by Gary R. Gibson, MD, FACP
We can deliver better health care to every U.S. citizen at less than one-half of 2.1 trillion dollars per year with constructive reform, a system wherein people receiving and providing care would feel greater satisfaction and dignity. Through courage and perseverance, we must identify and minimize waste, eliminate corruption and modernize our system. In a competitive world economy, we must reform health care effectively, or lose our position as a world leader.
In 1983, the seventeenth year of Medicare, administrative costs of the program were about 4%; stated another way, 96% of all Medicare money paid directly for health care. In 1983, “managed care” was introduced: Medicare checks stopped going to patients and began going directly to insurance companies. Currently, over 30% of health care expenditure (equal to 5% of U.S. Gross Domestic Product) goes into health insurance companies and never comes out again. These investor-owned health insurance companies should receive zero tax dollars, but rather earn clients through direct solicitation.
Health care reform will fail if we continue to pretend insurance companies manage care. They don’t manage care; they manage money and reward investors. The 25 year experiment with private insurance taking taxpayer dollars and not spending them efficiently has been a calamitous failure. It is time to turn a deaf ear to their lobbying influence, turn a page, and look to other world democracies for innovative, relevant examples of efficiency and quality. All administrative costs in U.S. health care should be below 3% of total health care expenditures.
Medical tort reform should ensure that 90% of monies exchanged in the malpractice system go to victims/families. Currently, victims/families of malpractice recover less than 40%, while 60% goes to insurance companies, attorney fees, and expert witness fees. Other democracies have methods worthy of study to design a better U.S. malpractice system.
Doctors, nurses and pharmacists must be trusted to do their professional best in patient care and not be distracted by third party directives. Doctors in primary care and most direct patient care practices should not be employed by hospitals as this too often conflicts with their oath or obligation of patient advocacy. No insurance company or benefit manager should tell a doctor, or other health provider, how to care for a patient. Such directives ignore the fact that the doctor is responsible for proper care and are in violation of a sacred covenant that is as old as civilization itself.
Drugs must be priced transparently so market forces can allow competition – without hidden rebates, pricing schemes or benefits conditional upon mail order. Pharmacy benefit managers must be eliminated altogether as they serve no useful purpose, only precipitating higher costs to patients and payors as well as interference with doctors and pharmacists who serve patients at the point of care.
The Federal Trade Commission must intervene to prevent actions patently injurious to the public health, such as Bristol-Myers Squibb’s 2007 payment to Apotex halting production of the generic drug clopidogrel and Pfizer’s 2008 accord with Ranbaxy preventing the introduction of atorvastatin to the U.S. until November 2011. The Medicare prescription drug benefit (Part D), enacted in 2005, has not made prescription drugs more affordable because of the profound influence lobbyists from the pharmaceutical industry and pharmacy benefit management companies exerted over Congress in writing the law.
We must retreat from the obsession with more tests, more drugs, more specialist opinions and more consumption of resources that relentless advertisements in the media are telling us we need. The “medicalization” of normal or benign physiological and psychological life processes has created insatiable hunger in the minds of millions, and it is making us more anxious, not healthier. When patients have been enticed by these solicitations, they are less likely to accept reassurance based upon a history and physical examination, and less able to objectively evaluate scientifically valid health care information.
The U.S. pioneered information technology, but lags behind other countries in utilizing the computer for storage of valid health information for doctors, nurses and pharmacists at the point of care. We must develop a national medical database, written and accessible by doctors and other providers at the point of service. Such a database will serve not only the individual patient but also to accelerate the evolution of clinical research. It would hold accountable all providers who author information therein. Currently, computerized templates are too often used to generate longer records to enhance hospital or provider reimbursement, implying a more comprehensive level of service. Such perversion of information technology adds noise to the medical record, not information. We must use this tool wisely.
Anyone rejecting national administration of taxpayer health care dollars should remember it was just that model of government funding and oversight that brought about such scientific and engineering feats as the Panama Canal, the interstate highway system, NASA and our modern military. We have an army of doctors, nurses and pharmacists as skilled as any in the world. They are trained and willing to fight against human suffering and disease. The war is perpetual and their battles are ours. Now is the time to excuse the lobbyists and work together to build a better health care system.
