Dear Mr. President

I am writing this as a representative of the examination room – one who sits facing patients, dealing with   our healthcare delivery “system” on a daily basis. I am writing this as one who will bear the brunt of what you accomplish or fail to accomplish in your attempts to reform our “system.” I write this as a primary care doctor who makes a living (or not) by what I earn from that “system.” I write as someone who has seen people not take medicine they need, not get the help they should, and not care for themselves as they should because of our “system.”

I talk to patients every day about what you folks are doing, and let me tell you what they are saying: nobody has any confidence in you whatsoever. Whether conservative or liberal, insured or not, black or white, elderly or young, all of my patients express frustration, disillusionment, and pessimism over your chances at getting it right. Nobody is confident, nobody is all that passionate anymore, and nobody is holding their breath.

Why no passion? Why wouldn’t people be invested in something so vital as our healthcare system? Because it seems to all that what you are doing in Washington is not about people’s health, it’s about politics. It’s not about caring for the frail and elderly, it’s about holding on to your power or regaining the power you lost. The cross-section of people I talk with is convinced that you would sacrifice what’s good for the country to get what’s good for your party. It’s hard to get passionate about your games and power struggles. It is as if the house is burning down and you folks are arguing about what color to paint it.

So what do people want? What is really important to my patients? Here’s what I see:

1. People want things to get simpler – The system is so complicated and so difficult to deal with. Please resist the urge to make more government agencies and more hoops people must jump through. Remove the impediments to care, don’t add more of them.

2. People care about information – Some patients want to have access to their own records, but most would be satisfied if their doctor actually had access to their records. The number of times I must work without hospital discharge summaries, medication changes, lab results, x-ray results, and consultant notes is appalling. My patients are more than frustrated that nobody is communicating; my patients are getting sick and dying because of it.

3. People are very suspicious – Very few people trust the big businesses in healthcare. You should thank the healthcare insurance industry, because they actually have less trust than you do! But whey you pander to their lobbyists, you undermine what little trust people have in you. People want you to represent them, the people who elected them, not those people with the money to finance better commercials for your re-election.

4. People don’t want a system that is secretive – The exchange of money in medicine happens behind closed doors, and when costs are out of control, that makes it look very suspicious. It makes patients mistrust me, and it gives a lot of room for questionable practices on all sides. You would score big points if you made a system in which the payment of doctors and hospitals was not treated as “off limits” to others. People don’t mind paying me for what I do, but the fact that I can’t answer the simple question, “what will this cost?” undermines their trust. Neither I nor they can afford to have that trust undermined.

5. Everyone thinks you are out of touch – People get passionate still when they complain about this. You are passing laws that you are not going to pay for. You are playing with our lives and our money, but you have your own insurance plans and special treatments that shield you from your own bad decisions. Our government is supposed to be “of the people and for the people,” but you are starting to look like an elite ruling-class. We all know that’s not good – it’s what made us rebel against the King in the first place. You need to somehow show you are still part of us and are willing to pay the same price we pay from your own decisions.

This list is not even close to being complete; there are lots of things people want. The details aren’t as important as the idea that you are actually listening. Don’t ignore the fact that one of the big political forces in our country today (right or wrong) is called “Tea Party.” There is an atmosphere of “us against them” that reminds me of the accounts of the colonies before they rebelled against the King. You are looking less and less like you care about us, and more and more like our enemy. This goes for all of you: democrats and republicans, liberals and conservatives. Stop pandering to your parties and start serving us. Stop jockeying for power and start fighting for what’s right.

If you don’t, I think it’s just a matter of time before angry mobs with torches show up at your doorstep, before another shot is heard in a small town in Massachusetts and another revolution is joined.

Don’t be foolish. Listen. You are not smarter than us; you are representing us.

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. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

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64 replies »

  1. I agree with Rob on the Majority of this subject matter,. However,Obama is just a puppet on a string !

  2. Nice detailed articles but if I may suggest, you need to bring some imagery to draw attention better, too much literature makes it hard to focus and grab interest. Just my 2 cents.

  3. So, Tod, you suggest that doctors not enter the debate about HC reform? Or should it only be our lobbyists and retirees? Why should we care about the process? Is it not GROWING UP to try to be part of the discussion/debate? Don’t I have valuable things to contribute?

  4. It seems to me that you (Dr. Lamberts) have too much time away from your patients if you sit at your computer and blog about politics! It also seems to me that a lot of the points you directed toward the President should have been in the other direction, at the party who IS for big business and IS beholden to the lobbyists of big business (big insurance and big pharma). So, GROW UP and let’s get behind our leaders who actually want to FIX our “system”. Now, cut off your computer and go HELP your patients!!!

  5. We The People, These words only apply to Senators, Congressmen and President not the AMERICAN PEOPLE. We have no say in our own country. Clinton changed our HEALTH CARE and now Obama. This is his religion not the AMERICAN way of life. Go back to our way, before CLINTON, of going to DOCTORS and not having to go to primary DOCTORS everytime we need to go to a specialist. Also tell them stay the hell out of Social Security every time this country has to bail our COMPANIES and other COUNTRIES. When you make a loan you have to pay back the company and that is with interest so should these companies and the GOVERMENT. Pay back SOCIAL SECURITY that the Goverment owes US and get the people OUT OF SOCIAL SECURITY that is not completely disable and that have not reached the age of 62 and older. THIS COUNTRY IS NOT OF FREEDOM IT IS OF DICTATORSHIP. Where are our RIGHTS AS FREE AMERICANS TO CHOOSE WHAT WE WANT YOU ARE RIGHT IT IS OF POLITICS NOT ANAIN OF THE PEOLPE. STOP GIVING Illegal Immigrant.

  6. I just read this blog about the health care issue, again, after reading about the earthquake in Chili and the impending tsunami predicted to strike today!
    ENOUGH OF THIS POLITICAL grand-standing from Congress and the President. WE,as people of the United States see these bills as positions of power, not for the good of the people. Scrap the ideas, form a panel of American people who have no agendas and begin at the beginning.
    I cannot believe that President Obama can be using strong arming to get this bill passed, just for his own agenda, which appears more and more to be for a power take over, a way to turn this country into a socialist dictatorship….Are we going to let him? He’s NOT listening to us Americans….We need reform of the insurance industry and legal systems that hike the costs for us. I grew up with no insurance available, everyone paid for care out of pocket…..Maybe we should go backward in order to move forward.
    With all the disasters and the breaches in homeland security, our health care packages should be much lower in priority. Come on Mr President, if YOU don’t want to be a one term President, change your ways and LISTEN TO THE PEOPLE!!!!!

