Health Care Reform S.O.S.

I am a simple physician and family man, trying to make a living and doing the best I can.  I graduated from Texas A&M medical school in 1982, did a three year fellowship in general surgery in New Orleans until 1985 when I moved to Colorado Springs.  I married soon after that and have four children.  I worked in a variety of walk-in urgent care/minor emergency clinics for many years and did physical examinations for life insurance companies.  For the past eleven years I have worked as the Occupational Health & Medical Coordinator for Colorado Springs Utilities.  So I have seen medicine from many perspectives; as a private physician, a patient/consumer and now a municipal government employed physician.  Over the years I have endured the rise and fall of the H.M.O. managed care debacle, saw the boondoggle of Diagnosis Related Groups (DRG’s), observed the decline and fall of the solo practitioner as they have been gobbled up by the behemoth medical corporations and now have seen the greatest insult of all, ObamaScare.  I am not a Harvard educated economist and I don’t have an M.B.A. from Wharton.  I am certainly not a politician (we should all be thankful).  But I do believe that over the years I have seen some things, endured some things and learned some things about health care which I would like to pass along to you.  Of course, this advice is free and may be worth what you paid for it.

Let me begin with a little story.  About a month or so ago, one of my 17 year old twin daughters told me that she had been feeling poorly for a few weeks.  She was tired and had a sore throat.  I looked at her throat, it didn’t look too bad but she did have some swollen nodes in her neck.  I called to get her an appointment with our family doctor (no longer in his own little practice, now an employee of one of the monolithic companies in Colorado Springs).  Being the middle of the week of course they couldn’t see her until the next week.  Well, by Saturday morning she was still complaining so I took her to a satellite walk-in clinic run by one of our local hospitals and on our insurance company approved list.  They weren’t too busy and we got in fairly quickly.  I paid my $40.00 co-pay and we were taken back.  My daughter was seen by a nice nurse practitioner who did a quick history and examination and then ordered a rapid strep test which was negative.  Following that a quick finger-stick mono test confirmed my suspicions that she did indeed have mono.  A prescription for some prednisone tablets for throat swelling and we were on our way.  We had maybe 15 minutes of face-to-face time with the nurse, all that was really necessary.  No problem.  Well yesterday, May 18 I got a bill from the hospital.  The total charge for the visit was, wait for it…$770.00.  After my co-pay of $40.00 was deducted, a $338.00 ‘insurance adjustment’ (read discount, which would still make the total bill $432.00) and an insurance payment of $177.69, my balance remaining is only $214.31!  Now of those charges, $146.00 was for the professional fee (nurse practitioner).  This might be reasonable for a physician exam, but not for a nurse practitioner.  That should be maybe around $50.00.  There was a $242.00 clinic fee, no doubt to cover the overhead of the nice new building they are housed in.  Please note this is not an emergency room, it is a walk-in clinic much akin to your family doctor’s office.  And when you go to your family doctor you are charged only a professional fee, which includes all of the overhead.  You don’t get charged a separate clinic fee.  My doctor is housed in a nice, new, big building with radiology and laboratory services, but doesn’t charge a clinic fee beyond the doctor’s professional fee.  But wait, the final charge was for laboratory services in the amount of $382.00.  This for a rapid throat swab strep test and a finger-stick mono test.  I did some research and found that you can purchase rapid strep tests for $1.82 per test and the mono tests for $4.49 per test.  This is about what I remember from my private practice days.  Each test is quick, simple to perform and only takes about five minutes.  By my calculation this whole visit should have come to around $75.00.  Here then is a microcosm of the problems we are experiencing with the cost and payment for health care around the country.

Let us remember in these discussions that what we are all talking about is cost and payment for health care services.  We have the best health care in the world here in the United States.  This debate is not about health care.  It’s about payment.  The problem with our system now is that the federal government has meddled in the payment system over the past decades and really screwed things up. 

