Physician’s Support of National Health Insurance?
by Robert Berry
On February 12th, Modern Physician summarized an Archives of Internal Medicine survey of Massachusetts physicians that indicated “they overwhelmingly support a single-payer healthcare system.” An article in the November 18th issue of the Annals of Internal Medicine entitled, “Support for National Health Insurance among U.S. Physicians: A National Survey” concluded that “a plurality of U.S. physicians supports government legislation to establish national health insurance.”
Many major medical journals and their societies have gone on record promoting single-payer healthcare and have conducted surveys to demonstrate support among their members. Yet they have virtually ignored the new grassroots movement in Insurance-Free Medical Clinics (IFMC’s) as well as the new trend in consumer-driven health plans taking shape outside the confines of academia. Not so with the popular press, however.
On November 6th a front page Wall Street Journal article entitled, “Pay-as-You-Go M.D.: The Doctor Is In, But Insurance Is Out,” publicized the growing movement in insurance-free medical clinics (IFMC’s), featuring ours as an example. Since then, patient controlled Health Savings Accounts (mentioned by President Bush in his State of the Union speech) have become universally available to all Americans under age 65 giving patients, not politicians or academic physicians, control over healthcare dollars.
IFMC’s will provide lower healthcare costs to Americans with HSA’s, since overhead at practices such as ours runs about one-third that of more conventional clinics, primarily because we do not process any medical claims.
Three years ago I opened a clinic for patients willing to pay for my services at the point of care. Unlike boutique practices that typically cater to the wealthy, my clientele has primarily been the uninsured. My goals were to provide affordable, quality care to those left out of our health care system and to jettison wasteful and dehumanizing bureaucracies as much as possible from my practice and from my life, even if it cost me financially.
These goals could be achieved only by eschewing contracts with third party payers, thus eliminating the substantial costs and hassles they impose on medical practices. Accounts at our clinic are settled directly and personally with patients immediately following their visits – as is done by most other small businesses in our community. As a result, my practice has only one full time equivalent (rather than the 4.5 required by the average family practice), is exempt from HIPAA compliance regulations, is free of documentation mandates and most other bureaucratic hassles, and has no accounts receivables. Best of all, I have been able to reconnect with the pure, spiritual purpose for which I entered medicine – the care of persons who appreciate my knowledge and skill.
Despite disdain from policy experts, I have found the uninsured neither destitute nor derelict. They are farmers, general contractors, local retailers, and beauticians who gladly pay our average $40 fee and partner with me in making intelligent, cost-effective decisions about their medical care. Some positively bristle at elitist paternalism. Most understand from experience the real costs of government mandates and are rightfully skeptical of political panaceas. All want a more level playing field – similar to that which the new HSA’s provide.
To our surprise, we have found that about one-third of our 4500 patients have some form of insurance. They have been willing to pay out of pocket for health care they have been unable to obtain with their health coverage. Our experience serving as a stopgap for these insured patients underscores the reality many countries with national health insurance are currently coming to grips with – that universal health coverage (for all its noble intentions) does not universally guarantee timely, quality health care. This reality explains why over one million Brits are awaiting elective surgery and why it takes over 26 weeks on average for a GP in Canada to refer a patient to an ophthalmologist. Inefficiency this inhumane suggests that when it comes to health care political mandates don’t work; for no one – not even Senators or Presidents – can coerce health professionals to care.
Not only have IFMC’s made medical care more affordable and accessible for the uninsured, they are strategically positioned to serve patients with consumer driven health plans such as HSA’s. With pre-tax, tax-deferred personal and family medical accounts supplanting low co-pay, low-deductible health plans, more Americans will soon feel the full cost of their routine health care decisions. As with other economic decisions affecting their households, they will search out the best value for their healthcare dollar (as the uninsured already do), finding it at clinics like ours. This new cost consciousness when applied to the nearly half billion patient-primary care doctor encounters every year could truly produce savings of revolutionary proportion for us all.
Perhaps these IFMC’s are what Harvard Business School professor Clay Christensen had in mind when he coined the phrase “disruptive innovation.” They are indeed a cheaper, more efficient way of providing professional services initially directed at low-end users that will likely catch on soon in the mainstream and eventually come to dominate the primary medical care market. In Canada, however, they would be illegal.
With the growing number of IFMC’s ready to accept the increasing number of patients with HSA’s, one wonders why the major medical journals have been silent.
Are You Really Insured?
by Alieta Eck
If you get insurance through your employer, you are really not insured. For when you get too sick to work, you lose your job. You cannot afford COBRA.
If you are self-employed and buy your own insurance, you are really not insured. When you get too sick to work, you cannot pay the premiums.
If you work for a big company and get your insurance through them, you are really not insured. The company can get downsized, lay you off or go bankrupt.
If you work for the government, you are only insured while you are employed. If you get too sick to work, you lose your job and your insurance.
If you depend on the government programs such as Medicare or Medicaid, watch it–they will go bankrupt in 20 years. Young taxpayers will never be able to keep up with the cost of the programs. And the next generation will have little patience with us when we are old and infirm. We certainly will not be in a position to be demanding of health care. People enrolled in these programs are already finding that it is harder and harder to find physicians. The program bureaucrats are being paid before the caregivers.
