Health Care Reform

In a 5/12/09 WSJ op-ed, Scott Gottlieb, M.D., a former official at the Centers for Medicare and Medicaid Services, criticized proposals for a health care system based on Medicare.

Medicare uses “its purchasing clout and political leverage to dictate low prices to doctors”, paying doctors 20 – 30% less than private plans pay. Although some advocate a public insurance option to cover the uninsured, Gottlieb (and others) predict that a public insurance plan will be less expensive and thus drive private insurers out of the market.

The lower reimbursement rates of a public health insurance plan will prompt doctors to take on fewer new patients with such a plan, a practice that is already occuring with Medicare patients.
Dr. Gottlieb writes “Government insurance programs also shift compliance costs directly onto doctors by encumbering them with rules requiring expensive staffing and documentation,” an onerous paperwork burden that adversely affects the 60% of doctors who are self-employed.

Medicare’s “fee for service” model is flawed, rewarding physicians for providing more care, not better outcomes.

This op-ed prompted a number of replies from other physicians. A California neurologist wrote that Gottlieb’s contention that Medicare pays 20 – 30% less than private insurance was “dead wrong.” He noted that “some insurance plans pay 5% to 10% more than Medicare rates” but the extra reimbursement is accompanied by “aggravation and overhead expense of dealing with private insurers and their patchwork of unfathomable private plan coverage, co-pays, deductibles, exclusions, required pre-authorizations and delays.”

At a high school reunion two years ago, I spoke with a classmate who had recently shut his practice down after 20 years to work for a company where he could spend his time seeing patients and doing research. “In my own practice, I was spending more of my time talking to case managers at insurance companies and managing the business that I was seeing patients” was his complaint.

A dentist wrote to the editor at WSJ saying that curtailing fraud, the introduction of electronic records and a single payer system would produce small gains. The biggest cost efficiencies would be the reduction of payments to doctors and hospitals, forcing many doctors to leave the field and hospitals to close. “Why should a bright, young, prospective medical student [spend] 10 to 15 years of additional education and training to do a job that pays piece-work wages, as an employee of the government.”

At my annual physical, my doctor at Kaiser enters a few salient facts, checks on a chronic condition, enters a few recommendations into the computer terminal in the exam room and he is done. My lab results are online. I may get an email from my doctor with a comment on a particular result.

When I got into an accident a few years back, there was no wasted time filling out a medical history. With little fuss and bother, I was able to get x-rayed and temporary treatment at one location, then get follow up care at another location. X-rays were digital and both they and my medical history were available to any practitioner at Kaiser. All of the people I came in contact with knew my history. Why can’t it be like that for everyone?

When we took our cat to the emergency room, we got a CD and an online link to test results and x-rays. We were given an access code to the data so that we could share the information with our regular veterinarian. Why can’t we treat people like we do our pets?

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