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Rob Lamberts seriousI have been asked by patients, readers, family members, and by fellow bloggers what I think about the bill  passed by the House of Regurgitants Representatives yesterday. I resent this. I have tried hard to remain neutral as possible, finding equal cause to point and sneer at both conservatives and liberals. It’s much more fun to watch the kids fight than it is to figure out which one is to blame.

But given the enormous pressure put on me by these people, as well as threatening phone calls from Oprah and Dr. Oz, I will give my “radical moderate” view of the HC bill. My perspective is, of course, that of a primary care physician who will deal with the aftermath of this in a way very few talking heads on TV can understand. The business of HC is my business, literally. So, reluctantly, I take leave of the critic’s chair and take on the position where I will be a target for any rotten fruit thrown.

1. It’s not Armageddon.

We are all still alive and breathing, and will continue to do so after this law is passed and signed. The bill does not change things as radically as the shrill voices on the right suggest. It does not constitute a government takeover of HC, nor does it seem to extend any government programs by a whole lot. It is really not about HC at all, but instead about health insurance.

The goal of getting more people insured is a good one. Our system clearly (from my perspective) makes my services unaffordable – especially if you consider what people pay for procedures and medications I order. The lack of affordable insurance does harm people; I see it every day. The system is broken and needs fixing. Anyone who says otherwise needs to get a urine drug screen ASAP and then seek professional help.

Beware of the fear-mongers who make this out to be the “pro-death panel” legislation. It’s really not that bad.

2. It’s not Nirvana.

It’s actually more like the Foo Fighters…no wait, that’s another blog post.

There are folks on the Left who think that we are entering a golden age because of this. Some suggest this is the “Waterloo for the Republicans.” No, this bill is simply a rearrangement of how money is being spent, not a fount of blessings to those in need. Some people will benefit from this – especially those with no insurance – but most people won’t see a whole bunch of change from it.

This bill addresses the problem of the uninsured, but does not deal with the much more important issue of cost. If anything, it may worsen the problem that is actually at the core of the troubles: out of control spending. Figuring out how things are going to be paid without controlling what is being paid for is like rearranging chairs on the Titanic. The reason people cannot afford insurance is not because there are enough insurance options, it is because of the incredible amount of waste in the system. Agreeing to cover more with insurance without controlling cost will make the situation worse, not better.

3. The process was a national embarrassment.

The debate in DC did not seem to be about people getting the care they need; it seemed to be about which side would win. The lack of bipartisanship is a condemnation of both sides, an indication that power is more important to our representatives than is representation. Why didn’t the Democrats agree to tort reform (which nearly everyone supports)? Why couldn’t the Republicans concede that having people with no insurance is a problem the government should address?

We have a terrible situation in our country: a HC system that is out of control in its cost and that will bankrupt us if nothing is done. Yet what this difficulty has won us is not a national resolve to fix this problem, it is an increase in the partisan screaming and a worsened environment to effect real and beneficial change.

To me, the debate turned debacle is a very good argument for term-limits for members of congress.

4. It missed the point.

The real problem in healthcare, again, is not who is paying. The real problem is that it costs far too much. We are not in a crisis because of insurance; we are in a crisis because of what is being paid for by insurance. For legislation to have a real chance for fixing this problem, it must find a way to control spending.

The problem of health insurance is far easier than that of cost. Here’s why I think cost-control is going to be an even harder thing to tackle:

There are industries making billions of dollars off of the inefficiency and waste in HC (see my post about the Sea Creatures). Devices that don’t really help people, and specialty procedures that are unproven are paid for while primary care gets the shaft. People like shiny technology and legislators have a hard time saying “no” to it – especially with the lobbyist dollars that will protect this waste-eating industry. It’s boring to promote primary care and doesn’t play well to the constituents.

