Scaling the Summit

You didn’t watch the President’s Health Care Summit? Hey, I get paid to do these things so the rest of you can engage in more productive uses of your time.

Here’s what I learned: The people who are proposing to reform our health care system actually know very little about how our health care system works.

  • Neither Democrats nor Republicans have any idea whatsoever about how to control the rate of growth of health care costs.
  • Neither party has any idea how to fundamentally improve the quality of care.
  • And although both parties would increase the number of people nominally insured, neither party truly understands the problem of access to care and neither has any realistic idea of how to achieve it.

Here is the lesson you can draw from all this: Under no circumstances do you want to give any of these guys power over your health care.

I will give the Democrats credit for coming up with lots of sob stories (every Democratic speaker had at least one heart-rending anecdote and most had two or three), even though almost none of them had anything to do with solving the problems of cost, quality or access to care. Since Republicans couldn’t produce even one sob story, here is a tear-jerker I offer them that I think tops all the Democratic ones:


“Tell Laura I Love Her”


On failure to control costs. Neither political party has a realistic plan to slow the rate of growth of health care costs. The only proposals that are being discussed are proposals that will shift the cost curve rather than change its slope. Democratic proposals to insure more people without expanding the supply side of the market (doctors, nurses, hospitals, etc.) and proposals to mandate the same premium for everyone (which will create perverse incentives for people to over-insure) will shift the cost curve up. Republican proposals for malpractice reform and proposals to allow the purchase of insurance across state lines will shift the cost curve down. However, none of these proposals will change the rate of growth of health care costs, which is the most serious problem facing this country and every other developed country in the world.

You cannot control costs unless someone (patient, employer, insurance company, government — someone, somewhere) is forced to choose between health care and other uses of money. And if patients are the ones making choices, providers will respond by competing based on price.

On the failure to improve quality. Did you know that somewhere between one in 200 and one in 500 patients admitted to a hospital dies there from some cause other than the medical condition that brought them to the hospital in the first place? The minimum standard regulatory agencies use in other markets is that risk should never fall below one in one million. Yet, it appears that none of yesterday’s Summit participants know this or have any earthly idea what to do about it.

The answer: We will not fundamentally improve quality unless providers compete on quality and no one competes on quality unless he also competes on price.

On the failure to improve access. Massachusetts has already done what ObamaCare promises to do: cut the uninsurance rate in half by enrolling people in Medicaid and subsidizing private insurance. But like ObamaCare, the Massachusetts health plan did nothing to liberate the supply side of the market. As a result, the waiting times to see a new doctor in Boston are twice as long as in any other U.S. city. And there are as many people going to emergency rooms for care in Massachusetts today as there were before the Massachusetts health plan was adopted.

Genuine improvement in access to care will require liberating the demand and supply sides of the market in ways that were never discussed at the Summit.

Comments (24)

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  1. Chuck R. says:

    Perhaps without realizing it, Obama gave everyone a crystal clear example of the fundamental difference between Dem and Rep philosophies on the issue of health insurance. The issue being discussed was small employer pooling, and the point being debated was the role of government in defining coverage in an exchange vs. allowing pooling via associations that would act like large, self-insured employers operating under ERISA to define benefit packages.

    To illustrate the danger people are under with insurance companies, Obama told a story, the key points of which were: “When I graduated from college, I bought a beat up car and bought insurance. After a number of months of paying my premiums I was rear-ended. I called my insurance company to file a claim, and got ‘laughed at.’”

    The conclusion he drew from this was that he was victimized by an unnamed insurance company that sold him a policy that would not fix his clunker. My guess is that he made a conscious decision NOT to buy comprehensive coverage for his auto, but only purchased liability coverage, which would pay the bills if he caused property or bodily harm with his junker. He didn’t buy insurance to repair his care because it was a junker. I did the same thing when I bought an old car for my daughters…liability only/no collision coverage. It is a generally-wise economic decision when buying an old car with little value.

    Based on the lingering outrage, one can conclude that if this debate were about car insurance, Obama would want the feds to regulate that all auto policies provide comprehensive collision and liability coverage…even if consumers didn’t want to pay for it and it did not make economic sense for them.

    Of course, we’re talking about health insurance, but the fact that he used the auto insurance experience as an example is telling. He (and his party) fundamentally believes that the government needs to step in and make decisions for people…and for companies…regarding the level of insurance they need.

    Under the democratic philosophy, that same young Mr. Obama–fresh from college, healthy and feeling invincible–would not be able to buy a simple, high deductible policy to protect him from economic catastrophe in case of a major health problem or accident. Rather, he would be forced to buy a much richer set of benefits at a much higher price.

    Thanks for the clarity, Mr. Obama. I, for one, choose to decide for myself what is best.

  2. Mark Shaw says:

    No one really wants to talk about what causes the medical issues to begin with. PEOPLE NOT TAKING PERSONAL RESPONSIBILITY. Look at the issues in the US, Smoking, Drug and Alcohol use, Obesity, etc. There is an issue with Pre-exisiting conditions, and it is unfair for an inusrance company to now want to cover or charge a lot for a cancer patient in remission (odds are that person will have more medical expense, so it does make sense to charge more, but is does seem unfair to the individual). But for every one of those cases, I can probably find a dozen where the pre existing condition is diabetes, high blood pressure, joint pain, heart problems, etc. driven by that person’s lifestyle. I like to drink as much as the next person and I like good food, but I also have a little self controll. Why should I pay for all of these people that don’t want to take care of themselves? People say that fast food (bad food) is cheaper, BS, $6.00 for a value meal at a fast food place, go buy a yogurt, a banana, an apple and and orange, there is a healthy lunch for less than fast food.

    My other entertainment this week was the politicians grilling the insurance company execs about company retreats, I am not saying the retreats are right, but it is not as if all of these politicians don’t take expensive trips on our dime and get nothing done for it. Can you say Climate summit?

  3. Phil Pfeiffer says:

    Could not be said any better. Some one needs to tell Obama health care reform for now is dead.