  7. Dr Lamberts’ views are interesting; valuable; worth attention. At the same time, a couple of his underlying premises deserve cautionary reflection:
    a) people are people first. Patients are a subset of that 1st population – and not in the majority, despite their accounting for a big portion of GDP. Patients are a health constituency – but not the only one, or arguably the one deserving of most of the attentions of reformers.
    Regroup around health. Persisting in making sickness – “patients” – the focal point of remaking a health system is a race to the bottom, which in the case of this subject is death.
    b) Primary care DOCTORS most certainly have an important role in provision of care, but it is and should be an evolving role, and one which includes a variety of primary care givers.
    Unfortunately, too many very well-meaning primary care docs want, like the most heedless reactionaries, to “go back” to some mythical time when their specific role was more central and/or more effective*.
    The lament about lack of patient accountability is instructive, especially when synthesized with a subsequent poster’s references to behavioral economics; people are ‘non-adherent’, are ‘noncompliant’ to authoritative, rational guidance with respect to a host of behavioral situations. Is it rational to expect them to be different somehow with regard to their medicalization?
    So, what to do? Dear rational healer, you must change your behavior – and change it as a dynamic of your practice – meaning ‘expect to continually amend it’, principally to systematize it, to integrate other primary care inputs.
    (*Also witness AAFP’s very recent decision to retract its already highly qualified support for retail clinics care, a small decision, one that will go almost unnoticed in most circles, that is very little about care, and almost entirely about power, about politics.)

  8. Natalie, I don’t understand. It seems that $1500 covers 5 home visits. This is $300 per visit.
    I see from your link that your PCPs will arrange for tests and specialists, but those will be additional expenses for the patient, correct? And so are the prescription drugs, and of course the hospitals, if necessary?
    One other question would be if the insurance plan, which you recommend that people still carry, will recognize the $1500 towards the high deductible.
    I can see how house calls on demand are really nice and high availability of a PCP is very convenient, but it seems to me that just like concierge medicine, this is better suited for relatively healthy and well off people. It is also probably a very good service for large employers, like Microsoft, which I think employs a similar service.
    Rob is right, this is not a model that can replace the current office based model of practice, nor can it replace standard insurance coverage. It’s too limited in scope and too expensive for most people.
    However, I can see how it could be relaxing for a doctor to practice that way, even though taking 1/3 off the top is pretty steep….

  9. “We have a couple of folks working on a grant to provide our platform services in inner city, indigent, even rural india, locations.”
    Grant from whom? If it’s so cheap why would people need grant money to afford it? Who pays for drugs etc.? Does the $125 include all office visits and the home visits, in other words you don’t charge anything else but the $125/yr?
    “It reduces costs of caring for patients by 80%,”
    Primary care and/or hospitals?
    “It eliminates the costs of defensive medicine which are detailed here…”
    No they weren’t “detailed” at all. Useless link. How would defensive medicine be eliminated?

  10. Our platform costs the same no matter what your existing health is… pricing is transparent, the 125 a month includes five home visits a year. We have a couple of folks working on a grant to provide our platform services in inner city, indigent, even rural india, locations. So as you can see it’s a national health pilot to replace medicaid/medicare as it continues to fail. ( which is very soon)…
    It reduces costs of caring for patients by 80%, period. It eliminates the costs of defensive medicine which are detailed here…
    And enables a whole generation of primary care physicians. Mister Gates and Buffet will be paying for it. And it will be executed while everyone else is still sitting around in meetings talking and arguing… I invite you to take a look at the value proposition for the customer here…

  11. Margalit: I am not really suggesting a revolution; I am simply drawing attention to the increased frustration people have with their “representatives.” It seems as if the folks in DC (congress, especially) are at the very least giving the impression that re-election is more important than representation. The Republicans don’t want Obama to succeed in this, because his success would help the Democrats (at least that is my impression). The same would happen with Democrats if it was a Republican president. Democracy seems to have devolved into demagoguery. THAT is how this resembles pre-revolutionary America. Our leaders are more interested in maintaining their job in DC than they are helping their constituents. You may not agree, but this certainly is the growing feeling among the people I see every day.
    Peter: I am talking about two different things. Medicare/Medicaid lead the way by paying with out question for things like cardiac stents (which are totally unproven and expensive) and other expensive procedures with even less proof to them. That is the reason for the Comparative Effectiveness Trials, which I absolutely support (as long as they are clearly apolitical). The other insurers do follow suit as well. Why? Because they just pass on the cost to consumers and maintain their profit margins. It’s REALLY bad PR to deny a cardiac stent, and so paying is the lesser of two evils. That’s the reality of medicine in 2010.
    Regarding those who don’t take their meds, it is the Medicare patients (Part D is terrible, and the “donut hole” creates havoc), insured patients with huge copays for drugs, and especially the uninsured.

  12. My sentiments EXACTLY – No compassion is the total key. You go Mr. Lamberts, but am fearful this is falling on “deaf ears” — My compliments to you for speaking out– I’m certain of the politics being more important than people and for people who have not faced life without insurance, little insurance, no tragedy, no severe illness, not yet elderly, etc. etc. they will not see it differently….. Thanks again for such a very truth full letter to our president.

  13. One more line before I become infracted myself, One wonderful group of surgeons in california stepped up, saved my arm, took the risk of helping me, they have my praise forever, they are the saints of my life, along with God my Lord, men who value quality of life, who are truly physicians for their patients most of all, If I could name them one by one, I would, but they do not want the publicity, they do what they do quietly, for they know and see the healthcare mess we are in..and stood above it for me! God Bless Them forever. Bless the hospital out of my area, who helped me, they took 70% less than they should have, who treated me like a very special person,God will shine on them forever. If it was not for our delivery system, malpractice threats, etc..more physicians would step forward..our way of medicine has tied their hands..in a firm grip.

  14. “I work for a big health insurance firm, I pay good money for my insurance,”
    Really Bob, how much do you pay and how much does the insurance company pay for you?

  15. “In this case I am referring to the money the government spends, so obviously this focuses on Medicare and Medicaid.”
    Well, what patients do you have in Medicare/Medicaid that, “…not take medicine they need, not get the help they should, and not care for themselves as they should because of our “system.” What in the Medicaid/Medicare “system” prevents them from this? And why is it only the government systems that pay for “dumb stuff”?

