined by insurance companies, who make more money by elbowing their way in as the middleman and confiscating as much of the transaction between patient and caregiver as they can. It might be smart to couple physician reimbursement to that for lawyers. I say this jokingly because, as everyone knows, lawyers are unlikely to allow their compensation to be reduced by arbitrary outside forces. Physicians generally are not going to fight for themselves, however, which is why it is so easy to take advantage of them, but that certainly is not the case for lawyers. With appropriate time and effort, I am confident that we can come up with an equitable system to take advantage of the ICD — 9 codes, the CPT codes, and computer systems, saving ourselves hundreds of billions of dollars a year that could be used to shore up Medicare or provide for the indigent.

When I first became an attending physician many years ago, our ability to take care of indigent patients was far greater than it is today. Almost all physicians voluntarily devoted a portion of their practice to the poor and indigent, fully recognizing that this represented a financial loss for them. At that time, however, reimbursement from insurance companies was much better than it is today, and our profit margin made charitable care possible and even fun.

Today, to a large extent, insurance companies call the shots on what they want to pay, to whom, and when. Consequently, even busy doctors operate with a very slim profit margin and find it much more difficult to offer care to the poor and pay for it out of their profit. I speak from personal experience because over the last many years, I have had to cut my staff significantly due to low insurance company reimbursements. That cut in staff also means a cut in services that we can offer. Our desire to help more people is at odds with our ability to do so, due to lack of funding. Although I could donate my services, I cannot volunteer the services of my operating room staff or other ancillary personnel to help care for a patient who can’t afford their own medical care.

This is an ideal place for the intervention of government regulators who, with the help of medical professionals, could establish fair and
consistent remuneration throughout the country. To accomplish this, essentially all of the insurance companies would have to become nonprofit service organizations with standardized, regulated profit margins. I should quickly add that this is not the paradigm that I see for all businesses, and in fact this is uniquely appropriate for the health-insurance industry, which deals with people’s lives and quality of existence. These things should not be treated like commodities or industrial products. That may sound radical, but is it as radical as allowing a company to increase its profits by denying care to sick individuals? In the long run this would also be good for the insurance companies, who could then concentrate on providing good service to their customers, rather than focusing on undercutting their competitor and increasing their profit margin. It would also drastically decrease the number of people each insurance company would have to hire, all of whom have to be paid out of the health-care dollar. Thus insurance premiums would decline, making health insurance more affordable for everyone.

But what about those who have no health-care insurance? How are we supposed to care for them when we are already stretched to our financial limits? Interestingly enough, there aren’t, in fact, 52 million people without health-care insurance in this country
¹
— all they have to do is go to the emergency room where by law they must be taken care of if they truly have an emergency. The problem is, emergency care costs five times as much as it would if they were getting regular preventive care in a clinic. And, unfortunately, the rest of us pay for it. The logical question we should ask then is, how do we get those same people to go to the clinic instead?

First of all, we must recognize that we are already paying for their care at a much higher rate when they show up in the emergency room. If we can get them to go to the clinic, however, we will still be paying for their health care, but at a much lower rate. We might do well to look at another government program that has been around for decades and saved millions of people from chronic hunger. The food stamp program allocates money for food in an electronic account at the beginning of each month. People learn very quickly not to go out the first five days and buy porterhouse steak, leaving them with nothing to spend on food for the rest of the month. They learn to look for bargains and other ways to stretch their allocation for the entire month. If we had electronic medical accounts for the indigent in this country, they too would have incentive to save money when medical problems arose. For
example, if Mr. Smith has a diabetic foot ulcer and goes to the emergency room, he will be adequately patched up and sent out — but if he goes to the clinic, not only will he be paying much less, but he will be patched up and an attempt will be made to get his diabetes under control, hopefully preventing a trip back in three weeks with another diabetic complication.

By looking at preventive care and wellness, we as a society will begin to save enormous amounts of money while achieving a significantly higher level of health. This is especially important as our population continues to age, since aging is accompanied by a slew of medical problems that can be avoided or reduced if detected early. Also, I am very fond of saying that if everyone ate three well-balanced meals each day, drank eight glasses of water or water-equivalent substances, regularly got a full night’s sleep, regularly exercised, and did not smoke or put harmful substances into their bodies, we in the medical profession would become very bored. Unfortunately, given the state of health in our nation, I don’t think we have to worry about that anytime soon.

Often when people are looking for a new job, they’re very interested in the health-care benefits that are offered. Because health-care insurance has become so expensive, most people are not able to afford it on their own and therefore need to be sure that their employer includes this as a benefit. But
why
is health-care insurance so expensive?

Much of the expense is due to coverage of catastrophic medical events. There was a time when premature babies or babies with significant birth defects simply died, which cost the insurance company very little. Now, however, thanks to developments in medical technology, we’re able to put such babies in incubators and treat them, usually saving their lives — but then we hand the insurance company a bill for $1 million. We can take an eighty-five-year-old woman with diabetes, hypertension, and thyroid disease who develops a brain tumor or cardiac condition, and successfully treat her, and then give the insurance company a bill for a few hundred thousand dollars. This kind of scenario, repeated on a regular basis, drove insurance companies to drastically increase their premiums, resulting in the situation we have today. I certainly applaud all the medical advances that have lengthened all of our lives while giving us quality of life, but there must be a logical solution to the ever-rising cost of insurance premiums.

One solution would be to remove from the insurance companies the responsibility for catastrophic health-care coverage, making it a government
responsibility. I can hear someone shouting now that the government can never do anything correctly, but I beg to differ. It is because of a government program known as FEMA (Federal Emergency Management Agency) that most of us are able to afford our homeowners insurance. If there were no FEMA, Allstate, State Farm, Nationwide, and all the other homeowner insurance companies would be telling us that they had to drastically increase premiums because there might be an earthquake, tornado, hurricane, tsunami, or other natural disaster that would otherwise drain their coffers. Homeowners’ insurance would be so expensive that you would have to ask your employer to cover it.