For some reason health care is one of the few, if not the only service we purchase with no idea of what the actual final cost will be at the point of sale.  Doctors don’t know, patients don’t know, the providing institution/company really doesn’t know and the insurance company doesn’t know until the final charge is hammered out weeks or months after the fact.  This is driven in part by the coding and recoding of diagnoses and procedures so to as to maximize the charges by the providers.  This thanks to the ICD-9/CPT coding monopoly owned by the American Medical Association (their primary source of revenue since only about 13% of practicing U.S. doctors belongs to the association) and promulgated by the Medicare system.  We need to divorce ourselves from this byzantine rubric and let doctors and institutions charge whatever they want in a free market where quality and service-level reviews and surveys are available for all to see.  Let insurance companies and patients choose where they want to spend their health care dollars to get what they perceive to be the best bang for the buck.

There are myriad different prices for this insurance company or that insurance company, for cash, for Medicare, for Medicaid; contract prices and discounts.  The providing institution doesn’t really know the price up front.  Frankly, I can’t believe that insurance companies agree to pay some of these outrageous charges.  The complexity of insurance company deductibles, co-pays, co-insurance and knowing where you and your family are in that calculation at any given point in time is impossible, particularly at the time you are receiving service.  Doctors don’t really know the cost of things they are ordering (and thus incurring costs) on behalf of patients.  There is no menu up front, in advance like say, in restaurants.  I recall a conversation in my doctor’s office about a year ago.  I was having my annual physical exam and the doctor ordered the usual annual lab work.  I asked him to make sure that he coded it as annual wellness lab work which is covered 100% by my insurance; otherwise I would wind up having to pay about $500.00 out of my pocket.  He was shocked and frankly in a state of disbelief.  He really thought I was joking.  When I explained that I and my co-workers had all experienced the high cost of these lab tests he honestly related that he had no idea that it was all so expensive.  So to try and put it in perspective, imagine going into Dillard’s (doctor’s office) to buy some jeans.  There are no price tags on the jeans and the store clerk (doctor) has no idea how much they cost.  But don’t worry they tell you, just pay a little bit now (co-pay) and we will bill you in a few weeks if it winds up costing any more.  Well, how much more you ask.  Well, we really don’t know right now.  So a month later you get a bill from Dillard’s for $250.00 for the balance on the jeans.  And oh by the way, it’s too late to return them.  Would you go for that?  Of course not.  If the prices were right on the jeans for all to see you would either buy them or look for a cheaper pair or go elsewhere to look for jeans.  Here is a real life story.  About six months ago on a Sunday afternoon I drove into Jiffy Lube to get an oil change.  You drive right up the garage door and they open your door and tell you to go inside while they drive your car into the bay.  There are no prices posted anywhere outside, they don’t hand you a menu of prices or tell you what the prices are (I know, I should have asked.  But shouldn’t the business tell you?).  Anyway, I got inside and the clerk started ringing up my order while they started working on my car.  The oil and filter change with a tire rotation came to $65.00.  I looked out the window at the Tire World next door and on their sign it read, “Oil/filter change and tire rotation $18.99.”  I instructed the Jiffy Lube clerk to stop work on my car and informed him that I did not want any service.  They sheepishly gave me the keys to my car (I have no idea what they had already done to it) and I drove next door for service.  Why shouldn’t medical care work that way?  One final real life example.  In my capacity at Colorado Springs Utilities I order a lot of MRI scans.  If we do them at the major hospital/medical corporation facilities they run $2000.00 to $2500.00, it takes several days to get one done and then a couple of days to get the results back.  We recently contracted with a small private company that does the same scans for about $700.00 to $900.00 per scan, they often get our employees in the same day we call and the reports are done much quicker.  There is also more personal communication between the radiologists and me, they are much easier to get in touch with and get questions answered.  The quality is just as good as the hospitals’ and the service is much better, not to mention the price!  Isn’t this the way it should be for everyone?  What a wacky system where people are consuming very expensive services, many times on a moment’s notice in difficult and emotionally charged situations and no one knows the cost of what is being purchased at the time.  It is being ordered by a doctor who doesn’t know, on behalf of a patient who doesn’t know, provided by an institution that doesn’t know and paid for by an insurance company that doesn’t know.  There is no direct accountability.  People are spending other people’s money on behalf of someone else.  And its six months before anyone has any idea of what just happened, then shazam!  Look what we just spent!  Oh well, whatever the insurance company won’t pay we’ll just bill to the poor unsuspecting patient.

