If Healthcare Reform Sinks, We May All Drown

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Healthcare reform (HCR) is complicated, not only because of the diversity of options but also the range and passion of opinions on the subject. Physicians are in the unique position of being able to see the debate from multiple angles. We are often insured ourselves, some of us are small employers who provide healthcare coverage for our employees, and we are intricately aware of all the ins and outs of private and public healthcare coverage for our patients. Yet, it does not take a physician to recognize that the current healthcare system is unsustainable. If costs are not reined in, healthcare has the potential to bankrupt the country—and lead to an even greater number of Americans suffering without adequate medical care.

While a single-payer system is utilized in many countries and has been carefully scrutinized here, that ball bounced out of the court a long time ago in the back and forth between the House and Senate on HCR. Some options I like that may still be in play include expanding Medicare enrollment to people aged 55 and over who lack healthcare coverage and creating a public option in a national exchange of insurance plans. The establishment of a committee consisting of an equal number of representatives from private insurers, CMS, both academic and private practice physicians, and public representatives to formulate and oversee regulations on health insurance plans seems like a reasonable method of getting all of the important players involved.

The current plans include some important provisions, and both parties have expressed support, at least to some extent, for prohibiting exclusions for preexisting conditions, getting rid of coverage caps, allowing children to stay on their parents’ policy until age 26 if needed, prohibiting discrimination by gender in policy pricing, and setting a cap on how much more insurers can charge older Americans for a policy. There is a little less agreement on whether the government should mandate that everyone have coverage and if healthcare coverage should be government-subsidized and to what extent for people who cannot afford it. There is also disagreement over healthcare savings accounts; the current Democratic plans reduce the maximum one can set aside, and Republicans favor raising the limit.

The goal of HCR is not only to cover the uninsured but also to reduce the percentage of our GDP that is spent on healthcare. These two goals would seem to be in direct opposition to one another. How do you cut healthcare spending by expanding healthcare coverage to millions more people? Some measures in the bill that focus on prevention and screening are a start. As oncologists, we know that earlier detection of certain cancers can reduce costs over the long haul. A provision in the Senate bill that would require insurers to cover routine care costs associated with clinical trials would help cut expenses by speeding the development of new therapeutics that are more targeted, more effective, and have fewer toxicities.

Tort reform to limit noneconomic damages is not included in the proposed legislation, but it certainly should be. The Congressional Budget Office estimated in October that enacting tort reform would shave $54 billion off the federal deficit over the next 20 years partly by reducing the practice of “defensive medicine.” There would be a marked reduction in frivolous lawsuits if plaintiffs’ lawyers could be countersued by physicians for more than $10,000 (the limit in a number of states), which does not even come close to the costs of litigation.

Physicians also have a part to play. Large groups of urologists, for example, have installed one or more linear accelerators to administer radiation therapy. This treatment currently has much greater profit margins as compared to active surveillance, brachytherapy, or radical prostatectomy. This has led to overutilization. Surgeons are sending patients to the emergency rooms for “emergency procedures” such as cholecystectomies and are charging insurance companies many times the reimbursement rates for the same procedure if done electively and are not billing the co-pays. This is not only unethical, but illegal. Many of our healthcare dollars are expended needlessly in the last 3 to 6 months of a patient’s life. If we pay physicians fairly for providing care to terminal patients, less might be spent on chemotherapy and other ineffective treatments and more time spent explaining to patients why some of these treatments may not be in their best interest. A redirection of the expectations for end-of-life care needs to be addressed by an aggressive public education program initiated by physicians.

President Obama has also called for universal adoption of electronic medical records in 5 years as a way to reduce costs. While this is not the time saving measure it is often touted as being, the data generated can help control costs but also provide answers regarding patterns of care. This is important when assessing where the waste is in healthcare spending.

The one thing none of the HCR proposals really answer is how the number of oncologists, primary care physicians, and surgeons—projected to decline in coming years as many retire—are going to handle the burden of millions more people gaining healthcare coverage. Meaningful HCR must include careful regulation of how care is administered. Panels designed to distinguish necessary from unnecessary treatments should include physicians, insurers, and government representatives, as well as healthcare consumers. Today’s insurers exercise too much control over what kind of care a patient receives and who provides it. Penalties on patients for seeing “out of network” physicians also need to be lifted. Patients should, for example, have options to see specialists as well as have access to doctors when, for example, an “in network” physician is booked or not taking new patients.

To an extent, we all pay for the uninsured when they get sick, through higher taxes, higher insurance costs, and higher costs for delivery of care. Extending coverage to everyone through meaningful reform will reduce the long-term drain of medical care on our economy while improving healthcare for everyone. This will not only be cost saving, but is also a compassionate and common sense solution.