Two weeks ago, The Annals of Internal Medicine posted three articles on health reform and invited readers to comment. The three articles highlight the perspective of physicians, more specifically internists who generally fit into the category of primary care physicians. As one commenter notes, the three articles read like committee reports.
There are some pretty heavy hitters among the authors to the three reports so I offer my comments with some trepidation. Bottom line, they miss the mark. I have this image of trying to land an airplane when the altimeter is 10,000 feet too high. The plane just doesn’t seem to touch down.
Except for the details outlined in the EMBRACE program, there is little to disagree with, it is just as if the the wheels just don’t reach the ground.
I administer a benefit plan for about 10,000 employees and retirees and their families. Every day most of the people who call our office are concerned about losing their health insurance. In most of those cases, they have been told by their doctor that they have no health insurance.
I’m sure some of those doctors are members of the American College of Physicians, so your members must know there is a problem out there.
In too many cases, the doctor’s office just got it wrong. The most frustrating are those cases when some cyber leprechaun snatched the member’s eligibility and tossed it to the end of a rainbow somewhere. There are times when it is the member’s fault. And some times our office actually made a mistake. And for the most part, I am talking about people with insurance.
We Americans struggle to get it right with people who are trying to do the right thing. That does not even begin to confront the issue of people on the margins of the system.
I can appreciate that your members are focused on evidenced based payment reform. That is surely high on my list.
Putting the cart before the horse
But I think you are putting the cart before the horse. Before we can reform the system, we need to find answers to some basic questions.
Question 1. How do we get patients into the system? I support a system of universal enrollment. Without patients, doctors have no customers. Doctors should not need to pay staff to determine eligibility for care. They should spend their money treating patients.
Question 2. How do we get the money into the system to pay doctors and hospitals? I think you are on track with a private, public financing scheme but I don’t think an “insurance exchange” gets us out of many of the vices that plaque our current system.
The method of reimbursement should be simple and clear. One of the fundamental flaws in our current system is that there is no clear responsibility for the cost of care. Every payer tries to shift costs to someone else. It is like the card game Old Maid.
Doctors and patients pay the price for this shell game. Physicians should not need to pay staff to figure out who should be billed for what service and how to get the balances paid. They should spend their money on treating patients.
Question 3. This is the question that the AIM seems to focus on: How do you distribute the money among providers? I maintain, that until you have adequately addressed questions 1 and 2, question 3 will continue to be an academic exercise.
We already have too many tiers
One article describes a proposal by the Healthcare Professionals for Healthcare Reform called EMBRACE. The proposal seems to be presented as an alternative to a single payer system. It outlines a three tier system with each tier offering a slightly richer benefit package. I suggest we already have a three tier system
Tier 1 – Poor people on Medicaid. Doctors aren’t paid enough to sustain a quality practice and their patients have no other recourse.
Tier 2 – Old and disabled people on Medicare. Better than Medicaid, and profitable for some stakeholders, but physicians seem to get squeezed the most.
Tier 3 – Working people with private insurance. That’s where physicians and hospitals make up for what they lose in the other three market niches.
We could add a high end tier for those doctors who treat wealthy patients who don’t mind paying the balances that insurance companies don’t pay. And ther are those who never make it to any tier.
If you are just going to overlay universal coverage, then your three tier model may be an economic necessity. But if you design a system that squeezes the administrative waste and headaches out of the system, you can afford a rich benefit design. I have been in employee benefits most of my career, and few benefit plans are as rich as what the single payer advocates seem to want.
The current system is not serving patients well and it is not serving doctors well, certainly not primary care docs. I support a single payer approach as the most rational start to health care reform. I agree that the single payer plan most discussed does not adequately address payment reform. It does address questions 1 and 2. I hope it will clear the deck for an uncluttered discussion of question 3.