We don’t have the IT to do it. Any attempt at cost control will fail without good health IT. Doctors control a huge percentage of HC costs, yet most are operating blindly. We rely on the word of the patient for what happens in other HC settings. If you are going to expect physicians to make prudent medical decisions and eliminate waste, you must give them adequate information. Unfortunately, the current push for EMR is not about delivering information to physicians, but instead about letting doctors document more efficiently. Use IT to inform, not conform. Use IT to enable docs instead of burdening them more.

“Rationing.” Any control of cost will be about denying care. I believe that denying care that harms patients is a good thing to do, as is suggesting cheaper alternatives if they are equal in benefit. Patients are angry when they can’t get Nexium covered by the insurance company, but OTC Prilosec is just as good for them. Patients are angry when they can’t get an MRI for their back pain when it is really not appropriate for 98% of back pain sufferers. People don’t want to be denied. Americans want an all-you-can-eat buffet of medical care. Unfortunately, any change for the positive will inevitably involve some sacrifice.

So, what do I think about the legislation? I honestly don’t think it’s that big of a deal. I think it’s good that something is being done about those without insurance, but I worry that nobody is checking the balance on the credit card. I like the arrangement of chairs on the deck, but perhaps the hole in the boat merits a little consideration.

ROB LAMBERTS is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. His writings have been described by observers as – among other things – “strange, yet not harmful” – a description we think fits him pretty well.

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59 Responses for “Rearranging Chairs”

  1. Rob Lamberts says:

    I just spent 20 extra minutes counseling a woman who was depressed and potentially suicidal. Should I value being on time more than I value spending the extra time needed? Office visits are unpredictable. I make it a point to get people out within an hour of their scheduled appointment, and generally run 20-30 min late if I get behind. I work-in visits during the day so people can be seen, and our office is open 7:30 AM-7 PM M-F and 9-12 on Sat.
    PCP’s don’t need more patients, patients need more PCP’s. The US has a 70/30 Specialist to PCP ratio because of the neglect of Primary care with the payment system. Most believe this is one of the main sources of cost. You are cutting your nose off to spite your face when you hurt the PCP. A PCP’s success is measured by people staying well and healthy. A specialist’s success depends on sickness and procedures, as does the hospital. So do you want to improve the lot of the docs whose job it is to save the system money, or do you want to drive them to money-consuming professions.
    By the way, I drive a used Honda with 120K on it. I do, however, probably earn more than you do. I am sorry if you think that’s a bad thing.

  2. Peter says:

    “Why don’t patients with higher paying insurance get preferential teeatment? Treating your best customers better is business 101.”
    Sure, why don’t we get to bid on how much we’ll pay for a doc appointment. Appointments then would be handled in order (and time) from highest bidder to lowest bidder. Careful Nate, you might just be one of the lower bidders.

  3. Peter says:

    “and therefore are not decreasing costs.”
    Margalit, but Trinity says they are decreasing costs? There is always an upfront cost to implementation that is factored into the future expectation of lower costs.

  4. Lisa Lindell says:

    “Should I value being on time more than I value spending the extra time needed?”
    Nobody said you had to choose one or the other.
    Peter-”Sure, why don’t we get to bid on how much we’ll pay for a doc appointment.”
    Nobody suggested putting Dr. appts on Ebay. By the way if healthcare really was an industry in a capitalist country, then the market WOULD set the prices and we wouldn’t be where we are today. The customer (market) doesn’t set the prices, really they don’t even know what they are.
    If you really think having a private citizen being ordered by Uncle Sam to pay premiums to an insurance company to pay for all services, for all people, from immunizations to IVF, from cradle-to-grave, is going to LOWER the cost of care for everybody, Peter, that just isn’t logical.
    I think a majority of citizens agree on the need for HC reform, but I think everybody has a different definition of just what reform is. I intensly dislike the very idea of my government ORDERING me to purchase insurance from a for-profit industry, to pay for your vasectomy, Peter. It makes me really angry. That doesn’t mean I “don’t care about poor people” as Maggie would label me, and it doesn’t mean I’m scared of or hate reform. It means I dont’ want the day to come when my children or grandchildren are ordered by their government to buy 4 gallons of Bordon milk every week.