  16. Interesting…. Let’s talk about the elitist out-of-touch government and let’s talk about pitchforks and rebellion against the King and the Tea Party and that one shot in Massachusetts…. Let’s indeed talk about our glorious past and how things were back then….
    Was the American Revolution a mob led revolution? Sure, we have our time honored stories that sound really good, but the country was governed, and the Revolution was governed, by the Continental Congress. And who were these governing folks? Torch bearing common people? Not at all. They were the financial, and highly educated, elite of the colonies. Go through the list of signers of the Declaration of Independence and try to find one “commoner” in there…. Heck, most of Congress, before and after Independence, was comprised of lawyers, just like today. Rich lawyers and plantation owners. How representative is that?
    Were “the people” behind (behind being the keyword) these liberation efforts? Yes they were, and Tom Paine’s media efforts helped a lot in shaping public opinion, not to mention the flurry of vituperate pamphlets that continued for many years to come. Not much different than what we do today.
    The mob led French Revolution failed, while the elitist, almost aristocratic, led American Revolution succeeded, mostly because it was governed from the very beginning, and it was governed by an elitist group of men possessing enormous intellect, integrity and yes, means.
    I would submit that our problem today is that our government is not elitist enough. We obviously lack the wisdom to choose our leaders, and by the way, those Revolutionary leaders warned in many of their writings that mobs cannot be trusted to either govern or wisely select their representatives.
    Guess what? We, the people, turned into a mob…..

  17. I, for one have personally experienced this nightmare of healthcare based on ability to pay or lack of adequate insurance. I, today am disabled because of the lack of surgeons who would help me regardless of my ability to pay. After almost 2 months of suffering with a broken and splintered arm, I found help, but it was too late, too much time and damage, for those doctors who are posting, I now have a total athroplasty on my right arm, I am now waiting for yet a 3rd operation, if ok’d by medicare, which I am not eligible for until June. Yes, I was sent home with a busted arm, and told you have no private insurance, try to find a orthopedic on your own, we cannot bring one in without coverage!! We have many great physicians, but they are also cut up in the mess of delivering healthcare in our country. I am 62 years old, worked my entire life,lost my career, my health insurance previously from a undiagnosed illness, I have felt like I was living in a 3rd world country trying to obtain this surgery, if you find this dis beleiving, then I encourage you to write me, walk in the shoes of one who now has no health insurance, no ability to work, lost her dignity..etc… I am just one of many who is truly in a gap, the grand canyon of gaps..I became more disabled because of lack of compassionate health care, ours is truly based on ability to pay, the only industrialized country frozen in this situation. No citizen, yes, I say citizen especially, tax paying citizens, whether now or in the past should become disabled because of our delivery system. Try being disabled, and the medicare system telling you ..you must wait 2 years more to receive medicare..even tho you are disabled?? We need healthcare reform, we need equal healthcare for all, My costs have risen to over $200,000 because I could not receive the surgeries when I needed them..THE SHAME IS UPON OUR GOVERNMENT, ACT, DELIVER, FOR THE PEOPLE, OR THE PEOPLE WILL THROW ALL OF YOU OUT..WE ARE FED UP IN CALIFORNIA WITH ALL OF IT. By the way, I was injured while volunteering to help others have food on their tables..when I was in need, I was turned away..BUT I WILL STILL BE A CALIFORNIA VOLUNTEER. Yes, I wrote our governor, he did not respond?? Why would he, he is part of our mess in california..the great state is broken..it may never be the same.
    Nancy, a California volunteer.

  18. THANK YOU DOCTOR LAMBERTS! Why is it that no one in government listens to what the people want? I agree with everything you said. I am ready with my pitchfork and torch. Please understand, I too want healthcare to change, but for the better. I work for a big health insurance firm, I pay good money for my insurance, but I would rather keep what I have than let the know-it-alls in Washington tell me what to do, when to do it, how to do it, and then charge me (and the next 10 generations) exorbitant fees/taxes. This elitist, we know better, attitude must STOP!

  19. The thread of comments and reactions to what I viewed as a “thoughtful” blog by Dr. Rob demonstrates the tremendous challenge we face in addressing this issue. It reinforces my belief in identifying “reality” as there is no one reality, but the many perspectives and viewpoints on a topic. I’ve often said that there is no reality, but only our individual lenses viewing it, and mine is often in need of refraction.
    Without attempting to be clever or engage in angry, defensive diatribe (which would be easy to do considering how frustrating the issue is), we have a huge challenge at many levels to make any headway. From a “political will” to address a constantly emerging crisis, to dealing with the “gap” which exists between what the health care experts, the politicians and our patients express, to changing a system or lack of system which is flawed beyond belief–only begins to touch the surface of why this is so challenging.
    Readings in human behavior and neuroscience demonstrate that once we’ve developed a belief system or stance, it is rare that logical discourse, alternative views, or additional information will impact our thinking. Additionally, when presented with an identical message, the interpretation of that message is capable of entirely being shifted to support our underlying belief system. That’s not a complaint, that’s a reality of human behavior, and our neuronal connections. While we talk about neural plasticity, it seems there are limits to what beliefs and values we can stretch.
    We need to value the diversity and intensity of the different beliefs and values, and the opinions expressed. However, we’re going to need to become open to considering other opinions which conflict with our value system, and contemplate the potential validity of different perspectives. While I think I’m an open minded, thoughtful person, being a physician for over 35 years has given me a “curse of knowledge” which impacts my capacity and ability to totally understand others. I’m working on that, have been for years.
    I’d encourage reading books like Drive by Daniel Pink, Switch by Dan Heath, Predictably Irrational by Dan Ariely, How We Decide by Jonah Lehrer, Counterclockwise by Ellen Langer, Blink by Malcolm Gladwell, Sway by Ori Brafman, to name a few—running through them are themes addressing human behavior and neuroscience which will help us understand how the diversity and intensity of opinions and perspectives expressed in this thread occur. Plus, now I understand why I make all the mistakes I do. Keep challenging us Dr. Lamberts, my lens is in need of refraction.

  20. “In truth, this post was written to both the President and the members of congress. I hold the latter more at fault for these problems than the former.”
    Reading your post from Canada, especially about your patients’ frustration with the complexity of the system, I can’t help but think that the US would really benefit from a single-payer system. Because the Canadian government can spread the risk over the entire population of the country, it’s a very effective insurer: everyone in Canada has health care, and total health care spending (public and private) is 10% of GDP. In constrast, in the US, the health care system is much more expensive (total health care spending is 16% of GDP), but about a third of people are either uninsured or underinsured (44 million uninsured and 38 million underinsured, according to PBS).
    The cost and the lack of access are related, of course. Basically, the US has more and more expensive health care (which is not necessarily better) for fewer and fewer people.
    Unfortunately I also think that generally speaking, the American public is too suspicious of government for single-payer to happen. Given that, the Massachusetts-style system (no discrimination based on medical history; mandatory even if you’re healthy, which lowers the cost of providing insurance; subsidies which cover the cost of insurance for lower-income families) seems like it’s as far as the US is going to get. Massachusetts introduced its system while Mitt Romney was governor, so I really don’t see how the Republicans can be so vehement in attacking it.

