Rearranging Chairs

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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Lisa LindellMGNateContrarianJohn Yosaitis MD Recent comment authors
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Peter
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Peter

“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… Read more »

Nate
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Nate

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.

Nate
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Nate

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… Read more »

Wendell Murray
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“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… Read more »

Peter
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Peter

” 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… Read more »

Lisa Lindell
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“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… Read more »

Peter
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Peter

“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.

Peter
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Peter

“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.

Rob Lamberts
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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… Read more »

Lisa Lindell
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Amen. Do you realize if just one doctor in one community, anywhere in America, right now launched an ad campaign “Guaranteed on-time appt time or the visit is free” they’d have market share. They’d have appointments booked months in advance. Can you imagine your local MRI imaging center running ads like this? Where do you think everyone would go for their MRI’s? Things like this are obvious to folks with common sense like Nate and myself. But these things don’t happen because we don’t have a “patient-centered” healthcare system. The business model doesn’t operate to serve its customers. Nate you… Read more »

Nate
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Nate

is it maybe time for PCP to get more efficient? for example distribution of capital cost. Office buildings and equipement only make money when they are being used. Most of your Dr offices are only open M-F 9-5 or 6. ERs and Urgent Care show there is demand for evening and weekend hours, why aren’t they bringing in partners or employing docs to work their off hours? Why don’t patients with higher paying insurance get preferential teeatment? Treating your best customers better is business 101. Personally I wont go to the doctor becuase it takes all darn day and the… Read more »

Nate
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Nate

All the PCPs I grew up with make more then I do, drive nicer cars, live in bigger houses, and have young hot wives. I was forced to upgrade my software to accept EDI at my own expense, I think its why I am single today, they can pony up the money.
I’m not a fan of rude goldberg solutions. If reimbursement is to low thn raise reimbursement don’t “make up for it” by giving them freebies and subsidies.

Rob Lamberts
Guest

Nate: it is the primary care offices that are getting the money, and they need it. The margins for primary care are such that it has stood in the way of spending the money on EMR. Most docs are not like me in that they don’t really believe in EMR. They don’t know how to do it. They will find any reason not to do it. Plus, they won’t be profitable on them without a lot of help. There are far more stories of failure than there are of success. PCP’s are quitting in droves and they are one of… Read more »

Nate
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Nate

Funny how we all pay for EMRs and HIPPA EDI requirements but docs yet they get to pocket most of the change.
We need to stop babying doctors they aren’t broke and can well afford to spend 20K to buy their own EMR and make it back in savings.

rc
Guest

“Why didn’t the Democrats agree to tort reform (which nearly everyone supports)? ”
Torts is mostly state law. So it can exist on a state level, but might have been unconstitutional for the federal authorities to address. The legal implications are sometimes hard to oversee for non-lawyers (including me), but totally reasonable.
http://en.wikipedia.org/wiki/United_States_tort_law#Federal_torts