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Two Birds With One Stone: Covering the Uninsured by Fixing Medicare

Victor Sandler

As a nation, we are in a heap of trouble. Our medical system is a
disaster—overly expensive and ineffective. On average, we spend two to
three times more per capita on health care than other developed
countries. Yet on measures of quality, we rank 22nd out of 23 among
those same countries, according to the World Health Organization. Not
only that, Medicare, our national insurer for the elderly and disabled,
is facing more than $30 trillion in unfunded liabilities over the next
40 years. We have 50 million people who are uninsured in this country
and millions more who are underinsured because employers have shifted a
larger percentage of premium costs to them and increased deductibles
and coinsurance payments, causing some to forgo medical treatment
because of the expense.

The bad news is that we are on a path that is much too costly and
clearly not sustainable. The good news is we can get off that path by
cutting medical costs dramatically without negatively affecting
quality. The way to start is by acknowledging the fact that we don’t
have the best health care in the world, as former President George W.
Bush and others have touted.

What we have is the most health care in the world.

The Causes of Medical Waste
The factors that feed our obese medical system are manifold. But three
are especially troublesome. First, there is an unfortunate ethos within
American medicine and society at large called “heroic positivism.”1
Essentially, it is the idea that the more we do to and for our
patients, the more they gain.

The very act of intervening, whether it
is performing a test or giving a treatment, connotes a benefit for the
patient. This philosophy leads many doctors to perform, and many
patients to submit to, unnecessary tests and overly aggressive
treatments. This is particularly true in geriatrics, where there is a
narrower margin of safety because patients are frail and have a short
life expectancy, giving physicians less time to achieve positive
outcomes. Many elderly patients would be far better off if we complied
with the “do no harm” maxim and offered them more conservative, less
risky interventions, or no intervention at all.

Second is our emphasis on procedures rather than prevention. Most
specialty care physicians are in fee-for-service practice. They eat
what they shoot. The more stents they place, the more hysterectomies
they do, the more MRIs they read, the more they earn. Most doctors are
not so mercenary as to ignore their patients’ best interests. However,
the financial incentives clearly drive them to do more, not less, for
their patients.

Third, and most insidious, is the conflict of interest that pervades
health care in this country. Eighty percent of medical research and 70
percent of continuing medical education for physicians is paid for by
drug and medical device companies.2 Sixty percent of medical school department chairs are paid consultants for these companies.Of
physicians who author clinical practice guidelines, 80 percent are on
the payroll of Big Pharma, and 59 percent have relationships with
companies whose drugs were considered in the guidelines they authored.Far
too many medical decisions are being shaped by this unholy marriage of
physicians and corporate interests. The physician covenant must be with
his or her patient. Yet, the influence of drug and device
companies plays a role in nearly every clinical decision made in every
doctor’s office and at every hospital bedside.

This results in unnecessary and unproven care. Evidence suggests
that at least 30 percent of medical tests and treatments done in this
country are unnecessary.5-7 Examples include the use of
statin drugs to lower cholesterol in elderly people who don’t have
coronary disease, PSA testing in elderly men, mammography in elderly
women, coronary CT angiography, Pap smears in women who’ve had
hysterectomies for benign disease, and chemotherapy in patients with
advanced cancer who are debilitated and close to death.

The Solution
The drivers of health care cost inflation can be controlled not by
rationing beneficial care but by eliminating ineffective care. There
are a number of ways we can do this.

First, we can start cutting Medicare costs by eliminating
ineffective care—that means not reimbursing for it. If research has not
established that a test or treatment benefits a patient’s health, the
government should not pay for it. We should base these determinations
on evidence presented by nonbiased medical outcome research
organizations such as the Cochrane Collaboration, which make such
information available at no cost.