    Move on to the real problem – The fatal impact of the Western banking system with mounting payments defaults and the wall of maturing debt.

    We are looking at the problem of states, but it is equally true for banks whcih, this year, are going to have to face up up to a real wall of debt towards which they are moving at top speed.

    Or rather, to use a more precise analogy, it is the wall of debt, like a tsunami, which is moving towards them. Just as the growing strength in the explosion of sub-prime loans in the US financial system was predictable from the beginning of 2006, that of this tsunami of debt breaking over the banks can be fully anticipated: indeed when one knows the total liabilities involved and that the borrowers are not, or no longer, solvent, there is no need to be a fortune teller to know what will happen in the future.

  4. Kenneth Artz says:

    Medicaid (the federal program that provides health care for the poor) spending is now the fastest growing line item in almost every state budget. In 2006, Medicaid spending accounted for fully 23 percent of the average state budget. When enacted in the mid-1960s, Congress estimated Medicaid would cost around $500 million the first year, however, the actual cost was double that, $1 billion. By 1970 the cost of the program had grown five-fold, to $5 billion; in the years following the cost of Medicaid ballooned, reaching a total of $336 billion a year by 2007. If President Obama is serious about taming the rising costs of health care, why doesn’t he jettison one of our country’s first “public-option” health care programs instead of proposing a brand new entitlement that will create “Medicaid-for-the-middle-class” and lead to the same types of unending, budget-destroying cost increases?

  5. Bob B says:

    Yes, I watched the whole thing because this is my field. It was basically a photo op for Obama to help his ratings. Interestingly he responded to the Republicans but not the democrats.
    I agree. They do not understand the American health care system. If we are going to bend the cost curve we must incent the people(us) to be accountable for our own health and purchasing our own insurance. Expanding Medicaid to pickup the uninsured is a solution but these huge cost increases are not in the trillon dollar package. As long as the health care provider industry just passes the costs along to the insurance industry nothing will change. The only reason Europe’s costs are less than the US is they ration access to care. We can improve both cost and quality. Read Help! your health care hanging in the Balance. www. robert very enlightening

  6. L Brody, M.,D says:

    I saw parts of the summit and believe the democratic powers that be want to ram through a bill. Any bill, even one twentieth the paper size can implement control of the illness system through regulation, interpretation and the usual bureaucracy. Of course, there may be consequences. I think the Democrats are betting on voter inertia, and believe they will come through it, or their current leaders won’t be around to see its actual operation. I think they feel it will be worth the risk because of the statistics of incumbency.

    I appreciate the work and thinking of Goodman et al, on the issues, and how they would give more responsibility to the consumer. This would improve the doctor patient relationship and take out many intermediaries, each of whom is a profit or cost center.

    On the tort reform/ malpractice issue, I believe this will not reduce costs. I believe this because I think that the standards of care have been put in place and cannot go backwards to a more relaxed standard. Why should a doctor or hospital expose themselves to risk? I think following algorithms, will simplify decision making at the cost of physician judgment. I don’t think physicians will relax current standards to save someone money. After all, you may not have to go to court, but there will be hospital committees, reappointments and community and professional reputation at stake.

    I hear and have heard horror stories. But I imagine there are many times more stories of satisfaction, acceptance, and appreciation for medical care. There are a variety of education and uneducated consumers, and government cannot do your thinking and planning for you all the time, at least not government to date.

    I prefer to concern myself with illness care and chronic illness care rather than health care. Health care to me is the consumers own business. Illness care or serious care is much more expansive and costly. I like the world of high deductibles, with consumer responsibility for initial costs. That will make them more prudent and
    cautious. At some point, government cannot protect someone from their own irresponsible behavior, whether it is speeding, driving when intoxicated, or not planning for rainy days.

    I don’t think there is a scheme that will protect everybody from illness care, but government wants the cash flow and the ability to limit outflow. Government, the body politic in power, will fight as hard as a consumer to gain control. But citizenry is coming to life. We shall see how this plays out.

    L. Brody, M. D.

  7. Devon Herrick says:

    The Summit was political theater. Neither side could really talk honestly about the issues without sounding harsh or insensitive.

    The Democrats told numerous anecdotes about hard-luck families, who had difficulty accessing health care in a time of need. President Obama talked about the need for ”minimum standards” so moderate-income Americans don’t find themselves with “Acme” brand insurance that would expose them to high medical bills.

    Yet, Democrats chose not explain how their proposal is based on the concept of gouging the young (and taxpayers not yet born) in order to heavily subsidize older people with chronic conditions (who tend to vote in greater numbers than minors and young adults).

    Democrats also wanted to side-step the issue of how their proposal would create a hug entitlement that would bend the cost-curve in the wrong direction (despite warnings that doing nothing would bankrupt the country).

    Republicans could not realistically explain how there will always be people whose luck runs out through no fault of their own (and sometimes their bad luck is exacerbated by poor choices). Moreover, society cannot alleviate all suffering at a price it is willing to pay.

    Republicans also could not easily explain how there is a limit to how much future taxpayers should have to pay so people alive today (especially seniors’ with drug coverage) don’t feel the sting of paying a medical bill out-of-pocket.

    All things considered, the White House Health Care Summit took away six hours of my life that I will never get back!

  8. Richard W. Walker says:

    The Democrats were adamant yesterday about claiming that they’d already included key GOP proposals in Obamacare. Is this the new tactic from the left for the benefit of public opinion? “You wanted a bipartisan bill? Well, gosh, didn’t we tell you? That’s exactly what this is. So, we’ll just go ahead and vote!” Let’s not.

  9. Brian Williams. says:

    The summit turned out to be nothing more than an opportunity for the President to tell Republicans (and a majority of Americans) that they are wrong and he is right.

  10. Chris Ewin, MD says:

    “You cannot control costs unless someone (patient, employer, insurance company, government — someone, somewhere) is forced to choose between health care and other uses of money.”

