CarlyleWalton

This was submitted to The Greeneville Sun two weeks (in 2002) after and in response to an editorial they had printed by Representative Zach Wamp. The Greeneville Sun did not run this essay.

Let Consumers Drive Healthcare’s New Models

In a recent editorial entitled, “Is Healthcare Facing a ‘Perfect Storm’?” Mr. Zach Wamp, Representative from Tennessee’s Third District, asked if factors converging today have the force to sink our healthcare system. If they do, he warns, the federal government might take it over completely. As a physician who primarily serves the uninsured (but welcomes all point-of care payers), I share his concern.

The British and Canadian systems have already demonstrated that universal health insurance does not guarantee timely, quality medical care. According to an August 11th article from London’s Sunday Times, over one million Brits are awaiting elective surgery – such a backlog now that the government is subcontracting the work out to other European nations.

Britain’s National Health Service, however, insists it’s making improvements, stating on its website, “Already more than three out of four inpatients are admitted within three months (emphasis mine) of seeing their GP, dentist, or optician.” Soothing words perhaps for the Brits, but with delays of this magnitude we Americans would be suing for malpractice.

The following quote (again from its own website) is even more incredible. “If you are suffering from chest pain for the first time and your GP thinks this might be due to angina, you will be assessed in a specialist chest pain clinic within two weeks.” Faced with a potentially fatal medical condition, Americans would never tolerate such inhuman inefficiency.

Despite many Americans’ infatuation with Canada’s system, it appears to be no better than Britain’s. Canada’s own National Post recently reported median waits for a CAT scan of 5.2 weeks, for an MRI 12.4 weeks, and for an ultrasound 3.2 weeks. Referral times for specialty treatment are even worse, partly because many Canadian physicians, “yearning to breathe free,” now practice in the United States. The average time it takes for a Canadian GP to refer a patient to an ophthalmologist is 15.8 weeks with another 10.8 weeks elapsing before the eye specialist actually initiates treatment. Little wonder that many Canadians follow their physicians and come here to receive timely care.

Centralized bureaucracies simply cannot and should not manage healthcare. Medical decisions are much too complex and personal to entrust to distant bureaucrats, many of whom not only lack basic medical knowledge but have also chosen for themselves comfortable desk jobs over more rigorous frontline patient care. Do we really want incompetent and uncaring people to control healthcare?

Americans used to entrust doctors with their medical decisions, and for the most part we liked the quality but eventually could not afford the cost. We then asked insurers to manage care, but they rationed it for their own profit and we didn’t like the quality. Now we seem to be facing another decision point about whom to trust with our healthcare decisions. So-called “policy experts” have been clamoring for years that our system is in “crisis”. They want us to jettison private medicine and submit to a single-payer system that other countries have already shown to be ineffective and even brutal.

But what are the alternatives? A recent editorial in the Wall Street Journal entitled “Where Are Health Care’s ‘Hondas’?” asked just that. Although largely unnoticed, new vehicles for delivering healthcare are being created everyday, and unlike the old clunkers are improving quality and decreasing cost. The biggest difference today is that the new models are consumer-driven.

Consumer-driven health plans with pre-tax, tax-deferred personal and family medical accounts are already available for most Americans through Health Reimbursement Arrangements and Medical Savings Accounts. People can set aside money into these accounts before taxes to pay for their routine healthcare, and that which is left over can be carried over to the following year.

From my perspective as a physician, those who pay for non-catastrophic care out of their own pockets tend to manage their health and care better than those who allow third parties to do so. Feeling the full cost of their routine medical decisions, they find the best value for their healthcare dollar as they do with other economic decisions affecting their households. Most insist that I provide thorough justification for the diagnostic strategies and treatments I recommend, thus insuring they receive cost-effective care.

Because I do not accept third party payment, or what most people today call “insurance” (even though insurance is usually reserved for catastrophes), I avoid all billing overhead, which can represent up to 50% of the cost of a primary care office visit. I can therefore offer my skills as an Internist and Emergency Physician at approximately ½ the cost of nearby clinics and usually less than 15 percent the cost of local ER’s. It seems incredible that such an elaborate financial maze has been erected to settle relatively small accounts. Americans pay about as much for routine car maintenance as they do for primary medical care, yet no one would think of having insurance for an oil change or brake job.

Increasingly, point-of-care payment clinics similar to mine are popping up throughout the country. One in Ocean Springs, Mississippi, featured recently on the CBS Evening News, charges $40 for every office visit. Another clinic in Vermont charges $2/minute or about $20 for a simple sore throat. Although these clinics are serving real needs in their communities, they would be illegal in Canada – as they would be in North Korea and Cuba, the only other countries in the world that forbid their citizens from contracting privately with physicians.