In 2006, the state of Minnesota created the Health Services Advisory
Council (HSAC), whose mission is to write authorization guidelines
designed to eliminate ineffective care and, thus, save the state money.
The council and similar entities in other states could be charged with
saving Medicare dollars as well. The federal government could provide
states with an incentive to do this by sending 50 percent of the
Medicare dollars saved back to them. The states could then use those
tens of billions of dollars to cover the uninsured.

Keep in mind that Medicare serves as a template for most other
medical insurance companies. The reimbursement decisions made by
Medicare eventually would be replicated in the private market. Thus,
the positive effects of these evidence-based authorization guidelines
would be felt across the whole health care system, resulting in huge
savings.

Second, we must urgently resurrect primary care, which is the
foundation of an efficient health care system. The American College of
Physicians warned in 2006 that “primary care, the back bone of the
nation’s health care system, is in danger of collapse.” During the past
decade, the number of graduates of U.S. medical schools entering
primary care specialties (pediatrics, family medicine, internal
medicine, and geriatric medicine) has dropped dramatically, as the
number entering other more lucrative specialties has increased.8
This is happening at a most inopportune time, as members of the baby
boom generation are entering their senior years and need the type of
coordinated, whole-person care these physicians deliver more than ever.

A number of measures must be taken to increase the supply of primary
care providers. Some of the options we might consider include defraying
the cost of medical school, which now exceeds $100,000, for doctors who
choose primary care specialties; mandating pay equity between primary
care and specialty care physicians; and providing the staff and support
that would give physicians more time for patient care and prevent
burnout. One way to expand access to primary care is by increasing the
supply of advanced practice nurses and physician assistants. The range
of services these providers perform is often limited by state statute
and reimbursement restrictions. Laws should be modified in order to
maximize their potential as primary care providers.

Third, we need to eliminate ineffective care at the end of life,
which is now poorly managed and excessive. The frail elderly and the
terminally ill all too often receive unwanted and expensive medical
care. Many patients might refuse some of this care if the true benefits
(often nil) and burdens (often great) were accurately explained to
them. We need to adopt tools such as POLST (the Physician Orders for
Life-Sustaining Treatment paradigm), which is designed to ensure
informed consent about the care people receive at the end of life. We
also need to do a better job of integrating hospice and palliative
medicine into our health care system. These services improve patients’
quality of life and decrease costs by discouraging undesired medical
interventions.

Fourth, we need to encourage the development of integrated health
care systems such as those of Kaiser Permanente in
California, Intermountain Health in Utah, and Mayo Clinic.  These
systems save money—as much as 20 percent compared with the cost of
other care—through improved care coordination, use of electronic
medical record systems, and elimination of duplicate services.

Conclusion
The priority for health care reform must be cost containment.
Eliminating medically ineffective or unproven care will accomplish this
goal without sacrificing quality. We can kill two birds with one stone.
The tens of billions of dollars saved by limiting Medicare
reimbursement for unproven care will provide the resources we need to
cover all of our citizens. Finally, we must continue to improve health
care delivery by rewarding physicians who practice primary care,
promoting better end-of-life care, emphasizing better care
coordination, expanding the use of electronic medical records, and
eliminating redundancy of services. By doing this, we can create a
cost-effective, high-quality health care system that truly is the best
in the world. 

Victor Sandler is an internist and geriatrician. He also is
bioethics committee co-chair for the University of Minnesota Medical
Center, Fairview, medical director of Fairview Hospice, and a member of
the State of Minnesota’s Health Service Advisory Council.

Editor's Note: An earlier version of this post omitted the footnotes that Dr. Sandler included with his posting.  