The ONLY real insurance is the kindness of our families and our communities. This is true charity– fueled by love. We had better be setting up institutions that are very inexpensive to run. We had better be figuring out ways to lower costs and get the government mandates off our backs. We need to solve the medical malpractice problem and have patients be truly grateful for the help we give them.
There are only three levels of care: 1) Health Savings Accounts (HSA’s) giving us the greatest degree of independence; 2) High deductible health insurance is good as long as we can afford it; 3) Charity for those who cannot pay their way and have no insurance.
Charity, Altruism, and Free-Market Medicine
by Madeleine Cosman
Charity is not altruism that requires one to sacrifice self for others. Charity is free market compassion. It cannot be demanded. It cannot be extracted. It cannot be centrally controlled. Charity results from volitional self-interest. Whoever gives charity gets reward. The giver feels good, enjoys gratitude of the receiver, believes that doing the right thing is virtuous. Charity inspires pleasing confirmation from others that doing good is doing well. Religious people store up good works on earth now for Heavenly reward later. Some people give charity for an income tax deduction.
Remarkably, charity resembles Adam Smith’s reminder that we do not get our dinner from the benevolence of the butcher, the baker, and the brewer but rather from their self-interest. Each exchanges value for value and in so doing expands the good. By working in one’s self-interest one also serves the greater community by making more product, more choice, more items for more exchange. By exchanging each has vested interest in peace and basic fairness and ethics. Self-interest is the key to perpetuating charitable achievements, just as it is for capitalism.
Just as achievements and products of the free market are close to infinite, so is true charity. Markets work best when uncoerced, unregulated, and rewarded. Likewise, charity.
Charity may be the only 100% coverage. Free market medicine cannot be 100% coverage because a truly free system allows some to elect not to be treated, not to be helped, and recognizes that some are beyond help. Charity inherently has the same limitations: some potential receivers will refuse help and some help will not help. Charity stimulates ingenuity. Charity initiates innovation. Because charity is rewarded, unlike altruism which is coerced, charity expands and inspires.
Medical Malpractice Can Occur with Good Medical Practice
I spent the best years of my life in the medical school and residency training in obstetrics and gynecology. When my non-medical friends were dating, partying, marrying, having children and buying houses that would dramatically appreciate over the years; I was dissecting cadavers, listening to tapes of heart sounds and honing my medical skills.
I took up the career of medicine in order to care for people. I was idealistic, for sure. While in medical school, there was a heavy load of books. Then we were on call every fourth night in the hospital. Maybe we got a couple of hours of sleep. During the residency, the workweek was between 100 and 120 hours. On one night, I delivered 8 babies vaginally and performed 4 cesarean sections. Eight years of medical training had at least twice as many years of work compressed into it. I finished with two goals in mind – compassion and quality of care. The rest, I was told, would fall in place.
Then came the malpractice suits. In the world of lawyers and malpractice insurance companies, it did not matter one bit if I met the standard of care. The Plaintiff lawyers do not care about the truth. They simply want to – “shakedown”, meaning get away with a good sum of money, by hook or by crook – after an adverse outcome. Although it is well known that most medical “errors” are “system errors”, meaning a series of minor events leading to the eventual adverse outcome; the lawyers may sue one doctor, who is considered most vulnerable, maybe because of his race, not the most responsible.
And the malpractice insurance companies have their own set of priorities. They don’t care if I practice good medicine, they will settle or fight a case depending on economic and political considerations.
It has taken me years of intense training developing skills and judgment, studying statistics and interpreting lab tests in real life situations. The lawyers do not have the necessary background to appreciate many advanced and even basic concepts of medicine. Somehow I am supposed to be able to convince these lawyers that I did the right thing! And if they do not, the jury may well not either.
How am I going to win? In spite of practicing good medicine?
If I do not win, the public loses. I see about five thousand patients every year. Many of them are particularly technically challenging cases that my colleagues refer to me. Just by odds, some outcomes are not going to be good. For each malpractice suit I face, I shall divert hundreds of hours of time to defend myself. That means less time for my patients, my family and my children. Less time to keep up with medical advances. Seeing patients as potential litigants rather than human beings. Practicing defensive medicine, ordering more tests. Less access and less affordable healthcare for the public.
Today, even if I provide free care for a patient or charge him/her less out of kindness or skip ordering one test of dubious value because the patient can’t pay, I can still be sued for a million dollars. This is completely contrary to common sense and keeps me from showing any compassion as a physician.
The medical malpractice has become a game, a lottery. In 2002, juries have awarded $80, $91 and $94.5 million dollars in different obstetric cases. In 2001, the highest jury awards were $100, $108 and $269 million dollars. The insurance costs for doctors and hospitals in 1983 were $2.5 billion, now they are $10 billion. My colleagues in Dade county, Florida are paying $249,196 for annual malpractice premiums. Plaintiff lawyers are the real winners.
(Please note: Articles that appear on this web site may not reflect the opinion of the editorial staff.)