But what about the uninsured? Many “policy experts” seem always to be touting the plight of this unfortunate group when justifying expansions in public health insurance programs. Yet, one might wonder just how genuine their concern really is when Princeton policy wonk, Uwe Reinhardt, PhD (ranked healthcare’s 10th most powerful “mover and shaker” by Modern Healthcare), referred to them in the August 14, 2000 issue of Newsweek as “expendable people – mostly low-income, hard-working stiffs, socially and politically marginal.”

I’m not sure whom he meant were “expendable,” but in my practice the uninsured are farmers, general contractors, pastors, plumbers, cleaning ladies, restaurant owners, independent truckers and other small business folk – you know, the ones who build and maintain the ivory towers where these policy people move and shake. They are also the ones who grow, prepare, and transport delicacies for their high-level meetings and who clean up the messes their parties produce.

Priced out of private medical clinics from the billing overhead imposed by managed care and faced with the choice between expensive ER’s and impersonal government clinics, these “socially and politically marginal” patients tell us our clinic is a Godsend. Little do they realize that government’s tax preference for low co-pay, low-deductible insurance products forces them to subsidize low-cost healthcare for people like Dr. Reinhardt. Yet, after having treated these “hard-working stiffs” for the last two years, I would trust them and their good common sense over a whole Ivy-league of policy pundits when it comes to making decisions about their own healthcare. In fact, they can probably teach the rest of us how to manage healthcare dollars more wisely.

Point-of-care payment clinics together with consumer-driven health plans might well be the twin engines propelling us out of healthcare’s “perfect storm.” They can decrease cost, empower patients, reduce employer liability, increase physician accountability, preserve patient confidentiality, relieve overcrowded ER’s, free up the people in claims administration and policy formation to care directly for patients, restore the sanctity of the doctor-patient relationship, and provide affordable quality care for the uninsured – all without a government takeover of healthcare.

Indeed, government would do well to remove its heavy hand from medicine, for no one, not even government, can coerce care. Doctors who accept Medicare live in constant dread of being imprisoned for unintentional billing errors while continually receiving lower reimbursement for their services. Medicare regulations have made it illegal for me to work part time in ER’s and for other physicians to treat Medicare beneficiaries in my clinic. If I employ more than 10 “full time equivalents,” I will be forced to comply with HIPAA and incur overhead and hassle that has nothing to do with patient care. Little wonder with rules as onerous and ridiculous as these and with government attaching less value to those who care for the sick that fewer of our young people are choosing careers in healthcare and more of our experienced physicians are leaving it in droves. Without caregivers, there can be no care – regardless of how much wealth politicians succeed in redistributing.

Most Americans know that universal health insurance will not provide them with timely, quality medical care. Oregon’s citizens already rejected this utopian nonsense 4 to 1 in last month’s election. We all know what’s at issue here. Some politicians and pundits are stirring up storms to cloud over their power-grab for 1/7th of the economy. It is time to tell them to back off and have enough faith in American ingenuity and compassion to allow ordinary citizens to test drive healthcare’s new models.

12/9/02

___________________

December 5, 2002

Mr. John Jones, Jr.

Editor, The Greeneville Sun

121 W. Summer St.

Greeneville, TN 37743

Dear Mr. Jones:

In a recent editorial entitled, “Is Healthcare Facing a ‘Perfect Storm’?” Mr. Zach Wamp, Representative from Tennessee’s Third District, asked if factors converging today have the force to sink our healthcare system. If they do, he warns, a government takeover might be imminent. As a physician who primarily serves the uninsured (but welcomes all point-of care payers), I share his concern.

The British and Canadian systems have already demonstrated that universal health insurance does not guarantee timely, quality medical care. According to a recent London Times article, over one million Brits are awaiting elective surgery – such a backlog now that the government is subcontracting the work out to other European nations.

Britain’s National Health Service, however, insists it is making improvements, stating on its website, “Already more than three out of four inpatients are admitted within three months (emphasis mine) of seeing their GP, dentist, or optician.” Soothing words perhaps for the Brits, but we Americans would be suing for malpractice.

Despite many Americans’ adulation of Canada’s system, it is no better than Britain’s. Its own National Post recently reported median waits for a CAT scan of 5.2 weeks, for an MRI 12.4 weeks, and for an ultrasound 3.2 weeks. “In some Ontario communities,” the article stated, “some patients wait as long as 20 weeks for a mammogram for breast cancer.”

Referral times for specialty treatment are even worse. The average time it takes for a GP to refer a patient to an ophthalmologist, for example, is 15.8 weeks with another 10.8 weeks elapsing before the eye specialist initiates treatment. In Canada, you will go blind before you are seen.

Centralized bureaucracies simply cannot and should not manage healthcare. Medical decisions are much too complex and personal to entrust to distant bureaucrats, many of whom not only lack basic medical knowledge but have also chosen for themselves comfortable desk jobs over more rigorous frontline patient care. Do we really want to permit incompetent and uncaring people to control healthcare?