  21. archon41: Well, yeah. I know they don’t have a “dumb stuff” policy (although sometimes I wonder – for other reasons), but they will tend to follow Medicare and especially the RUC – A group who physicians who help determine the reimbursement for the largest payor). Most private contracts are negotiated (either as an individual provider or with other physicians). In this case I am referring to the money the government spends, so obviously this focuses on Medicare and Medicaid.

  22. Margalit, I really think the problem is your ongoing failure to acknowledge your status as an inferior being.
    Dr. Rob, contracts of insurance don’t have an exclusion for “dumb stuff.” They are drafted in accordance with the predelictions of the Commissioner of Insurance (these can be quite otherworldly) and the hunches of underwriters as to what will appeal to employers.

  23. Margalit: That line was unclear – my point was simply that I cannot answer “how much do you charge?” even though I would like to and many of my patients would like me to. I have to have 100 different fee-schedules of what I am going to be paid and then charge enough to get paid reasonably overall by insurance companies. It’s terribly complicated – much more so than me having a sign: “$50 for 10 minute visits” (just picking a number out of the hat). I don’t speak for everyone, just for people I see (obviously), but have observed a huge cynical shift through this debate.
    Bill: Yes, I noticed I was contradicting some – I guess I do think the reimbursement rate is important, but equally so is the choice of what will be covered in the 1st place. They pay for dumb stuff. That would impact docs, but would even more so change their behavior for the positive – financially motivating them to do what saves the system money.

  24. Dr. Hodge, I am familiar with concierge medicine, but for $125 per month, you get an office visit or two (are they virtual visits or physical?). How about medications, tests and specialists, if you have a chronic disease like diabetes and COPD and maybe some heart problems…. What is the solution for these folks? The ones with the infamous preexisting conditions?

  25. Answers to Questions from Bill S. and Ms. Gur-Arie Why yes, our platform does have solutions for the uninsured, or the working poor. It is a simple monthly membership at 125$ a month, less than many in the middle class pay for a cell phone bill or fancy cable. We physicians are providing the services, do not forget, not the insurance companies. In fact upwards of 90% of the actual CARE provided in the country is at the gatekeeper of the primary care physician. This is quite inexpensive care. It’s a thorough exam, attentive history, listening to the customer ( patient ) and putting together a thoughtful and participatory action plan, in most cases costs less than 40 dollars. In my practice at least 80% of the time the best interaction is supportive care, watchful waiting, and reassurance. Our platform is a simple web ap virtual office that enables just this kind of interaction. Our prices are up front and transparent. Complete financial records and PHR ( patient medical records) accessible through our site.
    Everyone be patient. The market will sort itself out. Your physician will not be accepting insurance for much longer ( in primary care) Direct practice is an inevitable reality. 49% of primary care physicians are retiring, converting to cash ( direct) practice, or moving into other fields ( consulting, IT, executive careers)
    But when your physician leaves,( you have about a 50/50 chance of keeping him, you may have the choice to hold on to his care. I suggest you value his expertise, switch to a high deductible plan and pay him for visits as simply as you pay for groceries at the store. Because government “coverage” is a misnomer. It will never be a reality. Physicians provide “Coverage” not payors or government.
    More about our mission here…
    Personal Medicine International – About Us http://bit.ly/98nvxZ
    Natalie Hodge MD FAAP

  26. Dr. Ehausted, I think we went through my motives in a prior discussion, but let me assure you again that I have nothing financial to gain or lose personally from health care reform. Maybe a bit higher premiums if the bill passes.
    I find it fascinating that while you believe that your motives are pure, and I believe they are, you have difficulty believing that equally pure motives can cause someone to disagree with you. Actually, I am not even sure I disagree with you. Please don’t take this the wrong way, but sometimes it’s a bit difficult to figure out what you are advocating or opposing.
    Are there people out there that are irresponsible and greedy? Of course there are.
    Are there physicians out there that are equally greedy and dishonest? Yes, there are.
    Does this mean that all people and all physicians are greedy and irresponsible and dishonest? No, it does not.
    Is this the biggest problem we have in health care? I don’t think so.
    Health care costs per unit of service are higher in this country than anywhere else in the world. By a lot.
    Greedy patients cannot drive unit costs up. Something else is. A large part is due to hospital conglomerates and big organizations acting as monopolies in various geographic areas and thus dictating inflated prices. Physicians in private practice have very little to say about how much the insurer will pay them and primary care physicians are totally screwed. In our area a 99215 has been steadily increasing by 50 cents every year for the last 10 years. This is almost criminal. Particularly when certain specialists, for some reason, are grossly overpaid.
    The other factor in our high costs is over utilization. Again hospitals have a large share of this too. The minority of greedy physicians who own surgery centers and diagnostics centers are most definitely contributing to volume, and so is defensive medicine and so are the few greedy patients. However, patients’ greediness is usually limited to small things like office visits and maybe imaging tests or brand name drugs. The big ticket items like surgery are mostly not influenced by patients. People don’t usually ask for surgery unless a doctor mentions it as an option.
    And we feed children garbage and program them from infancy to crave even more garbage and to add insult to injury we spend tax money to help produce garbage cheaper, so we can consume more of it.
    And on top of this multitude of small interactions, there are the drug and device manufacturers who take us all for a ride. And then of course are the insurers who, as Peter keeps saying, skim a “small” percentage of an ever increasing top.
    I’m sure I left out more factors and causes and interactions…. The entire system is screwed up. But then there are those who don’t have admission tickets to this greatest show on earth. The poor, the uninsurable and the underinsured. Not the ones with the Nike shoes, but the ones that work hard for a meager living and barely make it.
    Then we wonder why it takes over 2000 pages to attempt to even partially straighten this mess out…..