Our elected leaders in Congress must wash their hands to prevent the further spread of greed and corruption which has infected our health care system in recent years, and made sick our entire U.S. economy.
Gary R. Gibson is an internal medicine physician.
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{ 12 comments }
Dr. Gibson,
Thank you for a terrific review of what has gone wrong with medical care in the USA. I think the bottom line is that when caring for patients became a business the quality of care predictably declined. Corruption is now rife throughout the system with all parties, including some doctors, sharing the blame for making medical care more expensive and more complicated than it needs to be.
I spent half of my medical career in the US Army where it was a government run system. All doctors, nurses, and other medical personnel were paid salaries. There were no financial incentives influencing medical decisions. And, there were no insurance companies telling doctors what they could and could not do.
Comparing my time in the Army to my time in private practice it is clear to me that the government run military system delivered much better healthcare than our private for-profit system.
Monte Ladner, M.D.
Boy, this article is all about broad strokes and little detail. The examples given of govt programs that worked – Panama Canal, military, NASA, and interstate highway – all happened at least 50 years ago. Special interest groups have flourished since then – and who of us remembers the details of the waste, corruption, etc of those programs. We will never know so those are weak examples.
Btw, the military procurement system is not known for its efficiency or productivity – that was a terrible example.
How about Medicare today? One year after it was initiated, it ran some 900% over projections. LIkewise with Medicaid.
Has the author ever heard of Amtrak, Fannie and Freddie Mae, Post Office. How about public education? Is that a model of efficiency? Take Wash DC spending $14,000 per pupil with 56% administrative costs – more on admin than on teaching!
Not every sentence in this article is naive and loaded with the “why can’t we all get along for the common good” but the overall argument is just wrong. It does not allow for alignment of incentives for everyone involved – patients, drs, hospitals, pharma, etc. That is why a top down model doesn’t work.
And for those who pine for the good old days in the military medical system, no one is stopping any MD from working in a hospitalist program. You do not see hoards applying.
We need to appreciate markets allowing individuals to pursue their own interests – be it MDs or patients. A command and control medical system is not in the spirit of America.
I worked at the VA when I was a resident. I work at a private hospital now, I would not want to have to go to the VA.
How things worked in the military is completely irrelevant —unless you are proposing to subject the civilian population to the military discipline. Do we get to goose step and make that cool stiff-arm salute? I am not sure that my knees can take the goose stepping.
Guy,
The VA represents what you get when you underfund a program.
Doc Stone
I guess the comment about goose stepping was an attempt at humor.
Recognize that in the military health care system we not only take care of soldiers, but also their families. You might have missed the part where I described my three children being born in a military hospital.
The example of the military is absolutely relevant. It is a huge nonprofit government run healthcare system that works quite well and serves a very large population of active duty soldiers and their families. It used to also serve military retirees until funding for that was removed.
The military healthcare system is a real time example of how a nonprofit government program works and is an effective model to be considered in the healthcare debate.
I have no idea what you’re talking about when you discuss subjecting the civilian population to military discipline.
When all you can bring to a discussion is poor humor and insults perhaps you should consider that you really haven’t got much to say.
Monte Ladner, M.D.
Evinx,
While you’re finding fault with public services I wonder what you think of the efficiency of Enron, Lehman Brothers, AIG, General Motors, Bank of America and all the other examples of market driven success stories that owe their existence to government bailouts (if they still exist – I know we didn’t bail out Enron and Lehman Brothers).
In an atmosphere of greed and in the absence of regulation people will always do the wrong thing. The myth that unregulated markets solve all problems is just that – a myth.
Yes, government programs are run by people and like all people they can screw up. But here’s the deal, in a Democracy you get to vote and if the people of this country paid attention and made the effort to stay informed and communicate with their elected officials maybe the government would work better.
When is the last time you got to share your opinions with the board of directors of any corporation? Have you have been given the chance to vote for the CEO of a corporation who had screwed the public out of billions of tax dollars?
Do you realize that after all the recent banking scandals there has been almost no change in the executives running the very banks who survived bad management only because of tax payer bailouts?