    Physicians order the tests that drive up costs….
    If we negotiate prices for our patients, then we keep costs down. (eg: The same labs cost $33 in my office and >$300 in the lab next door; the same MRI costs>$2,000 at the hospital next door and costs $450
    at another facility in Fort Worth).

    If you had an HSA, where would you want me to send you?

  11. Bill Lauderback says:

    John, excellent review. I did think Ryan and Coburn did a solid job yesterday.

  12. Howard M. Mintz, M.D. says:

    Mr. Goodman, You are absolutely correct. Neither plan will reduce costs since there is a total disconnect between the utilizer of the service and the payer. As a practicing physician of 28 years, I personally have an HSA and concur that this is the best method of controlling costs. The least expensive means of providing insurance coverage might be to have the government pay the deductible or 80% for those that cannot afford the insurance and then subsidize the premium. It is my impression that since Medicare stopped allowing balanced billing, patient utilization has skyrocketed. Furthermore, increasing the premiums for wealthier recipients only drives their consumption , since they then believe that they have prepaid for the service.

    Medicare cuts to physicians are to begin this Monday, and I think patients are going to find tremendous access problems. A much more effective method for controlling costs would be not to increase Medicare premiums on persons with the means to pay, but let physicians balance bill those that can afford the additional payments. Physicians use to provide significant, uncompensated care based upon patient need.

  13. Joe S. says:

    I agree with Bill. Ryan and Coburn were very good.

  14. ilovebenefits says:

    Excellent article. It is the rate of increase that is one of the issues. The other is that people by and large don’t have to make economic choices and are spending other’s money.

    It may be perfectly okay for health care to consume 20 or 25 percent of GDP, IF that’s where people want to spend their money. It is the rate of increase – faster than wages, faster than revenues and faster than people can be retrained — that is creating a huge portion of the problem.

    Unfortunately, most of the stakeholders in this debate have been co-opted. There are funds for all types of stakeholders in these bills. From technology, to pharma, to doctors, to those who will be employed in the 100+ new agencies…

    There is so much money in the system that any change gores someone’s ox. With massive change, innumerable oxen get gored. So what has to happen is that instead of people paying more of the bills with their taxes (and not controlling the spend) more money needs to be spent directly by the individual purchasing the service.

  15. John Seater says:

    *All* the talk about controlling costs and its rate of growth are misplaced. First, the measure of “costs” that almost everyone uses is total expenditure. That is not “cost.” The US spends more on personal computers than any other country, but nobody would argue that computer “costs” are high here. Indeed, computers cost less in the US than just about anywhere else in the world. Second, the cost of medical care is no business of the government. Neither is the magnitude of health care expenditure. The government’s job is to ensure the rule of law and property rights. Otherwise, it has no business in the medical market at all. Whatever happens to “costs” should be determined by the market, which is to say by individuals making voluntary exchanges. If society deems it desirable to subsidize poor people, it can do so with “health stamps” and “health insurance stamps” and leave the determination of prices and quantities to the market, as with the food stamp program.

    How to fix the mess? At the federal level: (1) End all tax credits for employer-provided health insurance and any other purchase of health-related goods and services. (2) Allow health insurance to be sold across state lines. (3) Reform the legal system to reduce abuse of malpractice law suits. At the state level: This varies from state to state, but there are lots of government interventions in the market that should be stopped, such as the local boards we have here in North Carolina that let existing hospitals determine whether new facilities should be built and who should build them. It should come as no surprise that, here in North Carolina, newcomers’ proposals usually are turned down and the new facilities are built by the same outfits running the existing hospitals.

    Every major problem with American health care is caused by some level of government interfering with the market. The cure is obvious: stop the government interference.

  16. MainStreet says:

    Not counting the many attempts to rein in health care costs in previous administrations, because the Democrats want to control 1/6th of our economy with a “comprehensive” health care bill, it has been over a year with nothing accomplished. If you take the Republican proposals piecemeal and pass individual bills, you would be well on the way of fixing many of the problems without destroying the best healthcare system in the world. After that you can tackle the main cost problem of increasing deductibles to get patients involved reducing frivolous doctors visits. This will take some courage on the part of our congressmen and the President, but if the Tea Partyers have any say in the next couple of elections, we may have people in office that will do the right thing.

  17. dr mattie says:

    Health Care Reform
    One Physician’s Open Letter to Congress
    In 1776 Thomas Paine scribed a document that reflected the sentiments of a society governed by tyrannical rule. Americans were tired of overbearing oppression. However, it was not until these grievances were communicated in Paine’s Common Sense, that the citizenry truly realized the extent of their tribulations. It became the manifesto that instigated the Revolutionary War. I hope that by relating some of the issues physicians are experiencing with the current health care system, a consolidated awareness will take place that will result in a better health care system for all.

    There are many physicians practicing within the current medical system that feel unrelenting oppression from regulation by governmental agencies and insurance companies, and the lack of critically needed tort reform. These physicians are earnestly anticipating major alterations to the health care system. The changes must occur in the methods of health care delivery to their patients. There must be the ability to readily have access to the various and necessary diagnostic and treatment options. Also, appropriate and timely monetary reimbursements for the care they have delivered to their patients must be received.

    The younger physicians of today do not remember Medical Camelot, but I do, and I remember it well. I sit here and observe the state of health care in this country. It is run by government, insurance companies and attorneys. I witness, as well as experience, the frustration physicians deal with every day and it all seems incredulous.

    Physicians were respected in the days of Medical Camelot and the conference of a medical degree, and all that it stood for, was one of the greatest privileges that could be bestowed upon a medical student. The physician was respected and trusted and his judgment was unquestioned.

    I was watching a program on C-Span this morning that was discussing the Apollo landing on the moon 40 years ago. Only twenty eight per cent of the people that are presently on the face of the earth were around then to remember this event. In this same regard, even fewer remember the relationship that existed in the fifties and sixties between the physician and his patient.