  27. Well said, Doc. As someone with an MPH and an advanced degree in health psychology, I agree that many of the patients here DON’T do the things that would save them costs later. There is no accountability here in the U.S. People don’t take care of themselves, demand expensive tests, don’t pay their bills….because they know someone else will pay it for them. Doctors are forced to cover their butts and give the patients the tests they want (even if unnecessary) because if they don’t, the patients either leave the practice or slap a lawsuit later on.
    As for not affording things like scripts, etc….take a week and work in new york city, in the projects. what you see might surprise you. People on welfare, able to work, not able to “afford” basics, walk around with the latest Nikes, pocketbooks, smoke incessantly (very expensive)….you get disillusioned REAL fast.
    We need accountability and people to get their priorities straight.

  28. Ms Gur-Arie:
    I’m just curious, your position on health care reform as per the legislative efforts currently presented by the Democratic Party is…?
    Is that because there is a push for more electronic medical record keeping, that, I am risking to infer here, benefits your professional needs? You have a personal stake because you or someone close to you is uninsured and has more hassles and risks for less access to medical care? You believe in equality and bettering mankind because people have the right, not the privilege or ability, to have health care? Another reason or combinations above?
    I like transparency, and while I will come across as hypocritical for using an alias in these comment postings, I am the real deal otherwise in what I write here. I despise profit motives when it comes to health care, as it has NOTHING to benefit care. People can say that is an overgeneralization, and they can find petty examples to allegedly prove their point, but, there is little to gain in helping people with health care needs when there is a buck to make first or simultaneously. There are more examples to this than the detractors can find to prove their point, and, often the detractors are hiding their true agenda to argue the point.
    Money is the biggest addiction in this culture, and those who are wise and realistic conclude this, maybe in different ways, but their deeds and actions show they watch crossing that line in pursuing the buck.
    I make a decent living, I am lucky my wife does not have to work a full time job to supplement the income I bring home, and I am glad for her overall. I live fine on what I make, I own three cars at the moment, hoping an adult child will take over one of them soon, own one home and have a realistic mortgage payment, and buy the things I overall believe I need (except probably more DVDs than I can watch realistically right now) and watch my credit card use with much caution. Am I better off than most? Maybe. Did I work hard to earn it? I think so. Do I make a committment in my job responsibilities that deserves how I am paid? Yeah, I don’t think it, I know it. And I really know that over 85% of people in this culture couldn’t, wouldn’t, and shouldn’t try to do what I do without embracing and accepting the committment that comes with being a doctor. And you know what, most detractors and dissenters take their position for reasons that don’t benefit the field in the end. Gotta blame someone for your troubles, eh, America? The mirror is not convenient when it is a painful reflection, hmmm?
    Dr Lamberts’ post here is on the mark for me. I added my opinion to give readers some other perspectives to what goes on in the minds of doctors who are genuinely concerned about not just where health care is, but where it will go if politicians rule the choices further. And, as George Carlin so well stated it, selfish ignorant citizens elect selfish ignorant leaders. So, to make change for the better, I am not interested in dialoging with rigid, inflexible, clueless leaders who really do not give a shit about you and me, unless it benefits them first.
    I hope to get through to those voters who realize the status quo sucks, and at least hope they hear what others, who hopefully are talking because those others want to see change, that can make healthy, responsible differences. Think about this: if we could do our job so completely and perfectly, we would put ourselves out of business, by reversing illnesses, then preventing them, and reinforcing healthy and responsible choices.
    I can’t think of any other profession that could tolerate the concept of working so well that it could not be needed. Because most are focused on a buck.
    There are doctors who are greedy, insensitive pigs who unfortunately got an MD degree and are misusing it. But, there are as many if not more who don’t.
    So, to all you detractors on your soapbox railing about how doctors are the major cause to this dilemma, when someone calls your field a hoax and useless to society, I am sure you are down in the mob calling for your own profession’s demise with them.
    Bullshit. You are hypocrites, and I can read through it the more you pontificate.
    Which, unfortunately, I guess I am guilty of pontificating with this comment. Sorry for the length.

  29. “Here’s one for you: the OB/GYN does the circumcisions on boys in our town. They get paid more for them than we pediatricians get for resuscitating a sick infant! We are getting what we pay for. It’s more profitable to be a specialist because dumb stuff is paid for.”
    Rob, you seem to be contradicing yourself. You say “I don’t think that cutting the reimbursement rates is main part of the answer” yet you complain about, “It’s more profitable to be a specialist because dumb stuff is paid for”. That’s because the reimbursements are so high for “dumb” stuff. I agree that insurance does not care about passing on costs to it’s premium payers, but how will you justify to patients that the insurance company knows medicine better than doctors and so can deny paying for treatments, even the expensive ones?
    “we just need to stop paying for expensive stuff that doesn’t work or has minimal gain.”
    That would be “comparative effectiveness”, which the Democrats are pushing in the bill. Are you for CE or not?
    “I also wrote about $100 hemorrhoid cream that insurance has paid for. Why? Why would they pay so much for stupid things and not much for the most important.”
    Because insurance has learned that a 5% profit off the top of an ever increasing top means more dollars and bigger bonuses, and that they can just pass the cost on to their premium holders. The fact is that this system will not get close to cost sanity without government control of prices, reimbursements and health budgets.

  30. Mary: I agree with you but we don’t have to take back something that doesn’t belong to them. We need to deny them. Deny the healthcare system our business in large enough numbers and they will either bend to the will of the people or no longer exist.

  31. Enough talk and debates, just do what is right for the people and the country, take back control from the insurance companies and remember the ones of us who have no insurance because we can’t afford it. Remember you can’t satisfy all the people all the time, but you do need to do the right thing, not the political thing!!

  32. Dr. Hodge,
    I would be interested to know how does your solution apply to the broader problem of the uninsured (the ones that cannot afford insurance)?
    Dr. Exhausted,
    I’m not sure I understand your assertions: politicians are out of touch with people, patients are irresponsible and non compliant, physicians cannot figure out what they need to do to fix the problem. Is that what you meant to say? If so, do you have any recommendations of what you think needs to be done?
    Dr. Lamberts,
    The people you are referring to here are your patients, who are obviously seen in your office and “don’t mind paying me for what I do”.
    Do you think that maybe there are all sorts of other people out there that are not seen in your office, or any other office, because they cannot pay you for what you do, and maybe these “other” people have different feelings and passions regarding health care reform?

  33. Nate: It is good to hear from the HMO lobby.
    I am well aware what an HMO is… a device to siphon money from hard working families while denying care and uping the premiums. It is the only business to increase costs well beyond inflation or any other economic indicator. But your right Nate and thankfully people like you have been “looking out for us” for a long time.