  5. Peter says:

    ” Peter, that just isn’t logical.”
    Illogical or not, price/budget controls in other industrialized nations do it for about half the cost – with mandates.
    “It means I dont’ want the day to come when my children or grandchildren are ordered by their government to buy 4 gallons of Bordon milk every week.”
    No, they’ll be told to buy milk, who’s (if they choose to drink it) they buy will be up to them, how much they buy will be up to the milk budget, at least with single-pay.
    Lisa, I don’t have insurance, I dropped it because I got tired of playing the corrupt health insurance game. I now self insure, to a point. I don’t support mandating coverage, I do support mandating support of healthcare. I also object to being forced to buy coverage through an over priced dysfunctional system that rewards overuse, abuse, greed and waste. I oppose being forced to buy insurance from a company that pays it’s executives millions in compensation while adding nothing of value. I will probably pay the fine. However, if you wanted to wait until costs were brought down so that coverage was “affordable” we’d never get to that point. Now that costs are in your face, people will push more to bring them down.

  6. “Not paying them a bonus for EMR will be shooting ourselves in the foot (much worse, actually).”
    Although I find Dr. Lamberts’ observations excellent by and large, I disagree with this assertion.
    There are sufficient and sufficiently good commercial and FOSS EMR/PM products on the market – despite too high prices for most commercial product, as I always note – implementation can be done efficaciously and fairly inexpensively and – as was Dr. Lamberts’ experience – the financial return can be quite high, so no financial incentive should be given to any physician.
    In addition a mandate should be issued that requires implementation of a working system within say a five year time horizon. The “working system” feature is a legal requirement on any vendor or implementer which sells or installs the system for the physician. Any vendor unable to sell and implement a working system would be liable for repayment of any funds disbursed by the customer and a reasonable approximation of the cost of disruption to the physician practice from the failed venture.
    With that mandate physicians would be happy to oblige. Vendors and implementers might be unhappy, but for every vendor unwilling to sign on, there are 10 more waiting to take the vendor’s place.

  7. Nate says:

    Rob can I make an appointment? I don’t rememeber the last time I waited less then an hour for a medical appointment except at miniute clinic.
    There are obviously some Drs that do better but by far the average Dr runs a terribly inefficient office. Scheduling more time between appointments then working on paper work or other task if things go as plan would be better then cram then all in the waiting room and work through them as you can.
    “I oppose being forced to buy insurance from a company that pays it’s executives millions in compensation while adding nothing of value.”
    As free Americans most of us on the right would admire this stand Peter, I ask then why you can’t follow the logical extension to governemnt. I oppose being forced to pay taxes to politicians with 2000 staff members making over $100,000, waste trillions, and add nothing of value. Your ok being ripped off 10 times worse as long as it comes from the government, those of us on the right dont want to be ripped off by anyone, corporate or government.

  8. Nate says:

    As an example in the past few years there have been times I went without cable tv, a cell phone, or flown because I felt the product I was getting wasn’t worth what I was paying or the way I was being treated. I want this constituional freedom for my entire life. With the exception of national defence and a couple other very limited needs they have no right to my money or to tell me how to live my life.

  9. Peter says:

    “As free Americans most of us on the right would admire this stand Peter, I ask then why you can’t follow the logical extension to governemnt.”
    Nate, I would love to be able to direct my taxes to the departments/programs I think are doing a good job. That would include the option of not contributing to the military, but even you think that freedom on contributions be limited to so called mutually and collectively beneficial departments. By the way I have no choice how revenue on my corporate purchases is spent for political purposes as industries form their own unions (associations) to lobby collectively, even shareholders have little choice. But I view healthcare as a necessary government program as you view defense. You should also realize that many government programs do not work as well as they could because corporations want it that way and extend their influence ($) to make it so.

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