Americans used to entrust doctors with their medical decisions, and for the most part we liked the quality but eventually could not afford the cost. We then asked insurers to manage care, but they rationed it for their own profit and we didn’t like the quality. Now we seem to be facing another decision point about whom to trust with our healthcare decisions. So-called “policy experts” are clamoring that we are in “crisis” and want us to jettison private medicine and submit to a single-payer system that anyone with any common sense can see won’t work.

A recent editorial in the Wall Street Journal entitled “Where Are Health Care’s ‘Hondas’?” asked if there were any new models of healthcare delivery that might supplant these old worn out clunkers. There are - they are the various consumer driven health plans and point-of-care payment clinics.

My practice does not accept third party payment, or what most people today call “insurance” (but in reality is prepaid medical care since in all other walks of life insurance is for catastrophes). Without the billing overhead which can represent up to 50% of the cost of primary care visits, I can offer my skills as an Internist and Emergency Physician at approximately ½ the cost of nearby clinics and less than 20 percent the cost of local ER’s. A similar clinic in Ocean Springs, Mississippi, featured recently on the CBS Evening News, charges only $40 per visit. Another physician in Vermont charges $2/minute or about $20 for a simple sore throat. Although these clinics are serving real needs (patients are voluntarily seeking care there), they would be illegal in Canada – as they would be in North Korea and Cuba – the only two other countries in the world that forbid their citizens from contracting privately with physicians.

Primary care physicians offer knowledge, experience, and a simple set of skills to the people within their communities. Over half of the patient-physician encounters in this country take place at this level. Why should there be an elaborate financial maze erected between them in order to settle accounts? People pay as much or more for routine car maintenance as they do for treatment at these clinics, yet no one has insurance for an oil change or a brake job.

Despite beliefs to the contrary, the uninsured are neither derelict nor destitute. In our community, they are farmers, beauticians, general contractors, plumbers, cleaning ladies, independent truckers and other small business types. One Princeton policy wonk disdainfully referred to them in Time Magazine as “expendable people – mostly low income, hard-working stiffs, socially and politically marginal.” These hard-working Americans are, in my opinion, far more competent than a whole army of Ivy-league “experts” to make decisions affecting their own healthcare (not to mention furnishing this elite with food, building their houses, and fixing their plugged toilets).

In general, the uninsured and people with high deductibles are better stewards of their health and routine medical care than are people with low-deductible, low-co-pay “insurance.” Feeling the full cost of their medical decisions, they find the best value for their healthcare dollar as they do with other economic decisions affecting their households. Most insist that I provide thorough justification for the diagnostic strategies and treatments I recommend, thus insuring they receive cost effective care.

The rest of America could learn a lot from these savvy consumers and drive healthcare into a more patient-friendly era. Already, consumer-driven health plans with pre-tax, tax-deferred personal and family medical accounts are available to most Americans today through Health Reimbursement Arrangements and Medical Savings Accounts. People can set money aside before taxes to pay for routine healthcare, and that which is left over can be carried over to the following year. If given a chance, insurance products like these can give Americans more control over their healthcare, increase physician accountability, and dramatically decrease costs for everyone.

Consumer-driven health plans along with point-of-care payment clinics, I believe, can serve as the twin engines that could propel us out of Mr. Wamp’s “perfect storm.” The ride might be rough for a while, but we must stay the course, allowing the creative genius and compassion of ordinary citizens to pull us through. Not only can these decrease cost and improve quality, they can preserve patient confidentiality (without the need for HIPAA), promote savings, reduce employer liability (and eliminate the need for a Patients Bill of Rights), relieve overcrowded ER’s, free up people involved in claims administration to care directly for patients, restore the sanctity of the doctor patient relationship, and make affordable quality care more available for the uninsured – all without a government takeover of healthcare.

Government can neither compel creativity nor coerce care. Quite the opposite – their policies tend to stifle invention and discourage neighborly kindness. For example, their regulations have made it illegal for me to work part time in ER’s, and they have made it illegal for other physicians to treat Medicare beneficiaries in my clinic. Little wonder with rules as ridiculous as these that fewer of our young folk are choosing careers in healthcare and more of our experienced physicians are leaving medicine in droves. Without caregivers, there can be no care – regardless of how much wealth politicians try to redistribute.

Most Americans know that universal health insurance won’t work. Oregon’s citizens already rejected it 4 to 1 in last month’s election. We know what is at issue here. Some lawmakers and their experts are stirring up storms to obscure their power grab over 1/7th of the economy. It is time to tell them to let ordinary citizens control healthcare.

Robert S. Berry, MD

Greeneville, TN

CEO of PATMOS EmergiClinic & President of Health & Care for the Uninsured