More on Healthcare Reform

Here's a few notes I wrote the last few months over on Facebook. I forgot to post them over here.

HEALTHCARE REFORM I COULD SUPPORT

(rough draft)

Now that the "public option" is on the ropes, I realize congress may actually come up with a healthcare plan I could support. Some people have accused me of having a vested interest in the status quo, but nothing could be further from the truth. In fact, having a pre-existing medical condition (a genetic heart disease) I am currently unable to qualify for private insurance on my own and therefore feel obligated to remain an employed physician to keep my group health insurance instead of going into private practice. My 2 year old son has the same condition and leaving my current job would put him at risk also. Although I like my current job, it bothers me that I couldn't go out on my own if I wanted to. So I have as much reason to be upset with the current healthcare system as anyone. I don't believe more government control and spending is the solution however. So here's a list of things I would like to have (or not have) in whatever healthcare legislation gets passed this year. Next to each is what I think the chances are that we'll get it. Some of these might surprise you. Maybe I’m not as Libertarian as I thought I was.

1. No public option - (85%)
It looks like the powers in Washington finally realize that this is a non-starter for a majority of Americans. We just don't trust the government to make healthcare decisions for us. I'm still wary that they may try to sneak this in somehow.

2. All persons living in the U.S. required to have health insurance - (90%)
If we want to drive a car we have to have auto insurance because if we get in an accident someone has to pay for it. If you are walking around and breathing in America you should be required to have health insurance because if you get sick or injured someone has to pay for it. There are too many people out there who could afford insurance but are making payments on their ATVs and their boats instead.

3. No government rationing of healthcare (45%)
I know this is vague, but I still want it in there somehow.

4. Expanding of Medicaid to include more of the working poor who really can't afford healthcare (99%), but with incentives to get private insurance as soon as possible (1%)
It even surprises me that I'm saying this. I never thought I'd approve of the expansion of a government welfare program. But if we are going to require everyone to have health insurance we need to make allowances for those who really can't afford it. Since the Democrats have been wanting to do this for years anyway I'm sure it will happen. I still wish there was more incentive for people to get off the dole though.

5. Tort Reform (10%)
Nothing annoyed me for in the healthcare debate than when President Obama lectured the AMA against practicing "defensive medicine" (ordering unnecessary tests to make sure we don't get sued) but in the same breath said that tort reform was not the answer. This is perhaps the only sure fire way to decrease healthcare costs. I have been named in 2 completely frivolous lawsuits in the last 2 years. Neither plaintive had any chance of winning, but it still cost me (actually my employer) tens of thousands of dollars in legal fees. That's time and money that would be better spent treating patients. Arbitration agreements and legal medical boards could allow restitution and punishment respectively when negligence actually occurs, while giving more money to the actual victims of malpractice and less to the likes of John Edwards. Unfortunately the trial lawyers have the Democrats in their pockets and the Republicans are wimps and only talk about tort reform seriously when there's no chance of it passing.

6. Health insurance companies required to accept those with pre-existing conditions (95%)
The insurance companies will receive a great boon when the law is passed requiring everyone in the U.S. to have health insurance. In return they're going to have to take a hit and accept people with pre-existing conditions who they may (and probably will) lose money on. I think that's a fair trade off.

7. Allowing interstate competition in health insurance (50%)
8. Provisions to allow individuals and small businesses to "pool risk" like big businesses do to lower insurance costs (50%)
These two provisions would make the insurance business more susceptible to real market forces and bring down prices. The "public option" would have been phony competition was actually aimed at putting more insurance companies out of business and decreasing our choices.

9. Make it easier for individuals to sue insurance companies who deny or delay necessary care. (30%)
One of the reasons it is so easy for health insurance companies to deny or delay medical treatments is they are somewhat insulated from litigation. It's much easier to sue your doctor or hospital than your insurance company because the insurance companies claim they are not actually involved in medical decision making. Insurance companies would be less likely to deny payment for treatments if the money they stand to lose from litigation is more than they would save by denying the care.

10. No public funding of abortion (5%)
The laws are such that unless a specific provision is placed in the legislation that says that abortion won't be paid for, it will be. Not much of a chance of getting that in there, but I can still hope.

11. No further government interference in how healthcare providers are compensated (5%)
It just bugs me that a bunch of politicians and lawyers think they should be the ones to determine what my services are worth.

12. Physicians given more control over what is "medically necessary" for a patient instead of the insurance companies or the government (10%)
I imagine a panel of physicians, completely independent of the government or the insurance companies, deciding what gets covered. It will never happen, but it would be cool.

13. No fair fabricating a crisis to rush passage of the legislation before Congress and the public have a chance to study it (20%)
Stop trying to convince us that if we don't get healthcare reform passed in the next month the economy will collapse. None of us are buying it. It's taken us 80 years to get this far, we can wait another 6-12 months to get it right if we have to.

14. No new taxes to pay for "healthcare reform" (2%)
Notice that the only thing above that would create more government spending would be to expand Medicaid. I'd have to insist they got money for that by cutting spending somewhere else. Start with the Cash for Clunker's program.

If the president and congress ditch the public option I will breath a sigh of relief. If they embrace tort reform I will be giddy. If they also put at least half of my other wishes above in their legislation I promise I will personally campaign for it, and I'll even wear a "Yes We Can" T-shirt to the mall.


YET ANOTHER WAY OBAMACARE MAY KEEP YOU FROM SEEING YOUR DOCTOR

(Rough draft)

President Obama recently said of his proposed healthcare plan, "We also want to start rewarding doctors for quality, not just the quantity of care that they provide. Instead of rewarding them for how many procedures they perform or how many tests they order, we'll bundle payments so providers aren't paid for every treatment they offer.... to a patient with a chronic condition like diabetes, but instead are paid for how are they managing that disease overall." That sounds good, like you'll get to spend more time with your doctor because he will no longer feel rushed to see his next patient. But what will this really mean in terms of access to your doctor? First of all, if they start paying me for "quality" rather than quantity, I'm going to start seeing 10 patients a day rather than the 32-38 I currently see. That will mean that as my patient it will probably take you 3-4 months to get an appointment with me instead of the week it now takes. Secondly, "quality" measure, while not completely arbitrary, are suspect. In my primary care practice the way the bean counters attempt to measure how good a doctor I am is by looking at my diabetic patients and seeing how well their glucoses are controlled, my hypertensive patients and how low their blood pressures are, how often my asthmatic patients have to use their rescue inhailer ext.. However, these measures can be deceiving. If a doctor has only patients with mild diabetes, mild hypertension or mild asthma it will look like he is doing a great job treating them. A very good doctor may attract very difficult patients that are hard to control and his numbers may look like crap. Rewarding doctors for these measures give them a disinsentive for seeing patients who are hard treat or non-compliant. If I'm going to be paid by these measures and you have difficult to control diabetes, sky high hypertension, or really bad asthma, I don't want you as a patient because you'll screw up my numbers and I'll lose money every time you walk in my office. This would force me to limit my practice to the realitively young and healthy (easily done by only accepting one new medicare patient a month). In other words, if Obamacare passes, you'll get relaxed, 1 1/2 hour visits with your extreemly compitant doctor, just as long as you're not really sick.

The more our president talks about his plan, the more I realize that as far as healthcare goes, he is extreemly ignorant. I lay awake at night, terrified, that he may be the one who determines the way I will receive and deliver care in the future.