Perspectives: Four Medical Opinions on Continuing Health Care Reform
Martin C. Burke, DO Associate Professor of Medicine Director, 150 East Huron Clinic Director, Heart Rhythm Center
Photo by Anne Ryan
Photo by Dan Dry
Photo provided by John Benfield
Photo by Dan Dry
Leah Mooshil Durst, MD Former Medical Director, Friend Family Health Center, Inc. Chief Medical Officer, Medical Home Network Clinical Associate, Dept. of Pediatrics, University of Chicago
John R. Benfield, MD, FACS Professor of Surgery Emeritus David Geffen School of Medicine at UCLA
Robert M. Sargis, MD, PhD Endocrinology Fellow University of Chicago Medical Center
From a Medical Center Physician
From a Community Health Center Physician
From a Pritzker Alumnus
From a Medical Center Fellow
American medicine is a behemoth of special interests that contributes to, as well as consumes, our economy. The American adage, “You have nothing without your health,” is the philosophy behind our ever-expanding, entropic health industry. A systematic and well-planned approach is needed to navigate a useful and lasting change to the current health delivery system. This will require completely dismantling and rebuilding our medical delivery system in a way that focuses on the doctor-patient relationship as its core mission. The doctor-patient relationship is alive within American medicine, though it is under attack by government policy, agencies, third-party insurers, pharmaceutical and device manufacturers and hospital conglomerates that secure huge profits without personal risk. The economics of health care costs have no seat at the doctor-patient table. The recent health care bill alienates this relationship further. The commerce of health maintenance or treatment will continue to be carried out without participation from these two key players and an understanding of the true cost of care. Charges are so extremely high that it defies any logical ability to qualify them to me, a doctor, or to the patient who is billed. Having health care rates negotiated between a doctor and patient rather than an insurance company and hospital or declared by the federal government would instantly contain costs. The special interests in the American health system do not want this action. The current system does not reward quality or complexity of care, which can only be judged by a patient and a doctor, not the “Wizard of Oz” behind a curtain. My fear that health care reform will not be done systematically and, consequently, will perpetuate the current third-party payer system in lieu of a strong nonprofit, fiscally sound public insurance option focusing on quality doctor-patient interaction is realized. It is egregious that health insurance executives are paid tens of millions of dollars annually because they raise premiums and pay providers less. How do we negotiate this corruption in our care of sick Americans? Wall Street encourages it, while our government believes this greed can be regulated. It is hard to rationalize sanely that expanding the current third-party payer system, without a sound, competitive, nonprofit public option, can be done without huge cost to patients, their care and the clinical caregivers delivering it.
Recently, a middle-aged gentleman came into my office for the first time after a three-day hospital stay for newly diagnosed congestive heart failure. The heart failure was caused by longstanding hypertension, which he never knew because he had not seen a doctor in almost 20 years. In his reasoning, why would he? He always felt fine. Besides, he didn’t have health coverage and could not afford to see a doctor. He worked but did not qualify for Medicaid insurance. He was referred to my federally qualified health center because of proximity to his home and our sliding-scale fee for the uninsured. Within this scope, he could establish a medical home for office visits and blood work and be connected with low-cost, generic medicines. But without insurance, he could not get diagnostic tests or a subspecialist’s consult, if needed. Especially with these barriers, I silently hoped we could stave off these needs. At his appointment, we discussed the new medications he’ll need to stay out of the hospital and improve his outcome. He’ll have regular office visits to monitor his symptoms, blood pressure and lab work. Nevertheless, statistics show heart failure will limit his life expectancy. I wish he were not in this predicament and that he received regular health care before his condition progressed to hypertension and heart failure. Diet and exercise could have been significant prescriptions in controlling this disease in early stages, but he didn’t receive that medical advice 20 years ago. At this point, even if there were affordable insurance options for him, he would have been denied coverage with these diagnoses. Our current health care system failed this patient and thousands like him. Medical benefits are primarily tied to employment, but not all employers can provide these benefits. For those with insurance, more often the care of disease is paid, but preventive measures are not, so paradoxically, we finance a sicker society. Once a patient has a disease considered to be a pre-existing condition, the next time the patient tries to get health insurance, obtaining coverage may be impossible. And those with chronic conditions also face loss of medical coverage and limited health care options if they lose their jobs. Thankfully, health care reform legislation addresses these issues; however, it does not comprehensively cover all individuals who live in this country. And there will be temporary gaps for many based on the timetable of rolling out various components of reform. However, these first steps are big gains that move us in the right direction.
