How to take money out of health care, and is a single-payer system inevitable?

by Bruce Douglas, MD

I’ve been practicing my health care specialty for sixty years and have enjoyed almost every minute of it. The minutes I have not enjoyed all have to do with “money.”

Financial transactions in doctors’ offices are the root of most evils in the relationship between doctor and patient. Along with that evil goes an additional detraction from good, humane health care called the fee-for-service system, which puts money between the doctor and his patient -and forces doctors to conduct their health care practices as businesses.

Health care is a “service,” provided by health care practitioners, that does not belong in the competitive, so-called free enterprise marketplace. Of course, doctors have to be paid, but the payment should not come directly from the patient. Reception areas in doctors’ offices should be places where patients register for care, provide their insurance information, fill out a history form, and wait to be seen by their doctor. Receptionists should enter the information in a computer and be fed all the information that has been stored, privately, about that patient, that the doctor needs in order to give the patient undivided, preventive-oriented attention.

Money should not be mentioned, directly or indirectly, because health care, at any level, cannot be equated in dollars and cents.

All of this is possible in a properly structured health care system. When HMO’s were first introduced, I was a staunch supporter of the new system. They were, in their purest form, designed to meet all the standards already mentioned; but it didn’t take long for the idea to be be translated into business terms and for patients to be treated inappropriately, like “customers”. Rationing raised its ugly head very early, and doctors, victimized by the system, changed quality care into quantity care.

What the USA, the last of the great nations on earth to be developing a system that makes health care available for everyone, needs is a coordinated system where doctors work together in groups, are paid salaries for the time they spend with patients, regardless of whether they are giving advice to pregnant women, shots to little children, evaluations and prescriptions to sick adults, or surgical services in the operating room. Each group decides salary levels based on experience and training and, most important, results, equated in qualitative terms.

How can this transformation take place? It must start in medical schools and in training programs, where students are trained to focus on patients, with a stronger emphasis on primary care and restrictions on the numbers of specialists produced. The financial discrepancy between primary care providers and specialists must be erased. This can be done within the ranks of professional health care organizations and health care educators, with support from government.

Yes, this system will only work well in a so-called single payer system, essentially expanding Medicare for the whole population. I don’t care if it’s called socialized medicine. All I care about is the patients who need our care. If government is the only entity that can organize such a system, so be it! That’s the way it works all over the civilized world. My wife is English, and I have experienced the English National Health Service on many occasions. It is a remarkable way of providing health care if a nation prioritizes health care as an important entity that must be funded adequately. Almost all English patients, Canadian patients, and French patients love their health care systems, and they are willing to pay the taxes necessary to keep them going. Most of the problems arise when governments squander money on less important programs and not enough is retained to make high-level health care available for everyone.

All this is not going to happen immediately, of course; but it has to start somewhere, and the wherewithal exists in the bills presently before Congress. If the Democrats rally together and pass a bill with some version of a so-called public option, America will be off and running towards a health care system that we can be proud of in the eyes of the world.

Bruce Douglas is an oral and maxillofacial surgeon.

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