With health plans paying less and less of the cost lately coupled with the federal government lowering the pre-tax flexible spending account family annual allowed contribution from $8000.00 to $2500.00, individuals are discovering that they are suddenly on the hook for high costs that they never were in the past.  Much of this happens after they have actually incurred the costs and can’t really do anything about it.  One result of this will be that people simply stop going to the doctor and getting tests done, sort of self-selected rationing.  And maybe that’s what the progressives in government want.  But the result will be a less healthy population, less preventative care and ultimately much higher costs down the road for late intervention.

Another problem is the costs created by liability and malpractice litigation and the resulting payments and settlements.  We need meaningful tort reform and perhaps a system like Louisiana where all malpractice and medical liability cases go before a diverse board who rule on the validity and likelihood of success of the case before going to trial or mediation or settlement (at least they did back in the 1980’s, not sure about today).  Sort of like a grand jury.  You can still go to trial with an adverse ruling by the board, but the likelihood of prevailing is very small.  Most don’t.  This weeds out frivolous suits and grandiose settlements.  A cap on payouts based upon reality and common sense would also help, as well as making the loser pay the other party’s legal fees.

With all of the vacant commercial real estate available why do medical companies and clinics need to build fancy new facilities, and then have to pass all of those costs on to patients and insurance companies?  Why not use existing buildings which can be re-finished for far less than new construction?

Get the government less involved, not more involved.  They have already screwed things up and driven up costs enough with Medicare/Medicaid and now ObamaScare.  When the government gets involved they just screw things up, make things too complex, less efficient and effective and increase costs 10-100 times.  Get the government out of the way and let the private sector solve these problems.  The reason we have these challenges in the health care payment/insurance industry in the first place is because of government meddling, regulating and dictating.  To paraphrase Ronald Reagan, in our current situation government is not the solution to the problem, government IS the problem.

Get rid of the electronic medical records requirement!  Virtually every physician I have talked with despises electronic medical records.  They are a disaster.  They are impossible to use, they don’t fit the model of what doctors do and trying to find useful information in them is like looking for a needle in a haystack.  Not to mention the privacy implications and problems.  And I just received a notice from my malpractice insurance carrier informing me of a seminar they are going to be providing discussing the difficulty of defending malpractice lawsuits due to electronic medical records.  Just say no!

And by the way, never, never, never let the I.R.S. get anywhere near health care, health insurance, medical records or anything health or health payment related!  Period.  After the recent scandalous revelations need I say more??

Repeal ObamaScare in its entirety immediately and replace it only with the free market!

Doctors are now talking about and actually are retiring, retiring early, switching professions and jobs to something out of the health field.  They are advising their children not to go into medicine.  All as a result of ObamaScare and the mess the federal government has made of the health care industry.  They are leaving in droves and the projected shortfalls are staggering.  And you can’t make that up with physician assistants and nurse practitioners.  Not that I would want to.

We must begin to look at the opportunity for different ways of delivering health care, such as Indian Reservations, off-shore, cruise ships, concierge medicine, private co-ops, etc.

I know you have heard from many highly placed Ph.D. health care economists with all of their complicated, complex solutions to the problem; many including much more government involvement.  Just take a moment and think that the solution might actually be less, not more.  It might be simpler, not more complicated.  It might be less government, more private sector; less government control and more personal freedom and responsibility.

Well, thank you for the opportunity to bend your ear a little bit from someone in the trenches on the front lines out here in fly-over country.  I hope maybe one little thing I have said might make some sense and spur some further thought and discussion.  Hopefully we can fix this thing before we have to wake up Ralph, because of course he ain’t never seen a wreck like this before in his life (story for another time!).  And I fear the health care industry is headed for a wreck of epic proportions if we don’t do something in a big way and quick.

God help and bless us all and God bless America!