NEW @ THCB PRESS: Surviving Workplace Wellness. Spring 2014. Al Lewis and Vik Khanna. e-book edition. # LIGHTHOUSE Healthcare. Illuminated.

President Obama asked anyone with a better health care reform proposal to bring it to his attention. As a physician who has practiced for the past 37 years, I have been in the system long enough appreciate a better way to approach this problem than is being debated.

Heath care system incentives are wrong, and are primarily responsible for its spiraling growth. Increased utilization engenders increased expense. The proposed health care reform will not reduce the growth of health care expenditure. It does nothing to change incentives driving its growth. Utilization and costs must increase if all Americans are covered as proposed, unless incentives are altered. Patients initiate the process of health care, and physicians, and suppliers benefit from increased utilization. Utilization will not decrease until patients are made financially responsible for their health care decisions.  Substantial Increases in annual deductibles and co-pays will change this incentive. People may overspend and waste time, but nobody wants to use expendable income wastefully on health care. Making people think about the cost is the ONLY way to stop wasteful spending that has led to spiraling growth of health care costs, and the only way to do this is to have more come out of their own pockets!

Patients need to take greater financial responsibility for poor lifestyle decisions. Diseases caused by poor lifestyle decisions (smoking, alcohol and drug abuse and overeating) do not deserve the same level of coverage as unavoidable conditions such as appendicitis and Type I diabetes. Lifestyle related illnesses such as type II diabetes in the obese, alcoholic hepatitis and cirrhosis, and lung cancer and COPD treatment in smokers, rate punitive deductibles or co-pays. Also conditions doctors have never been able to cure like the common cold should be excluded from coverage. Grandma needs to resume the role of diagnosing a viral cold, putting the afflicted to bed, and making the chicken soup that will provide the cure!

Educate people about the probability of effectiveness and cost of heroic end of life treatments. It has been said that the majority of Medicare benefits are paid out in the last few days of life. When faced with a terminally ill family member, families react emotionally and irrationally requesting providers to “Do Everything”. They need to be informed of the cost and probable futility of further measures, of the existence and content of the living will, and if they still request the treatment they need to be financially responsible for the cost! To reduce waste, people who cause waste have to pay for that waste.

Regulate Health Insurance companies like utility companies, so they cannot raise rates without scrutiny and justification. Higher co-pays and higher annual deductibles should result lower insurance premiums as they will result in lower benefit payments. To ensure that insurance companies comply, this industry needs to be regulated, with active close oversight. Health insurance is unlike any other insurance. Insurance was originated to spread the risk of high cost for rare events over a large number of people.  How often do people die, have auto accidents, or lose jewelry compared to the frequency with which they generate health insurance claims? Further, if health insurance is deemed to be warranted for all, it is comparable to electricity and water, and should be treated like a utility. Utilities are closely regulated and cannot raise rates without approval. Health insurers should be treated the same!

Replace Malpractice litigation with an arbitrated No Fault system and cap awards.
Reduce the incentive for the wasteful practice of defensive medicine. A system of No Fault coverage, funded by annual contributions by hospitals and physicians will accomplish this goal over time. There should be a reasonable cap on awards limited to actual damages subject to mandatory binding arbitration completed within a year of the incident by panels of physicians, hospital representatives, and members of the lay public.

Reduce cost of obtaining FDA approvals.
Drugs and devices are priced differently in the US than in other countries. Part of the reason is that rates elsewhere are negotiated by governments. The higher cost incurred by companies attempting to get FDA product approval as compared to costs for Approval in other countries justifies higher US pricing. The FDA must address this reinventing itself or it will continue to foster high cost for innovative thinking and new product introduction.

Change antitrust laws to remove physicians from statute. Physicians need more time with patients. This will only happen when physicians are in a position to negotiate contracts with insurance companies. Today’s “negotiated contracts” are “take it or leave it” offers by insurance companies. Antitrust laws have prevented physicians from organizing and negotiating on an even footing with insurance. Insurance companies are not encumbered by the same antitrust laws. These unfair laws need to be repealed.  Reducing practice costs by reducing the amount of work required to collect payment from insurance companies, and empowering providers to negotiate with insurers, will improve provider quality of life, and fewer potential doctors will choose other fields over medicine for their life’s work as is happening today.

We may need universal health care insurance, but we do not need to go broke providing it. Changing incentives will reduce utilization; regulating insurance companies, eliminating the high cost and trauma of malpractice litigation, reducing the cost of innovation, and putting physicians on even negotiating footing with payers, will accomplish the goal of reducing the spiraling growth of health care in the USA while preserving the good in our health care system.

Barry L. Fisher has practiced as a physician for over 30 years. He has worked for the VA, the Air Force, in private practice, and as a full-time academic.

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