    It was an exclusive association that could not be interfered with by anyone. It would have been analogous to a priest discussing openly what a parishioner had disclosed to him while in the confessional, an unthinkable breech. Government has no place in this privileged relationship. We had HIPPA back then before it was given a name by the government, it was called trust. I truly believe that the vast majority of physicians practicing today, in spite of all of the frustrations they experience, still have the purest of intentions in wanting to help their patients. These physicians are wonderful doctors. Will somebody please tell this to the attorneys?

    Sometimes, it is very difficult to have people react to an injustice, even though it should be a reflexive action. To paraphrase Thomas Paine, maybe this is because when bad deeds are repeatedly carried out over a long period of time, there develops the superficial appearance that the performance of these deeds, no matter how wrong, seems to be right. Time becomes the exonerator of these deeds and reason falls by the wayside.
    The practice of medicine has been altered since the passage of the Medicare/Medicaid Act of 1965. Over these past 40 plus years the insidious changes affecting the practice of medicine in this country have been tolerated by physicians and exonerated by time. Physicians, having always been too busy trying to treat their patients, lost control of the ball which in this case was the practice of medicine in this country.

    This ball was quickly picked up by the government and insurance companies and as a result the physicians lost control over their profession. Time cannot continue to pass and exonerate any more of the indignities and regulations that physicians must deal with everyday imposed upon us by governmental regulation, insurance companies and lack of appropriate and necessary tort reform.

    It seems that in our society the measure of respect that an individual is given is
    in direct relationship to the paycheck he earns. Respect does not seem to be related to the amount of time one spent learning and honing professional skills. It has nothing to do with the long hours worked or the immense responsibility faced. This is quite evident when I compare the salary of a transplant surgeon against that of a professional athlete, musician or actor. What has happened to the value system in American society? A physician spends thousands of dollars on his education and the greater part of his existence in learning and perfecting his skills. He has the capability of saving lives. Yet, he is not even compensated a small percentage of what the athlete, musician or actor is. I have to wonder about the distorted value system of American society.

    Physicians were never a wealthy lot; however they were able to have a comfortable lifestyle which was commensurate with their level of training, experience and degree of responsibility. The physician was esteemed, his opinion respected. This is how it should be. Unfortunately, it is not even close to how it is. It all has to do with governmental control of the medical profession.

    After the Medicare/Medicaid Act of 1965 was passed I remember my father saying to me “The golden age of medicine that we once knew is now over. Once the government gets involved in the practice of medicine it will be to the detriment of the physician”. My father was clairvoyant. He has been dead now over twenty five years and his predictions of what would happen to the medical profession after governmental intervention took place are evident today.

    The physician has become devalued since governmental intervention and it gets worse everyday. Why would an intelligent young man or woman want to incur thousands of dollars in educational debt and spend the bulk of their life in training only to realize they can’t make a living performing their trade? It would take an extremely altruistic individual to assume this lifestyle.

    Fewer students are choosing medicine as a career choice for just these reasons. Some medical students are actually dropping out of medical school as they witness their debts mounting and see the prospect of earning a decent living is not even a remote possibility. Medicine used to be a profession composed of the best and brightest individuals in society.

    Many physicians I have known have been forced to leave the practice of medicine for the same reasons. They have had to take out loans to meet expenses until payments from the government and insurance companies arrive. It has become a financial juggling act just to keep a medical practice operating.

    I cannot remember the last time Medicare gave physicians a raise. I believe it was in 2001, and this was miniscule. I know it has been several years. However, Congress had two or was it three cost of living raises last year; I believe these raises are written into their contracts.

    Society does not realize that what a physician bills is not what he receives as payment. Medicare, for instance is responsible for 80 percent of the payment. The remaining 20 percent is the responsibility of the patient in the form of payment by the patient or via a secondary insurance. The 80 percent received is not 80 percent of what was billed but rather 80 percent of what Medicare allows. This in most cases is a lot less. Neither one of these payments is made expeditiously.

    Usually, the physician must maintain a staff of individuals knowledgeable in all of the different insurance company’s practices in regard to collection. If all the detailed nuances are not accurately followed, payment will be deferred until these are corrected. In order to even collect for services rendered, computers, hardware and software, forms, and postage must be purchased. So in effect, large sums of money must be spent before collection for services rendered can even be attempted. If I were a congressman I would have a budget for these expenses.

    I have been a physician for 31 years. My father was also a physician and my greatest mentor. He always expressed to me that the difference between a good physician and a great physician was that a good physician knew what he knew but a great physician knew what he knew and also knew what he didn’t know and wasn’t ashamed to admit the difference. Common sense—the stuff which isn’t so common anymore.

    My father’s office occupied a portion of our house and as a child I knew all of his patients by name. HIPPA laws were not enforced at our dinner table and I learned a lot about diagnosis and disease through discussions of the medical conditions ailing his patients. I accompanied him on house calls, some of them in the midst of a blizzard to deliver a baby, or in the middle of the night to attend to a sick child. His arrival was always welcomed with gratitude and love displayed by these families.

    There was a wonderfully special relationship between my father and his patients which I hope I have with mine. He was not just their physician but their confident and friend. He didn’t have malpractice insurance; in fact, getting sued for malpractice wasn’t even a valid concern. His patients knew, without a doubt, he was doing his absolute best for them. People don’t typically sue members of their family which is what he was to his patients. He was trusted and loved. He was available to them any hour of the day or night, as I am. Something I believe they call concierge medicine now.

    Visits to his office were never rushed and multiple problems were discussed. His patients, as are mine, were considered to be a part of his extended family. What did all of the special care he gave to his patients cost— four dollars, payable in cash at the time of the visit.

    Of course, some services he performed did cost a little more, like the cholecystectomy, removal of the gallbladder, he performed for the bartered price of a grandfather clock. He was also paid in clams, tomatoes, and lobsters among other things. But the important point here is that the form of payment was decided upon by my father, as the physician, and his patient and what was mutually agreeable to both of them.