When government fails in a Democracy maybe it’s because the average citizen is not paying attention and participating by communicating with their elected officials.
Capitalism is a great idea, but our American experiment has clearly shown that capitalism only works when it is carefully regulated.
Unregulated free markets have brought us to our current calamities of overpriced healthcare and economic collapse. The government has failed us because our nation stood by while corporate lobbyists essentially bought the government and used it as their piggy bank.
I’m not sure what you meant by special interest groups – but they are not the government, they are private interests who buy government favors with well funded lobbyists.
By the way, Fannie Mae and Freddie Mac were publicly funded, but privately operated with almost no oversight.
Monte Ladner, M.D.
DMonte
I agree some regulation is necessary but this statement you made is simply incorrect:
Unregulated free markets have brought us to our current calamities of overpriced healthcare and economic collapse
Health insurance has been over-regulated. Ever hear of mandates? Have you heard that you cannot buy insurance from out of state? Have you realized the problems caused the third party payment (tax free benefit of employer provided insurance) was bcs of price controls just after WWII? Look at what is happening in Mass thanks to Romneycare. And Hawaii. This programs are failing. Look at Medicaid and Medicare – cramming down price controls to drs and causing 20% drs not to take on new Medicare patients. These are unsustainable bcs the system is actuarily unsound. It will implode.
Yes, capitalism is imperfect but it weeds out failures IF the govt will not bail them out. Capitalism will create choices – since when are drs in favor of monopoly/monopsony power? Govt run healthcare (directly or indirectly) is monopsony power. It does not enable choices and innovation to develop. What innovation has come from the Post Office? How about Amtrak?
And btw, you are wrong about Fannie Mae — there were over 100 full time regulators inside FM every day. Big business will always attempt to use govt power to promote their own needs. That is what special interest groups do. We need to diminish their influence and the way to do that is to eliminate the power of the Fed govt.
Yes, we need govt regulations in the same way we have rules for football and referees – but the refs stay impartial – govt by its very nature is anything but impartial.
That is the reality.
It took nearly 100 years for govt to shutter just 1 program – rural electrification. An 1898 program could not be terminated – even long after electricity was brought to every rural area – and that is why private industry is the best route – allow evolution to occur and failures will disappear. Govt tends to reward failures with more money. And yes, the military too is no doubt riddled with waste and corruption. But you and I cannot have differing amounts of national defense. So we must do our best to pressure the Defense Dept for smarter procurement. But with almost all other goods and services, private sector will surely create more choices and more innovation.
Evinx,
Here is the problem in our country today. You and I don’t know each other and we’re screaming our individual political ideologies at each other across cyberspace. The reality is that you and I are probably a lot more similar than we are different, but each of us has “drunk the kool-aid” of the media outlets we choose to get our news from. You clearly get most of your information from Fox news, and I clearly don’t. Therefore, it is impossible that we will ever be able to agree on anything because we are each coming to this conversation with a completely different set of “facts.” As an interesting aside, I sign my full real name to my posts and you can google me and find my website and know much more about me. I will never know who you are beyond the screen name of “evinx.” Conversations with people who aren’t willing to reveal themselves is an odd consequence of the web. I’m not sure it allows us to really understand each other’s point of view.
I submit that neither of us really understands the issues we are talking about as deeply as we should because the information we need to fully appreciate what is happening in our country has been intentionally distorted through a campaign of lies by the special interests who are covering their tracks. And this is not a new phenomenon.
I agree with you that innovation springs from entrepreneurship. But, greed makes people do things that are not in the best interest of others. The government should be a force to balance and level the playing field. To do that the government has to be free of undue influence from any particular group.
I will close out my participation in this particular thread by going back to the original post. You should know that as people like you and me debate healthcare reform the health insurance industry is pouring $1.4 million per day into lobbying our government. I really don’t think it is fair to blame government, or to rule out the role of government, when our current government is so completely corrupted by corporate money.
I do believe in the idea of a government of the people, for the people, and by the people. We just don’t have that right now. We have a government owned by corporate America and working on behalf of corporate America.
Monte Ladner, M.D.
