Thursday, June 18, 2009

Tune in to UHF-Universal Healthcare Failure

Another President, another stab at healthcare reform. Also another failure at healthcare reform. How do I know this already? I just do. Aside from the glaringly obvious fact that you cannot provide universal healthcare or even almost universal healthcare for people who do not all care enough about their health, you also cannot force providers of healthcare to provide their services for free.

Let's look at the proposals. Obama wants physicians to curb excessive tests performed out of defensive medicine. What a fantastic idea! I'm sure that physicians would like to order fewer tests that they have to interpret and explain to patients. Especially if those tests do little to help diagnose the patient. Now I will admit that there are many physicians out there who now order lots of test because they are simply dumb physicians. Someone had to be at the bottom of the class. But overall I still believe that excess testing is the result of fear of litigation. Is the test to confirm a clinical diagnosis? Is confirmation really needed or really does it look better in a juryroom of nonphysicians that a tangible "test" was done with results in black on a white paper? If something goes wrong, what will be more accepted in a courtroom to the lay public--test results that have ranges and positive/negative values or a physician's clinical judgement? I'll put five bajillion dollars on the prior. You want to cut costs from testing? Then accept that clinical diagnoses are indeed valid. Don't trust the physicians to make good clinical diagnoses? Then don't get medical care.

Another proposal is to tax healthcare benefits and use that slush money to fund healthcare for the uninsured. Now that's a Harrison Bergeronian approach if I ever saw one. Why not tax gym memberships and use that money to pay for gastric bypass surgery for the obese? Or tax vegetables to pay for smoking cessation billboards. We'll call it a Virtue Tax. Because there are obviously way way more virtuous people in America than sinful people, so I'm sure there'll be trillions of dollars rasied by this tactic. People for some reason also believe that offering healthcare to the uninsured means offering them fantastic healthcare that covers brand name drugs, specialist visits without referrals, and nonstandard of care procedures. It doesn't. The "healthcare" that the uninsured will get it access to a primary care physician (PCP) who won't be able to spend more than ten minutes a visit with them because they have to see the other six thousand newly poorly insured (NPI) as well and get paid by the government in Zimbabwe dollars. The NPIs won't even have decent prescription coverage and will only be able to get medication that was brought to market before 1975. More likely than not, the NPIs will look more like a hybrid of medical assistance and Medicaid patients. And because they will still be the worst covered, they will still have the highest morbidity and mortality with respect to health issues.

A third proposal is to cut hospital as well as physician reimbursement up to 30% in order to stem to rising cost of healthcare. We will address hospitals and physicians separately. Hospitals are almost always teetering on being in the red, if not living in the red. Few hospitals are in the black, and the ones that are happen to be in wealthy cities. Not a surprise since wealthy people have GOOD insurance that pays the provider adequately for services rendered. Also, in wealthier cities there are fewer uninsured or poorly insured that access the hospital services, which offer little to no reimbursement for services rendered. And hospitals cannot turn away uninsured or poorly insured patients. Unlike regular private businesses, which can refuse to to do business with a patron (for the most part), hospitals must treat every patient that enters the emergency room. And if they need admission, they are admitted. You can imagine the ensuing cash flow drain on the hospital for services, tests, medications that will essentially never be paid. Which means the costs of services, tests, medications need to go up so that money can be reclaimed when someone with better insurance actually pays their bill. So if we cut reimbursements, that will effectively also cap or prohibit raising prices for services. The NPIs and their throwaway insurance will not pay even close to what the utilized services cost, and the hospital will hemorrhage money like a ruptured aortic aneurysm. Hospitals will close and--well, you can make up your own ending to that story.

Now what about cutting physician reimbursements? In the short term it will save quite a bit of money. In the long term it will devastate healthcare. Why? How long does it take to become a physician? Four years of medical school and at least three years of residency. You add more years for different specialties, but at least seven more years after college, sometimes ten or more. And what do medical students get paid for four years? Nothing. They pay high tuition fees. What do residents and fellows get paid during training? Perhaps fifty thousand on average these days. And they have to pay back college and medical school loans or capitalize the interest on those loans. Meanwhile, college graduate Joe U. goes into business and starts climbing the corporate ladder. Joe U. is already earning a higher salary, getting 401k benefits, starting to save more at an earlier age because he can, and has fewer loans to repay. Over seven years (perhaps more) that adds up to a pretty penny. Now you want physicians to not only be paid less, but you won't let them deduct school loans because they "make too much". With that landscape even fewer people will want to become physicians. Who will treat the NPI then? Physician extenders, of course. At least that's what Governor Rendell and his wife (a nurse practitioner) want you to believe. I have nothing against physician extenders. But that's what they are--physician extenders. If you want to have a nurse practitioner or a physician's assistant treat you today, what they do is overseen and signed off on by a physician. In the future when there are fewer physicians, who will oversee the physician extenders? And if you want to give the NPs and PAs more autonomy, I also have no problem with that. Just make sure they have the same liability with the same malpractice insurance costs as physicians. Many politicians like to allude to the increased use of physician extenders but are mysteriously absent when asked to make a written statement that NP/PA training is equivalent to MD/DO training. Why not use more teaching assistants in the school if you cannot afford more teachers? What's the big deal, anyways? There are some teachers that simply get paid too much and a teaching assistant can deliver pretty much the same curriculum, right? You don't have a problem with your child learning from a teaching assistant instead a teacher, do you? People home school, so how much training do you really need to teach? As long as your child passes the equivalency tests it's fine. As long as you are alive at the end of the calendar year you're fine.

The fallacy is that everyone deserves healthcare. Healthcare is a privilege, not a right. If you decide to smoke four packs a day and booze it up every weekend, you do not deserve a forty thousand dollar coronary bypass operation when you have your heart attack at the age of forty seven. It is unfortunate that money is inexorably tied to healthcare, where many poor people who deserve healthcare cannot afford it, and many rich people who do not deserve healthcare abuse it. Is there a solution to the current healthcare crisis? Likely not a good one, unfortunately. But gains can still be made. Consideration should be given to allowing tax deductions on school loan interest for all income levels, especially if we are serious about education being important. Consideration also should be given to the government producing generic medications. It's a big business that not only generates revenue against the deficit, but also allows the government to reduce costs by pushing generics in its health insurance plan. It already controls the formulary at the Veterans Administration Hospitals, and veterans do not have any worse outcomes than the public. The other fallacy is that if you make healthcare/health insurance affordable, everyone will but it. Obviously not true because the President is leaning towards forcing everyone to "opt in" to insurance. We had to force everyone to get car insurance. And we are population that will wash our cars every Saturday but never get our cholestrol or blood pressure checked. Perhaps health insurance should be tied to auto insurance. The slogans wouldn't even have to change. You'll still "be in good hands".