Three headlines from The New York Times on November 9, 2009, illustrated the problems posed by the health care revolution.
My greatest hope for health care reform is that it will transform health care economics to be more focused on patients and their health. The current system is entirely unsustainable. While we pay vastly more per capita than any other industrialized country, objective measures of health outcomes consistently show that our system fails to provide us with appreciably better results than countries spending a fraction of what we do. This results from several fundamental flaws that must be addressed. First, the current for-profit health care model creates a fundamental conflict between patients’ needs and insurance companies’ goals. Patients suffering with illness should not have to fight with their insurance companies to cover needed care. The health care system should be structured to protect patients and not to deny them care and drive them into bankruptcy in order to support company profits. While provisions in the bill to prevent denial of care based on pre-existing conditions are a tremendous leap forward, we must also ensure that patients have unencumbered access to requisite care. Second, by heavily relying on an employer-based insurance system, patients are placed at enormous risk if they lose their jobs or if they’re self-employed and cannot afford high insurance premiums. This sets up a vicious cycle with unemployment leading to the loss of insurance resulting in deterioration of health, making it difficult to re-enter the workforce. While the recently passed health bill works to alleviate this problem, rapidly rising insurance premiums may outstrip government subsidies and re-establish a situation in which health care remains unaffordable to many. Finally, the present fee-for-service model of physician reimbursement should be replaced with a system that rewards doctors for improving the health of their patients. This will undoubtedly be a challenge since doctors may be wary of setting up practice in communities with pre-existing poor health. But if we want a health care system that works, we need to appropriately align the interests of all involved to the ultimate goal of patients’ health. The cumulative effect of this would be to ensure that more patients are getting highly-involved, quality care while simultaneously reducing costs through the abandonment of diagnostic and therapeutic approaches that don’t work. My greatest disappointment with health care reform is that it stopped short of universal coverage, and I fear that we will lose the political will to change the fundamental flaws in the system. This moment in history offers a unique opportunity to address the disparities in health care that are tremendous barriers to social equality in our country. If we neglect to meet this challenge now, we risk perpetuating a system that fails all of us.
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“Sweeping Health Care Overhaul Passes the House: Slim Margin for Plan to Cover 36 Million” It is good that our health
care system is striving to pay for the care of more than 36 million uninsured Americans but regrettable that we will still fall short of universal coverage. “Abortion Was at the Heart of Last Minute Wrangling Over a Contentious Bill” Abortion is a relatively small part of the health
care issue. It should not be a central focus. It is shameful that political wrangling and obstructionist methods impede progress. “Curing Health Care” American health care is the most expensive without providing better results. The infant mortality rate in the United States is the highest among 16 nations; life expectancy of American newborns is 1.7 years less than the non-U.S. average. Americans neither live longer nor do we have better results from cancer therapy than other nations. My suggestions: 1. Initiate change where government control already exists. Allow Medicare patients to access government-controlled health care systems, such as the Veterans Affairs, the Public Health Service facilities and perhaps even military facilities, by adding the required resources and making the needed changes. 2. Decrease costs by changing practice patterns. Existing practices are inefficient. For example, nearly all patients with acute appendicitis do not need CT scans for diagnosis and cure. The army of employees for billing is excessive. A system that provides rewards for resisting overuse of testing and therapies should be developed. Only qualified medical practitioners can decide how to trim fat, maintain quality and allow doctors the freedom needed for individual care. 3. Give leadership roles and authority to people who have personal experience in the practice of medicine. A common denominator among Mayo Clinic, Cleveland Clinic and Kaiser-Permanente, frequently cited as models, is their leadership by doctors who have actively practiced. The health care bill has passed — a giant step forward. Too bad that it will be four years before mandated changes occur and that cost containment efforts continue to be largely the turf of administrators instead of the responsibility of doctors. It is time to stop being politically correct and timid. Let us step forward with courage and determination to reform health care.
Spring/Summer 2010 49