Dr Ladner
You wrote:
You clearly get most of your information from Fox news, and I clearly don’t.
As assumption on your part. Perhaps I watch Fox News for maybe 3 minutes a day – oftentimes, zero.
You wrote:
I sign my full real name to my posts and you can google me and find my website and know much more about me. I will never know who you are beyond the screen name of “evinx.”
You are correct in that I use a screen name – which I do for basic security. Having an IRS agent casually mention that saw something I wrote on the internet is very disconcerting. Since then, I use screen names. Nevertheless, we are talking about viewpoints and who we are and our titles should not make a difference.
Greed is such a loaded term. If you mean playing by the rules, and people pursuing their own self interest, I see nothing wrong with that. If you mean, cheating + lying, of course, we are on the same page.
I think our core differences are that you trust govt and I do not. I do not trust big business either so I want more choices and more individual freedom with personal responsbility. If, as you say, we have a “govt owned by corporate America,” then that is bcs of the national govt having too much influence. Political infulence is a corrupting force. Eliminate the basis for the influence and we can eliminate the corruption.
OK. Ladner, I will be direct, dry and humorless. What works in the military is not going to work the same way in the nation at large for a wide variety of reasons.
Your reaction to my communication is one illustration of that. The military culture –and that includes family members to a great degree–highly values direct communication, a mission orientation, following the rules and full honesty. They are values specifically selected for reinforcement precisely because they are conducive the smooth operation bureaucratic organization engaged in a collective endeavor–on in which the individuals subject their own interests and whims to those of the group. The civilian cultures is far more pluralistic on all points.
The military personnel and their family members are a much better behaved and better quality of people characterologically than the average civilian in my experience. They also have slim expectations of privacy and accept a certain surrender of rights that are not so willingly surrendered by those not in that enterprise. Even some in the military are uncomfortable–I have had numerous career service people through the years seek care with me as a civilian because they wanted some aspects of their health care out of the military’s hands. They had no complaints about quality–the problem was privacy.
If I were a volunteer military physician, I would accept the compromises to my professional autonomy that go with that and strive to be a positive contributing member. If I were forced into that position by conscription or by the government’s destruction of private medicine, I would carry that personality that led to those earlier sarcastic indirect comments into that work situation. Coupled with resentment and my deep seated beliefs about what freedom is supposed to be about, I would wage a secret war at every step attempting to miss no opportunity to sow inefficiency and chaos and otherwise undermine what I would consider a tyrranical destruction of American freedom. Many patients would react in the same way. That is why every statist health system that survives have moats and fences like Cuba and North Korea or has pressure valves whereby the discontented can slip out. Canada has the US within 30 miles of 90% of Canadians. Britain has a thriving purely capitalist medical sector.
Fortunately, America has always been blessed with the paradox that many are willing to temporarily surrender their freedom to defend the freedom of all Americans. But there are always some that come away from that with Bismarkian fantasies of the efficiencies they might achieve carrying the military models of social organization to the civilian sector–which would destroy the freedom they fought for. The imposition of military models in civilian life has been a siren song for our nation since Teddy Roosevelt. It is one of the quarters from which liberty is threatened. I am not saying the military is a threat to liberty. It is not–it is the defender. But it brings with it an element of temptation. It is not the uniforms and violence that defined Mussolini’s political philosophy–it was corporatizing every aspect of the individual life into some kind of organanization.
As it is, people who want salaried docs in for-profit or not-for-profit organizations can find them and get their care that way. Those who want to work that way as physicians can do so. Those physicians and patients who wish a more direct relationship without institutional intermediaries can have that. That is the freedom that this government was founded to protect. The freedom of each to chose the values and modes by which he will pursue happiness.
Doc Stone,
What a paranoid rant!
I’m talking about a working model for a nonprofit healthcare system and you’re afraid I want to take over the world.
Old John Wayne movies appear to be your only exposure to the military.
There really is nothing left for us to discuss on this issue.
Monte Ladner, M.D.
DocStone
I took your comment for what it was: a centerpiece on the value of individual freedom. How Dr Ladner came up with “paranoid rant” seems to give testimony to his nature rather than your, imo.
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