  34. Reading with interest… Also a Primary Care doc and also from the ” South” it seems to me that all the expenditure of energy over government and meetings and ” reform” is an utter waste of time. Innovation, Implementation of emerging technologies, integrating health 2.0 tech into medical practice, Developing consumer facing PHR to eliminate need for staff, eliminating third party payors from your life and contracting directly with consumers. Providing service and attentiveness and a ” Customer experience” that makes ” Insurance” a mute point. Stop waiting for the government… you will be out of business by then…Take a look and watch what is happening…
    Natalie Hodge MD FAAP

  35. “Do you think that instead of the Hospitals or care providers like yourself billing the HMO’s and then waiting 90 to 180 day for payment and instead bill the individual, through a Healthcare club or non profit would that reduce cost?”
    Bill your an …..
    Do you actually read this crap somewhere or just make it up yourself? Apparently besides not knowing what an HMO is you never heard of prompt pay laws.

  36. Bill S you don’t seem to know what an HMO is, your discussing a PPO FYI.
    Less then 10% od Americans are in HMOs, they only have 25% of the private market FYI
    The rest of your post is equally accurate and meaningful
    The mistake being made in discussing healthcare is to many people like you have no idea what your talking about. Not that your opinions are “off” but you don’t even understand basic facts. Hard to inteligently discuss something when you don’t know what your discussing.

  37. Bill: anything that would simplify things would help. There clearly needs to be transparency in billing so people understand the cost (the $10 copay hurt us a lot) and also to reveal hidden gougers.
    Not sure about hospitals, though. They are a totally different beast (and not always lined on the same side as doctors – especially PCP’s)

  38. You make very valid points and it is interesting to see a doctor’s point of view. I have been a patient in the system for so long I do not know what it looks like from the opposite end.
    My experiences with the system have nearly killed me, several times. Please check out my blog if you would like details.


  40. Rob: Do you think that instead of the Hospitals or care providers like yourself billing the HMO’s and then waiting 90 to 180 day for payment and instead bill the individual, through a Healthcare club or non profit would that reduce cost? It seems that a lot of people don’t seem to understand that the high cost from the hospital billing the HMO is because the Hospital knows it will have to wait for it’s money. Would paying a care provider directly and within 30 days help to reduce costs?

  41. Health Care Reform – what Congress should be talking about:
    The health care reform debate should include exploring ways to eliminate unnecessary expenses and fraudulent charges, without creating unneeded cuts to programs (such as the massive proposed cuts to Medicare) or sacrifice of the quality of care…and limit the need for the massive taxes that have been proposed for mandated insurance.
    Identify and implement cost-saving steps without simply adding to the deficit and the additional burden of the current health care bills. Identify positive solutions by systematically reviewing unnecessary expenses, rather than simply adding complexity, expense, un-popular restrictions, and tax increases.
    “As many as 60% of all emergency room (ER) visits are for non-urgent problems.”
    “National statistics put the cost of treating non-urgent conditions in ERs at about $21 billion.” (August 25, 2008)
    “According to the National Center for Health Statistics, the average emergency room visit costs $1,049, while the average physician’s office visit cost around $153. Emergency room treatment for non-emergency medical conditions is a major contributor to the rising cost of health care.”
    Establish more urgent care or walk-in clinics for treatment of non-emergent health problems. A triage nurse in the ER could refer non-emergent cases to a nearby clinic and reserve ER’s for the treatment of life and death situations.
    Identify and eliminate preventable conditions with simple actions that SHOULD already be a standard.
    Consumer Reports reviewed an easily-implemented change that would save approximately $1.39 billion health care dollars for the 33000 lives lost each year (not including the health care costs for those who managed to survive) from Hospital-caused MSRA blood infections introduced by central line catheters to provide nutrition and hydration, etc. Treating these infections costs approximately $42000/patient. A simple 5-step program (such as handwashing by health care providers) was shown to reduce these infections to zero occurrences in hospitals where these measures were implemented. (Consumer Reports Magazine, March 2010). Congress should enact legislation requiring all hospitals to publicly and clearly report this data, and to follow the simple checklist. Medicare does not cover the massive expense of these hospital-introduced infections because they consider them avoidable. Instead, Medicare should list the hospitals it will not support due to this avoidable condition, rather than punishing the patient.
    Provide for appropriate health insurance for the un-insured through the implementation of inexpensive catastrophic policies for young people who are at low risk, higher income people who do not want to pay for comprehensive health insurance, or those unable to afford health insurance. Rather than imposing a fine, identify them and enable them to either get the health care they are eligible for, or purchase inexpensive catastrophic insurance, providing subsidies for catastrophic insurance as needed.
    Medicare is under-funded. Place a cap on Medicare (and Social Security) benefits such that people in the high income bracket are not eligible for these benefits, in order to preserve the benefits for those who do need these programs. Legislatively prevent Congress from raiding Social Security and Medicare, in order to help offset the solvency issues.
    Many individuals and self-employed Americans do not purchase health care because individual insurance is disproportionately expensive when compared to group insurance (which averages the risk). A path for the individuals and self-employed (sole-proprietors) to have access to group health insurance would lower their cost-basis and encourage them to purchase health insurance.
    Health care costs escalated when patients began to expect to only be responsible for a co-pay (with a majority of health care expenses covered by insurance). Provide incentives for insurance companies to provide traditional coverage policies for those who prefer to pay for office visits out of pocket, with health insurance covering the remaining medical expenses.
    Add guarantees that health care reform would include effective regulations, fair options and quality care, by requiring the House and Senate to have the same health care system that they pass for the American people.
    Health care represents a substantial sector of our economy. Address the needs without adding to the problems. Legislators should to listen to the people, health care providers, insurance companies, and those who sell insurance so health care reform includes their ideas and needs and respond to the concerns and problems encountered.
    The majority of people do not want this rushed through without their voices or concerns being heard. We do not want our taxes to increase from the legislators not taking reasonable steps to identify and eliminate unnecessary expenses without sacrificing the quality of care in this country.
    Obama’s proposal adds to the tax burden of people earning under $200k: “raise the floor on the itemized deduction for major medical expenses to 10 percent of AGI for the non-elderly and non-disabled; ” (It is currently 7.5%)…this will increase taxes on many regardless of income…
    It also uses modified adjusted gross income instead of adjusted gross income for many calculations…meaning it adds back in many deductions, such as any deduction for student loan interest or qualified tuition and related expenses…so the net result is that it uses a larger number when computing taxes than the IRS does in federal income taxes.
    The stated reason for health care reform is skyrocketing health care expenses. These bills should provide savings, not an enormous expansion of the deficit.