    His office records were not electronic medical records costing thirty thousand dollars per physician, but rather large index cards with all the pertinent information needed for treatment. The rest was committed to memory. There were no insurance companies, no attorneys nor governmental interventions. It was a sacrosanct relationship of the most special kind and I feel privileged to have been able to have been a witness to his practice of medicine for I feel it made me a better physician. He frequently would tell me that there was an art to the practice of medicine—I have to wonder if it is not a lost art.

    My father practiced for nearly fifty years. When he died his funeral service was held in a large cathedral which was standing room only to people of all ages and walks of life that he had impacted in a very special way. He was beloved. I wonder if the physicians of today and of the future will know what to be this kind of physician means. I am relieved that he is not here today to see what the practice of medicine has turned into for it would surely kill him.

    After his death, his patients communicated the need for me to take over his practice and I did. I have also worked as a compensation physician, a corporate physician, an ER physician, and a preceptor to interns and residents, among other things. In the last few years, I have been an advocate for malpractice and health care reform and yes I still make house calls when needed.

    Until recently, I felt that I made the right career decision. I know I have saved many lives and I never place my head on my pillow at night wondering why I am here. However, I do go to sleep wondering how I am going to be able to afford the necessary expenses one incurs in the practice of medicine.

    The first ten years of practice I concentrated upon paying back my school loans and accumulating the startup costs of going into a medical practice. I cut cost corners when I could; not just for myself but for my patients as well. My practice was in a poor neighborhood and I charged what I knew people could afford but that barely met the utility bills.

    After all of these years in practice, I am far from wealthy. I did manage to pay off all of my school loans but my car is ten years old and I have to scrimp and save to meet monthly expenses. My children were ill with severe asthma and juvenile diabetes. Because these were preexisting conditions, I had trouble getting health care insurance. When I did finally find a company that would insure us, the premiums were unaffordable, over 5000 dollars a quarter plus additional co-payments.

    I continue to spend long hours for meager payment and now there is talk of pending cuts in Medicare reimbursements to physicians. Presently, about forty five percent of the physicians in this country are fifty-five years of age or older. A large percentage of the physicians have stated that if the proposed Medicare cuts are allowed to pass they will either retire or quit the practice of medicine altogether and I will probably be among them. This will leave us with a national shortage of about one hundred thousand physicians and who will fill their stethoscopes.

    I was watching a health care reform program on C-Span 2 last week and this three hour program concluded with the premise that physicians should be paid based on patient based outcome. This is ludicrous. Don’t the bean counters realize that I have absolutely no control over a patient once he leaves my office until his return? If his laboratory parameters or physical findings have deteriorated this is not my fault. Perhaps his HgA1c, a test done to monitor diabetic compliance, increased because he ate cherry pie everyday and didn’t take his medication as advised. I resent the implication that I somehow could have done things better in regard to treatment of this patient. I practice the best medicine that I can on each and every patient visit, as I am sure the majority of physicians do.

    The patient must assume some liability for his medical condition. If a patient continues to smoke after a reasonable period of time has been allowed to help wean him off of tobacco and within a certain period of time he develops a medical condition directly related to this physically harmful behavior maybe the patient should have to assume a portion of the liability for his health care costs.

    What impressed me most about this healthcare program I viewed was that there was not a practicing physician in the room. Would an aeronautical engineer design a multimillion dollar aircraft without consulting a pilot that would eventually be flying this aircraft? To do so would be fool hardy and only result in having to bring the aircraft back to the company for redesigning at a cost of how many more millions. Physicians must have a necessary role in deciding any reform that is to be instituted.

    The family practitioner used to be the backbone of medicine in this country. We did it all. We were taught to do it all. I was raised with the philosophy that the body was an integrated system of systems and each system depended upon the other for total bodily function to take place. We were taught to treat the disease and not the symptoms that the disease caused. Well, sadly, the backbone is now broken. As the different specialties were added we were no longer permitted to perform certain aspects of our training. The hospital staff would not allow it. So, unless you were out in the boon docks, your practice started to become restricted as to what treatments you were permitted to perform as a family physician. The standard of medical practice was determined by the way your peers, the specialists, deemed that it should be practiced and if this standard was deviated from the physician was subject to disciplinary action. It seems that the practice of medicine is becoming so specialized that we will soon need to see an ophthalmologist for the right eye and another for the left eye.

    All of this specialization has resulted in populations of physicians that only know about their particular specialty. There are thoracic surgeons that cannot prescribe an antihypertensive medicine because they were trained to be surgeons and not practitioners.

    The family practitioner must be utilized, once again, as the hub of the wheel and the gatekeeper or sentinel for medical care instituted in this country. If this is accomplished, step one, a key step, in turning the medical system around will have taken place. This is a simple and yet effective solution. Simplicity is the key word here because; once again, to paraphrase Paine, the simpler the solution is, the easier it will be to repair if and when that time comes.

    In the course of my day, much of my time is spent on the telephone with insurance companies trying to get a test, a treatment or medication approved. Sometimes a call can take as long as 40 minutes. How many of these calls can a physician deal with during a work day and still see patients. And my time on the phone is not monetarily compensated for at all. Do you know of any attorney that will talk to you for free?

    Why should I have to spend hours on the phone getting a test or medication approved by a person who knows nothing about my patient or myself and additionally has no medical training? Who knows my patient better than I, his physician? I am a trained and licensed physician, why shouldn’t the logical choice of what care my patient needs come from me, his physician. If this policy was the accepted one, imagine the cadre of unnecessary people that could be cut from the health care payrolls.

    Family physicians could also regulate the care delivered to their patients by the referring specialist. By merely discussing the case with the patients family physician and explaining what needs to be done in the way of testing or procedures the family physician could deem what would or would not be necessary based on the input and needs of the referring specialist. This would also cut costs dramatically since unnecessary testing would be eliminated.

    Around 82 percent of the people in this country see a physician on a regular basis. The remaining individuals do not see a physician until grave symptoms occur. Maybe if it was a requirement that everyone should have an annual physical with some basic testing and appropriately scheduled mammograms, pap smears, colonoscopies and cardiolyte stress testing a lot of disease could be prevented or corrected before grave illness ensued the treatment of which would cost thousands. In short, preventive medicine should be utilized.