References
1. McCue JD. The naturalness of dying. JAMA. 1995;273(13):1039-43.
2. Abramson J. Overdosed America: The Broken Promise of American Medicine. New York, NY: Harper Collins; 2004.
3. Campbell EG, Weissman JS, Ehringhaus S, Rao SR, Moy B, Feibelmann S,
et al. Institutional academic-industry relationships. JAMA.
2007;298(15): 1779–86.
4. Choudry NK, Stelfox HT, Detsky AS. Relationships between authors of
clinical practice guidelines and the pharmaceutical industry. JAMA.
2002;287(5):612-7.
5. McKinsey Global Institute. Accounting for the Cost of U.S. Health
Care: A New Look at Why Americans Spend More. McKinsey and Co. December
2008.
6. Dartmouth Atlas Project. The Care of Patients with Severe Chronic
Illness. Lebanon, NH: The Dartmouth Institute for Health Care and
Clinical Practice; 2006.
7. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder
EL., The implications of regional variations in Medicare spending. Part
2: health outcomes and satisfaction with care. Ann Int Med.
2003;138(4):288-98.
8. Bodenheimer T. Primary care—will it survive? New Engl J Med. 2006,355(9):861-4.

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John Ballard
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“An Enthoven-ish sort of idea.” Exactly. At least for tiers 2 and 3. I’m radical enough to go for a tax-supported tier 1, boosting local mental health and public health department clinics to serve walk-ins that now routinely go to hospital emergency rooms for all kinds of non-emergencies. A public-private “exchange,” a la Ethoven, might also work at the safety net level depending on local needs and resources. At the grass roots I don’t think any “one size fits all” is feasible. As for all that commodity stuff, I’m way out of my depth. Whatever you say is fine with… Read more »

Tom Leith
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Tom Leith

> That’s why they say you can make a small fortune > in the commodities market… starting with a large > fortune. You are confusing a contract for future delivery of a commodity with the commodity itself. You have bought the commodity when the transaction is complete, and you could have bought the same thing from any other seller for about the same price. Hair replacement, fertility treatments, […] Those who want to keep themselves or their family members alive in a vegetative state for years, abortions, nose jobs as treatment for depression, sex changes, sex unchanges… All this is… Read more »

Nate
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Nate

“Single-pay certificate of coverage/summary plan description: “You get sick we’ll cover you”. There, no lawyer needed, both sides understand the contract.”
Peter you don’t really believe that do you?
Will your plan cover abortions at 8 months 20 days becuase mom wants to go to spring break?
How about your depressed and nothing short of nose job will cure it?
Sex Change?
Sex unchange?
Medicare exclusions and limitations are bigger then any private policy I have ever seen.

John Ballard
Guest

Tom Leith, I disagree that “In a commodity market you know what you’re going to get…” The commodities market, like all markets, is a guessing game. The bid price only equals the sale price when a transaction is complete. Until that moment, no one, whether seller or buyer, knows what he are going to get. That’s why they say you can make a small fortune in the commodities market… starting with a large fortune. I would say that in the case of health care what you get is even more uncertain. Why else would physicians consult one another or patients… Read more »

Tom Leith
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Tom Leith

Nate writes: > You can’t underwrite risk when you don’t > know what you’re underwriting. Correct. And the courts will always construe the terms of a contract, especially 20-100 pages of mind dumbing detail not even experts can agree on the meaning of at any particular point in time, against the party who drew-up the language. So when the dispute comes to “I thought when I got sick, you’d pay for whatever my doctor did to me” versus “No, we didn’t agree to pay for that under these circumstances” the usual way of dissolving an apparent contract (i.e. “Here’s your… Read more »

Peter
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Peter

Single-pay certificate of coverage/summary plan description: “You get sick we’ll cover you”. There, no lawyer needed, both sides understand the contract.