  42. Dr Lamberts:
    Excellent post, noted by a colleague in a different specialty, but a medical graduate first and foremost.
    My patients say the same thing, and we all agree: the current crap, er, crop of politicians in all levels of government, local, state, and federal, are out of touch with the pulse of the public. But, we have to depend on the every day voter to rise up and exercise their rights and responsibilties to evoke proper change.
    You and I have seen who are the every day voters. They are the ones who are more so non compliant, respond to media sales pitches for quick fix answers, expect to be cured for illnesses and diseases they often contributed to the origins in the first place and will not change habits and behaviors that continue the problem, and, they never want to hear “NO”, even when no can lead to a “YES” later when it is indicated and appropriate.
    Watch how people will attack me for that last paragraph. They think because they are educated and can write so much more eloquently and defend the defenseless, I am wrong and inappropriate. Yet, at the end the day, I include a good many of them in that above description. I am not talking about indigents and uneducated persons, I am talking about flagrant ignorance, inflexibility, rigidity, and non-conformity.
    Often the very representation of political party supporters. Which entrench this pathetic system of current American Politics on those of us who are independent, moderate, invested and caring.
    You may not agree with the majority of what I have written above, so sorry if it offends. I am offended by the current state of American Medicine that has not only capitulated to outside interests, but has turned a deaf ear to the very soul of our profession: advocacy.
    Advocacy for patients, for proper standards of care, for limit setting, and not selling false hopes.
    When the majority of our colleagues, not 50.1%, but closer to 75-80% figure out what we as doctors need to do to help save and restore health care as it should be provided, then there may be a future of hope and faith.
    God knows I’ll never see it in my specialty. Sorry to hide behind an alias, but retribution is still a very active process in my experiences for speaking out.
    a board certified MD for more than 10 years
    (you have my email if you want to confirm authenticity)

  43. Peter: we agree more than disagree. Again, I don’t think that cutting the reimbursement rates is main part of the answer; we just need to stop paying for expensive stuff that doesn’t work or has minimal gain. I wrote about the Da Vinci robotic surgery that is so heavily pushed. Do doctors need to stop using it, or do insurers have to stop paying? The latter would be much more effective. I also wrote about $100 hemorrhoid cream that insurance has paid for. Why? Why would they pay so much for stupid things and not much for the most important.
    Here’s one for you: the OB/GYN does the circumcisions on boys in our town. They get paid more for them than we pediatricians get for resuscitating a sick infant! We are getting what we pay for. It’s more profitable to be a specialist because dumb stuff is paid for.

  44. So I’ve been sitting here all day watching the big healthcare summit. Lots of talking, but the bottom line is very simple.
    Democrats keep carrying on about how we need to do this because it’s the right thing to do, complete with all sorts of examples of sick and broken people.
    The Republican message is that we should start over because there was too much paper used for printing the bill.
    The President is now summarizing the agreements and disagreements. Whatever….
    The 60 votes requirement in Senate is an accident due to a misunderstanding of one member 200 years ago.
    51 votes IS a majority…. by Constitutional definition.

  45. “you might be surprise on how much your physician is being paid.”
    Even the specialist?
    “how come you guys do not complain on how come your insurance premium every year is too high, and keeps on going up every year.”
    Are you saying people don’t complain about their healthcare premium costs? And why are those premiums rising 6%-10% compounded yearly – because docs and hospitals in the system are sending them the bills.

  46. all medicare patients- medicare sends you your explanations of benefits- take a look on how much was your physicians charges and how much medicare paid- commercial insured patients you get this explanation of benefits to- check your remittance too. if you understand all the figures you might be surprise on how much your physician is being paid. may be this will stop you from complaining that they were paid so much. then you can start comparing this charges to other expenses you have when you go have your car fix or when you call a plumber. keep in mind your physician takes care of your life and went to school and trained for more than ten years- (they are still studying for new treatments). i always hear everyone’s complain about doctors- i think whatever they earn they surely deserve it. how come you guys do not complain on how come your insurance premium every year is too high, and keeps on going up every year.

  47. “Peter: I am primary care.”
    Rob, I specifically pointed to specialists, not PCPs. I am not for cutting reimbersements for PCPs, in fact I would increase the reimbersments to attact people into primary care. But you need to take from one to pay the other or the costs never go away, that’s why I would pay specialists less and PCPs more. I do not point the finger at a single source but docs and hospitals generate the bills. If you deal with private insurance no doubt you can see all the excess paperwork that multiple payers present. I also assume that if you wanted to go cash only and save your patients about 50% you’d have to establish a whole new practice with all new patients because your insurance contracts don’t allow you to bill “their” insured as your patients. So yes private insurance generates a lot of the waste and time that does not go into treating your patients. If you want a simple payment system support single-pay or go cash only.

  48. “and as a patient who hears from fellow patients daily, we are angry at the Republicans for holding up the man we elected as our leader.”
    Really Diane? He had a super majority and still couldn’t pass it, do you ever own up to your failures and accept responsibility? Republicans held up nothing.

  49. Mr. Lamberts, I am not sure I understand what you’re saying, maybe because I am an American who can’t afford health care now because is jobless. See the facts in detail and then criticize efforts. It seems you are putting the blame on the wrong people. I wish you were in my shoes to understand what it feels like when you wake up in the morning with numbness in your left arm and left part of your body and don’t have the economic resources to visit a Medical DR. You are talking in the name of so many people and it seems that instead of taking care of them you are out there to get your patients’ opinions and distort it to your advantage which you use to attack what is good and necessary for our country. God bless you and hope he hears your pleads.

  50. Peter: I am primary care. My reimbursement has fallen while the cost of care has gone up dramatically. I absolutely agree that some docs are getting way too much – but this is not due to how much they are being paid, but what is being paid for. I get paid more if I see more people and do less on them as a PCP, but a cardiologist gets paid more for putting a stent in a person’s heart than I do for seeing them for 10 years. Pointing a finger at a single source is a little simplistic. I admit docs are part of the problem, but the root of the problem is the payment system. Paying PCP’s less would be dumb, by the way.
    Bill: yes, but the HMO’s initially did good, reducing length of hospital stay and denying unnecessary procedures. That’s not bad. They just got used to huge profit margins. I agree 100% that they should not be setting the agenda.
    Aaron: ? Best care? Uh, I am not sure which system you are looking at.

  51. Does anyone in government know the word simplify? Does it take almost 2700 pages to change health care? Let the public know what is happening in a way that each one of us can understand and not hide behind rhetoric. It’s all talk and very little action.