    As a family practitioner, I have learned the value of a thorough history and detailed physical examination. This can save thousands in medical costs because diagnostic tests should be ordered to confirm a diagnosis that is already strongly suspected and not to figure out what the diagnosis is. How many of the tests that are done today are fishing expeditions. If time were taken on the initial patient visit to obtain a detailed medical history and chief complaint followed by the performance of a thorough physical examination, family history, habits, etc. thousands of dollars could be saved. Once again, tests should be done merely to confirm the diagnosis which is already known to be true from the extensive information obtained from the patient.

    There are those among you that would say that this practice, of placing the family physician in control, would place too much trust in the family physician and that fraud or kick backs could occur. Well, there is a very simple solution to this as well. Exact a stiff fine and penalty for any physician engaged in such illegal activity such as incarceration for up to 10 years and fines and/or penalties of up to one million dollars along with the suspension of the physician’s practice privileges.

    The practice of defensive medicine in response to fear of litigation must come to a halt. How many diagnostic tests are performed everyday because of the fear that an attorney may be looming in the background. This practice must stop. I truly believe that the vast majority of physicians in this country are good doctors and want the best for their patients. If a lawsuit against a physician is determined to be unfounded or frivolous, stiff penalties should be enforced against the plaintiff and the plaintiff’s attorneys along with the assumption of all legal costs of the physician. In this country it has become easier to sue a doctor than to see one. Caps must be instituted. Perhaps this practice would curtail many of the unnecessary lawsuits that are filed daily.

    Of the students that are now graduating from the colleges of medicine and osteopathic medicine in this country, less than ten percent are entering the specialties of family practice or internal medicine. At this rate by 2017 there will be no more family physicians. The solution is not to employ nurse practitioners and physicians assistants to take the place of these physicians. These two groups are what their name implies; they are not physicians and should not be utilized as such.

    Osteopathic schools of medicine primarily turn out well trained, “hands on” holistic physicians versed in all areas of medicine that concentrate on treatment of the disease entity and not just treating the presenting symptomatology. Until recently, the greater percentage of these physicians assumed positions in the family practice arena. However, with current reimbursements for family practitioners such as they are, the osteopathic medicine graduates are also going into specialty training programs.

    How do you entice more physicians into the field of family practice? This is very simple; pay them what they are worth. Instead of being at the base of the pyramid the family physician should be at the apex. All of the specialists eat off of the family physician’s plate and he is left with the few crumbs that remain. The average doctor upon graduating from medical school has at least two hundred thousand dollars in educational debt to be paid off. Why would they want to assume a specialty that will pay them next to nothing?

    By the time a patient of mine is delivered to the specialist a working diagnosis with necessary diagnostic testing has been performed. The patient knows why he is going to see the specialist and the specialist knows what he must do for the patient. And I, as the family practitioner, am still in the loop, being made aware of any changes or additions that may become necessary in the patient’s care.

    The majority of patients I see everyday in my practice have more than one complaint. The average Medicare patient is on an average of nine medications and each is associated with its own disease entity. For instance hypertension and hyperlipidemia or diabetes and obesity and these problems can be handled concurrently by a family physician. If each of these medical problems would necessitate going to a specialist the costs would prove to be phenomenal and would pose a great deal of inconvenience for the patients in that they would have to travel to many physicians instead of the “one stop shopping” approach provided by the family physician.

    And what about the cost entailed in reimbursing each one of these specialists for the care they provided. Would it not be more cost effective to pay the family practitioner more for the multiple diagnoses he dealt with on a particular visit than to pay several specialists their higher fees? Medicare is being used by some of these patients like Master Card. These people are “doctor shoppers” and will go to three or four dermatologists for a skin rash to get different opinions. If this had to be cleared with the family practitioner, how many millions of dollars could be saved; and the family practitioner could have probably handled it anyway.

    The ball, control over the practice of medicine, for all intents and purposes has been dropped once again. I, for one, intend to pick it up and run with it. Shame on me for having let go of it in the first place and shame on all of us as physicians for not even trying to get it back. However, this is the nature of being a physician. It is about dealing with all the necessary demands made all day long by patients, peers, pharmacies, insurances companies etc. with little time left over for the politics involved. I think there are a lot of physicians that now realize this. And, hopefully they will all rise to the occasion.

    As I watch the “political physicians” in Washington attempting to tell me where the fault lies, I see that each and every one of these governmental aficionados hasn’t got a clue about what would make the current health care situation better or worse from personal experience. Why would they? They have a health care plan apart from the rest of us. How many senators and congressmen over the age of 65 actually use Medicare? Hey Congress, if what you are advocating for the rest of us is so great when can I expect you to sign up? After all, aren’t you representing me? If this is true why should you have better health care benefits than I have? Maybe it we all had the same health care plan, Congress would fight harder to make it a more perfect system, for after all, they would be subject to what this plan entitled as the rest of us would be.

    There seems to be a great deal of concern about the cost of this reform and where the monies needed will come from. First of all, why don’t we start with the 10,160 pork projects that are earmarked for 2009 to the tune of 19.6 billion dollars? Do we really need a skate board park that will cost five million dollars or would the money be better spent if it was sent back to Washington and allocated for health care. I realize there are congressmen that will shy away from this concept, thinking that it will cost them the next election. However, I think his constituents would respect a man who advocated returning the money to Washington for health care where it would perform the greatest good for the greatest number. After all Mr. Congressman, this isn’t about your reelection campaign but rather about what will make health care affordable and accessible. Greed cannot be the superceding factor here. However, it has be the force driving so much of the political system in Washington for so long that it has become routine behavior.

    There has been some talk that these projects, should not be recanted for they would improve the economy of the area they are designated for. Well, in the case of the skate board park, the project will last two months—at the end of that time people will be once again unemployed and five million will have been spent.