Nate
Guest
Nate

“It isn’t. In a commodity market you know what you’re going to get, everybody pays the same price, and that price falls to the long run average cost of the thing in question. And since medicine isn’t a commodity, I don’t think medical insurance can be a commodity. Certainly it isn’t today.” I wish I could write as well as Hootsbuddy. Federal and state laws require when I sell an insurance policy I deliver either a certificate of coverage or summary plan description. These are 20-100 pages of mind dumbing detail about what you’re going to get. There are very… Read more »

Tom Leith
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Tom Leith

Dr. anon writes:
> Why oh why is our legal class never
> asked to give up anything?
They are, at least around here. It is presumed by just about everyone here that medmal cases will be handled by arbitration or at least a special medmal court. It will also help if the standard of care is truly standard. My guess is the legal eagles will try to horn-in on the arbitration process. My hope is that it will be dominated by doctors, preferably academics.
t

Tom Leith
Guest
Tom Leith

Hotsbuddy writes: > health care INSURANCE may be a commodity It isn’t. In a commodity market you know what you’re going to get, everybody pays the same price, and that price falls to the long run average cost of the thing in question. And since medicine isn’t a commodity, I don’t think medical insurance can be a commodity. Certainly it isn’t today. > anything short of universally available > basic health care is a form of rationing. But as soon as you use the qualifier “basic” you’re “rationing” too. About the only thing we seem to agree on is that… Read more »

John Ballard
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Apologies to Dr. Sandler. I got so wrapped up in the previous comment I failed to recognize the excellence of this post. I especially like the emphasis on igniting a renewed interest in primary care. A trend to specialization over the last several decades has led to some truly great specialists, but there is a crying need for old-fashioned family doctors. When one of our children was still a toddler my wife mentioned to her OB doctor that her daughter wanted to be a doctor when she grew up. His reply was cute but revealing: “Tell her to become a… Read more »

Hootsbuddy
Guest

I have been reading THCB posts and comments now for several weeks and am getting somewhat familiar with screen names and arguments. In some cases I can glance at the writer’s ID and guess where a comment is headed before I read it. Nate is perhaps the most persuasive, impressive voice of insurance interests. I stand in awe of his adroit, take-no-prisoners, sometime epic comments. This gem above jumped out at me: “Insurance should be a commidity, it’s a pure numbers game and we have way to much margin in ours. I can’t think of any other commodity market with… Read more »

rbar
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rbar

Peter, You wrote: “Do doctors want total absolution from errors/mistakes/incompetence?” I don’t think so, I certainly don’t. What I really ask you to make an effort to understand is: There is a difference between honest errors of judgment and negligence. In fact, the jurisdiction largely already acknowledges that, but unfortunately, that did not really penetrate fully to our jury based courts. Please do read the following from a state court of appeals: “A physician is not an insurer of the results of his diagnosis or procedures. He is obliged to conform to the accepted standard of reasonable care, but he… Read more »

anon
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anon

Peter As a primary care physician as a matter of course whenever I smell the possiblity of a dissatisfied or unrealistic patient, I refer like hell to any number of specialists. My specialists, who already default to intervention described above, can smell as well as I can so they have the patient undergo as aggressive testing as possible. Getting sued is a long, drawn out process akin to water torture, with plaintiff attorneys, with the connivance of the system, actually using the stress of getting sued against the physician/defendant. I have seen a plaintiff attorney in open court verbally threaten… Read more »

Tom Leith
Guest
Tom Leith

Nate writes: > Under the present system someone should never > receive treatment from a provider they don’t > have a contractual rate with. > Even when a bill is not paid by the insurance > company it should still run through them. Practically, this means everyone should be going through a PPO-ish thing. So, how is this “buying direct”? It sounds to me like you’re doing arbitrage against two things: 1) tax laws 2) carriers’ inability to capture all the value of their networks Fine. Go for it. People should listen to you, especially for the short term. But… Read more »

R. Cohen
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R. Cohen

As Dr. Sandler says, we should absolutely be focusing on containing Medicare-related costs as a means for informing broader healthcare reform. Emphasizing the need for a more robust primary care system is an excellent place to start; however, to tackle the problem more precisely, we must focus on addressing costs related to those with chronic conditions, including with improved primary care and physician extender provided care coordination and chronic disease management. When broken down, approximately 30 percent of seniors account for more than 80 percent of Medicare costs. Most of that 30 percent is comprised of those with chronic illnesses… Read more »