  52. I personally hope that the reform will not be passed. The United States of America has the best medical care in the world. Citizens of other countries that have universal health care, coming to America to get medical care prove it. I believe that passing health care would add to our deficit not take away from it. Although there are numbers and statistics that say it would save us money, I do not see how that could work. The only thing I see it doing is adding to the debt that I will have to pay later. Along with the cost of healthcare reform, it would also put government in charge of another very important agency. It seems to me that they have a hard enough time trying to fix Social Security and Medicare and adding a government option of health care would be an unwise decision and only add to their to-do list. There may be problems with our current system but why not fix the small problems in the system and continue giving the best care in the world.

  53. The mistake we as americans, and our elected officals make when discussing Healthcare Reform is that we are trying to play with rules set by the Health Corporations that have made the “system” what it is today. Originally, the point of the HMO’s was to negotiate fair prices from the providers. Can anyone say that the HMO’s are doing a good job…? It is much like joining a home improvement club so they can negotiate better prices from contractors in your area, but instead cost you 52% more than if you went out and requested bids independently. Would you stay in that club? The simple answer is NO. So why do we stay in our Healthcare Clubs? Lack of Choices and any real competition. I believe to reform our ability to provide health care cannot be based on the existing formula but must be controlled and administered at a local level. Instead of local moneies pouring into the coffers of the big HMO’s a local club or non profit would handle the care of it’s members. The only role for the government (State or Federal) would be the same as the current controls for local banks, regulation and oversite.

  54. “My personal perspective (seeing the system from the inside) is that the increased cost is due to waste and inefficiency, not because hospitals or doctors are paid too much.”
    I guess you could argue that because doctors and hospitals create the waste and inefficiency then they are paid too much. But in this “system” it’s the waste and inefficiency that puts money into the pockets of doctors, if not hospitals as well.
    I will point you to this link if you haven’t already read it.

  55. I am not an American. I am surprised that Americans do not see that the GOP do not want to do anything to fix the healthcare system. They should be “fired” if they do not see the healthcare system here is the worst of all industralized countries. They are OK with billions spending in Iraq and not here to take care Americans health.

  56. Peter: In truth, this post was written to both the President and the members of congress. I hold the latter more at fault for these problems than the former. A single post is not the place to say the “how” of fixing things. This post is simply meant to vent from the perspective of a primary care physician. Criticizing me because I didn’t give a complete plan is a little hollow. The problem is complex.
    My personal perspective (seeing the system from the inside) is that the increased cost is due to waste and inefficiency, not because hospitals or doctors are paid too much. I have written about this extensive (on my blog under the category “The Healthcare Problem” as well as “American Medicine”). The waste I see on a daily basis is absolutely incredible. The inefficiency is appalling.
    I agree with you, Tim, about the reasons for gridlock. That’s a bad thing, and it’s OK to rant against it – especially when you have to watch people’s health being compromised because of political aspirations.

  57. Good grief.
    Again, for the millionth time, the Republicans in Congress did not “hold up” health reform, since the Democrats had all the votes they needed to pass and sign a bill into law. They couldn’t agree among themselves.
    Also, even if they had, each and every one of the 535 people in Congress is just as elected as the President, and has the right and the obligation to “hold up” the President. it is not the function of Congress to support the President, or even to do what is best for the country. (Sorry to have to be the one to break this to you.) The function of Congresspeople is to represent SPECIFIC constituencies.
    Also, what people on these blogs (and political hacks) call “playing politics” is also called “getting re-elected”, and is actually the main incentive built into the system. There is no reason in the world for, say, some Senator from Connecticut or Nebraska to do anything other than what the people in their State will like. If obstructing Barack Obama is what will get some Senator re-elected then that is what they should do. (I’m a conservative as you might imagine. I’d have said the same thing about GWBush.) The power is divided. On purpose.
    Everybody promotes gridlock when they are in the minority, and screams bloody murder when they are in the majority. We’ve lost the ability to govern ourselves, we’re heading for disaster, blah blah blah.
    Grow up. Get the votes and use them. If you don’t have them, you don’t have them.

  58. “Because it seems to all that what you are doing in Washington is not about people’s health, it’s about politics. It’s not about caring for the frail and elderly, it’s about holding on to your power or regaining the power you lost. The cross-section of people I talk with is convinced that you would sacrifice what’s good for the country to get what’s good for your party. It’s hard to get passionate about your games and power struggles. It is as if the house is burning down and you folks are arguing about what color to paint it.”
    I thought this should have been addressed to Mitch McConnell, not President Obama.
    “I write as someone who has seen people not take medicine they need, not get the help they should, and not care for themselves as they should because of our “system.”
    Would that be because they can’t afford to do those things? And if it’s because they can’t afford our “system” where would you cut to make it affordable for them? Would you advocate that your fellow specialists cut their fees? Would you advocate hospitals be community owned non-profit? Would you advocate that doctors be on salary instead of FFS so there is not financial reason to treat. Would you advocate that Medicare be allowed to negotiate drug prices? Would you advocate a mandate for everyone to buy insurance, and if so what subsidy plan would you put in place to pay for those that can’t? Would you advocate for increases in taxes to pay for increased coverage to your patients? Would you advocate government oversight of insurance premiums? I could go on but you get the gist.

  59. Yes, that is rub of it and we do know what is right:
    Decent health care for all Americans.
    Reducing cost of health care.
    Improving quality of health care for all Americans.
    Enough with the canned, paid for infomercials and canned, irrelevant, campaign style rhetoric!
    (expletive withheld)
    Just do it!

  60. I actually am not allowed to post my costs. I can’t share a fee schedule or I am violating Pete Stark’s antitrust laws. If you read my blog, you’d see that I would love to post my fees up front, but to do so I ‘d have to drop Medicare and Medicaid, which my conscience won’t allow…yet.

  61. I am guessing your practice is in the South. “Everyone” “All” Always” Please. There is a big country out there, Doc, and as a patient who hears from fellow patients daily, we are angry at the Republicans for holding up the man we elected as our leader. Most of the things you say your patients want are things YOU want. Though, I have yet to meet the doctor who had any desire to tell me the cost of a visit. They treated me like scum after I asked and never acted like they wanted to see me again. Nothing is stopping you but your representatives from POSTING costs. Then we unhappy patients can choose the best DR for the fairest price. (Oh, and have none of your patients asked for your “track record?” How many patients were satisfied with your service? Now THAT would be very helpful and save us a lot of time.)

  62. > Stop jockeying for power and
    > start fighting for what’s right.
    Doctor, that’s the nub of it — there is no agreement about what it right, about the goal against which we should measure “progress”.