    I took the liberty of accessing the National Institute’s of Health web site in order to obtain some current facts and figures to base cost calculations on. The most recent statistics are from 2007—hard to believe in this day and age of computers. Nonetheless, I will use the figures from 2007 since they are the most current ones I could find.
    There were 119 million visits to an emergency room in this country based on the most recent figures. Of these visits, 12.8 percent resulted in an admission to a hospital. That leaves 88 percent of these patient visits that were not admitted. Out of this 88 percent let’s just say, and I am being generous here, that twenty percent were ill enough to be seen in an emergency room but not ill enough to be admitted. Maybe these patients had a laceration, fracture, nosebleed etc. That still leaves 60 plus percent that probably were using the emergency room inappropriately, that is, for a non emergency such as a sore throat.

    Although treatment cannot legally be refused to these individuals, they can be told that they will be seen after the sicker patients and that they will need to pay for their visit at the time the care is administered. In short, it will not be covered by medical insurance because it is considered to be inappropriate use of the medical facility, going to an emergency room for a non emergent visit. The patient would be told that he should contact his family physician where the cost of care would be much cheaper. Of course, criteria would need to be defined about what constituted a medical emergency. A triage officer, well trained in symptomatolgy and its connection to the various disease entities, would be necessary to enforce the parameters regarding what constituted an emergency and what did not.

    The average ER visit is about 2000 dollars, remember these figures are two years old and I would guesstimate the fee is probably higher. However, if one were to multiply 119 million, the number of ER visits per year, by 60 percent, the number of frivolous visits to the ER per year, and then multiply that number by the average cost of an ER visit which is 2000 dollars, almost 143 billion dollars could be saved annually. Add this to the 19.6 billion allocated to extraneous pork projects and we now have about 163 billion in the health care coffers.

    Don’t forget we have also placed the family physician back in his position as gate keeper and there will be billions saved by not having to employ the insurance bean counters because the family physician will be the one who determines what care in the form of testing, referrals, medications etc. will be needed because, as stated before, the family physician knows his patient better than anyone else in the health care arena.

    The referring physicians, the specialists, will also need to clear their requests for particular treatment modalities with the family physician as well, which once again will save billions in unnecessary diagnostic procedures.

    There are over eight hundred million patient visits to practitioners every year. The average person sees their physician about three to four times a year. If patients were responsible for the cost of these visits, which is averaged out to be about fifty dollars, another forty plus billion could be added to the health care coffers.

    Keep in mind people may say they can’t afford this expense- but how many people in this country waste money on frivolous purchases like alcohol, tobacco or getting nails done etc., which costs much more than the three or four annual physician visits.

    Also, keep in mind that in 1950 health care was 5 percent of the GNP. Now, in 2009 it is 16.9 percent. One has to be willing to pay something for the technological advances that have been made.

    However, some cases may need these visits to be subsidized and this could be done with a voucher specifically designated for the health care visits of these individuals. This could very easily be worked out. We are now up to approximately 203 billion saved.

    Now let’s discuss over charging by the hospitals. A patient of mine went to the hospital urgent care for a tetanus booster after regular hours last week. The visit was exceedingly brief, less than ten minutes. The cost of this visit was 1,709 dollars. A vial of ten tetanus booster shots costs about 200 dollars. However, it is cheaper if buying in bulk, as I am sure a hospital would do. The patient was charged 173 dollars for the immunization, 169 dollars for the nurse to give the injection, 1,146 dollars for the physician visit, billed as a level 4, and 221 dollars, the fee of the physician out sourcing group. I guarantee you that this type of billing practice is a regular occurrence. If these ridiculous billing practices could be checked how much more monies could be saved.

    Now we know that insurance will not reimburse for the amount billed. However, the unfortunate individual that is unable to afford health care insurance will be expected to pay this fee or else be reported to a credit agency etc. Now, if a patient had those type of funds available wouldn’t he have health care insurance? The majority would. So, in effect, this patient is penalized for not being able to afford health insurance and he can afford these penalties the least. Something is very wrong with this picture. Laws should be passed that do not allow hospitals to charge uninsured patients more than they would normally get if reimbursement occurred via an insurance company.

    Preexisting medical conditions must be treated no differently than any other illness. When new technology, medications, etc. becomes available it must be readily accessible to patients. And if your particular medical condition would require the expertise of a physician not in your area, you should be able to go to where the best possible care will be given.

    I originally thought that the purpose for health care reformation was to provide insurance for the 45 million or so individuals that did not have any coverage. How many of these individuals are citizens of the United States. Since when does illegally crossing the border into the United States grant automatic health care entitlements. This situation must be looked at very carefully.

    Since not all individuals are unhappy with their current health care coverage, (70 percent surveyed); if these individuals desire to keep the coverage they presently have it should be permitted. If however, they wanted to opt into this system there should be no penalties involved and no time constraints. The same would follow as far as the ability to opt out of this coverage.

    If health care is only eligible to that portion of the 45 million people that are citizens and individuals that are satisfied with their present health care plans are permitted to keep them, then isn’t the projected figure of 600 billion dollars required to enact this plan a lot less?

    Fraudulent billing must be investigated and checked. There was between 70 and 120 billion dollars collected last year as a direct result of fraudulent charges. These providers must be punished, in the form of incarceration, fines and/or penalties and loss of licensure. All of these funds must be recovered.

    My point, in all of this is how much thought and serious number crunching has been performed by Congress? Were any of these probable solutions even thought of before additional taxation was proposed as the solution?

    And the reform that has been instituted in Canada, as well as other countries, is not working. There are long lines of patients needing medical attention and not receiving it in a timely manner. There was actually a lottery in one town in Canada yesterday for a visit to a family practitioner. In Canada, there were 249 neurosurgeons last year, 147 of them left Canada to come to the United States. The average wait to see a specialist in Canada is eighteen months. If a patient has been diagnosed with cancer and referral to an oncologist takes eighteen months, death may occur before necessary treatment is given.

    We all need to be on the same page when it comes to health care reform in this country and we need the input of our physicians and our patients. This reform cannot and will not be successfully accomplished by “political physicians” each advising a different medication to solve the health care crisis.

    Input from practicing physicians is necessary if any reform that is to be instituted is going to be truly feasible. How much input has been sought from physicians up to this point? I do not remember receiving any surveys or getting any phone calls asking my opinion as a physician as to what would be necessary in order to achieve reasonable health care reform that would be beneficial to all individuals concerned. I refer back to the aircraft analogy, when designing a plane make sure you consult the pilot.

    When I entered my profession, all I wanted to do was treat patients. I wanted to be a good doctor. Now I realize maybe I should have stayed in school a few more years and gotten and MBA and a law degree to be able survive in this current medical climate.

    The present health care bill that is now being crafted has gone from 616 to over 3000 pages in length. Who is going to read and access this bill to make sure it is what our doctors and patients need. And what is the big rush to push this bill through. Who is going to be able to read this volume of material in the short interval of time that has been allocated to push this bill through? And it must be read and dissected. How long did it take the President to decide what dog he was going to get? I know it was well over six months. How long has he been in Washington and he still has not figured out what church to belong too. Shouldn’t health care reform, that will affect millions, be carefully thought out? Representatives from all involved groups should come together and all pros and cons be carefully examined. I was always taught that haste makes waste. I truly believe that in this case this adage most certainly pertains.

    Shame on you Congress if you would vote on a bill without even reading it. You shouldn’t be in Washington, you shouldn’t be representing me.

    Let’s keep this bill pork free Congress. We do not need the additional expense of adding pork to an already expensive proposition. The waste must stop.

    I beg Congress, on behalf of my colleagues and my patients to read and digest this bill and consider all possible avenues of reform before relegating it any further. If this bill is not constructed properly, many lives will be adversely impacted. How many more millions will need to be spent if it becomes necessary to rewrite this bill and what are the patients and doctors to do in the meantime? It is imperative that physicians are consulted and their expert advice sought.

    Congress, don’t be misled by the stance taken by the AMA. This organization does not represent the prevalent sentiments of practicing physicians in this country. Of the 900,000 physicians and medical students in this country only 16.4 percent are members.

    I took an oath 31 years ago. In taking this oath, I promised to keep my patients from harm and injustice. I intend to do whatever it takes to make sure the promises I made when taking this oath are kept. I cannot and will not allow these injustices toward the medical profession and my patients to go on any longer. I implore all physicians to do the same or suffer the consequences of working within a profession dominated by government, insurance companies and attorneys. As physicians we must do the right thing for our patients and our profession.

    It just makes common sense.

    Dr. Mattie

  18. Kenneth A. Fisher, M.D. says:

    To effectively control health care costs many issues need to be addressed.

    Over-consumption in the United States is ubiquitous. Many of us buy houses we cannot afford, cars that are too big, vacations that are too expensive, take in too many calories and over utilize health care resources. Our televisions bombard us with drug and device advertising along with a multitude of things we do not need. Presently the health of our economy is based on an obsession with consumption. There is no doubt that we have an excess demand for health resources that generates income for many but is bankrupting our nation. It would not be rationing to deliver only care that has proven to be beneficial.

    The only way at this time to adequately meet the crushing need for primary care is to have medicine and pediatric sub-specialists practice primary care for many of their patients.

    The Medicare payment schedule is perverse; it over-rewards technology and under pays evaluation and management. As the nation’s largest insurer Medicare does drive the industry. Medicare is controlled by Congress which is susceptible to lobbying efforts by special interests and large commercial groups thus explaining our technology obsessed style of medicine. We therefore need to create a Federal Reserve Bank for health care to remove Congress from day-to-day control of our health care industry.

    To effectively control medical costs, provide care to all Americans these factors and others must be addressed. The solutions are on my blog, , Thank you, Kenneth A. Fisher, M.D.

  19. Stan Ingman says:

    I did note the naive story about an Canadian MP coming to USA for Treatment .. as if this proves USA is best system in World.

    Or the naive story that Republicans want the people to manage the system and not the government.. what is that mean?
    Republicans story line.. do small changes. Where were they for 8 years . Insteady they gave us Medicare Part D. Great way to control costs!

    So, I hope Democrats now move forward to get reform underway. This will merely be the beginning first step. A leap of faith I am willing to take.

  20. Ralph F. Weber CLU says:

    Asking congress to reform healthcare is like asking a gynecologist to tune up your car.

  21. Kathleen S Adler, PhD says:

    Thanks, John.

    I really appreciate your updates and am thankful you answered the call.

    Kathleen S Adler, PhD
    Economist & Proprietor, Economics Made Clear, Plano TX.

  22. Loretta Ekis says:

    Good article. I’m glad he sat through that long-winded meeting. I had no patience to do that!

  23. Dean Schooler says:

    Mr. Goodman, your perspective is much appreciated. In my view, the president’s “summit” was anything but a summit. What struck me was how the president, depending on the moment, moved from being moderator to leader to combatant to commentator to combatant to facilitator to rulemaker to storyteller to critic to summarizer. He seemed to be bending the conversation back to himself and his view of changing the way in which we do healthcare in America. The Republicans tried mightly to shift the agenda and made substantive contributions, which was only successful when the president accepted the idea of “undercover patients.” In the end, the president closed off the possibility of another summit. So why can’t the Republicans design a summit of their own and invite the president and congressional leadership, mix in a few governors and healthcare expertise, and treat citizens to a real learning experience? Make it a shining example of “we do summit right.” And, in the end, not draw conclusions but rather ensure that there’s real dialogue on some matters, exchange rather than soundbites, and highlight agreement and differences. After all, a free society thrives on debate and ideas – nieght of which, except for the Republicans, characterized the summit last Thursday.

  24. [...] in Massachusetts, which adopted some of the Obamacare policies a few years ago. As John Goodman writes in his Health Alert ("Scaling the Summit") for February 26, "As a result, the waiting times to see [...]