Special Correspondence/ What Health-Care Crisis?
Barnes, Fred & Doctors & Patients
Though I pretty much agree with the specifics of Fred Barnes's article ("What Health-Care Crisis?" TAS, May 1993), including the expectation that whatever changes (reforms) are brought about by the...
...An enlarged prostate is hardly a serious illness—at least anywhere in the world except in the minds of the lay American public...
...Susan Reynolds says in her lovely letter, "eventually things get cheaper...
...Practicing medicine can be a hell of a lot of fun when a doctor has something effective to offer her patients, and I'd like the chance to enjoy the practice of medicine rather than working my way through the ditches of administration, regulation, and waste...
...But the free market—consisting of patients seeking the kind of care they want—has decided this is appropriate, and I'm willing to go along...
...He agrees that the uninsured are disproportionately young, thus healthy...
...Thus, more and more of the nation's resources are devoted each year to health care with no end in sight...
...M.D.'s are obsessed with getting large fees from patients, getting rich big, and retiring at 40...
...A fetal monitoring device detected that our unborn child (the 8-year-old Freddy) was having trouble during labor...
...Bless you for your article, which was a breath of fresh air...
...Yes, Fred, there is a health-care crisis...
...It's the same attitude held by people—not just doctors—all over the world, particularly in Canada...
...Eventually everyone dies, but at least a doctor can try to help it be later and less uncomfortable than it might have been...
...Let physicians enforce and limit treatment according to scientific studies, unencumbered by patient demands and threats of malpractice...
...Start paying primary care physicians based on time spent with the patient...
...That's why people get cheap Medigap insurance policies...
...It's the reason people flock here for care...
...But it is naive to believe this amounts to "universal access...
...How we treat serious illness is indeed one measurement of a health-care system...
...Nevertheless, streamlining the paper chase, freeing up funds for patient care, and building our health care upon a personal, primary physician are the only hope for saving our current system from collapse...
...By my own, I make too lit-tie and Donald Trump makes too Muth...
...Our president gets all bent out of shape at the low rate of immunizations—for pity's sake, the shots are available free at the county health departments...
...Get the federal government out of the payer status...
...In addition, there's health-cost inflation caused by government intervention (Medicare, Medicaid...
...But we don't need them leeching off the system when they have a fraction of the formal education, training, continuing education requirements and responsibilities that physicians shoulder...
...One other point on technology: In every other industry or line of work, new technology is a sign of progress...
...And if countries with socialized medicine have a better attitude toward patients, as Mark McLaughlin insists, so much the better...
...This seemingly uncontrollable escalation is bad enough in itself, but even worse when we look at what we are getting for our money...
...Barnes accurately notes that crime, poverty, drug abuse, and a host of other nightmares contribute to our unique health-care problems...
...Our current system of health-care financing is nothing more than a microcosm of the federal deficit's inevitable outcome: bankruptcy of a system that wants a Mercedes while paying for a Geo...
...A few more of Barnes's points: • "The uninsured get health care, only less of it than the insured...
...What should he tell patients who don't want to take tests for fear of losing their insurance...
...This will get patients off the assembly line...
...Hunter says...
...No crisis...
...My suspicion is that, as Dr...
...Still, I appreciate Dr...
...We have devised an inverted pyramid of payment, with an increasing number of patients at the top feeding while decreasing numbers at the bottom pay...
...On this, he's just wrong...
...Of course, such an outcome is inevitable in a system where the supply of health-care services is expected to meet all demands for them, and payment is the responsibility of insurers and the government, of anybody other than the recipient of the treatment...
...TVs did...
...Barnes, I think you need some hands-on education about medicine, public health, and the current system of financing health care in this country...
...the lawyer insisted that since "the insurance will pay for it" and his client had been insured for nearly a week, I should order the test...
...I'll deal with the question of health-care costs in my next TAS piece...
...My guess is Americans will always spend more on health care because they have the discretionary income to pay for it and they value it highly...
...Why perform an MRI scan for headaches that began when the spouse walked out of the house if a physical shows no evidence of a tumor...
...While primary and preventive care are important, the best measure of a health-care system is how well it treats the seriously ill...
...Barnes makes some good points—and arrives at the wrong conclusion...
...Just a bit too facile...
...4. Control compensation of medical personnel...
...If the trouble hadn't been discovered, the child might have died...
...Hunter also says that if doctors won't take "primary care responsibilities in return for top-notch reimbursement incentives, get them out of medicine...
...The elderly, who require more medical care, are covered...
...The problem is that when they do get care it is very expensive...
...We pay oncologists to keep giving cancer victims expensive and worthless treatments but we don't pay primary-care doctors to sit down with the patient and family to discuss appropriate alternatives...
...I'm thankful for the new device, which wasn't available when my two oldest kids were born...
...Let the desire and challenge of becoming a neurosurgeon—or an endoscopist, or whatever—be the primary motive for that training...
...You may come spend a week with me in my office anytime you choose...
...The current hodgepodge of 1,500 different payers, each with its own rules, regulations, limitations, fee schedules, and exclusionary clauses for preexisting illness, and the inability of citizens to keep insurance if they change jobs adds billions to our healthcare bills...
...physician...
...This means folding Medicare and Medicaid into the single system...
...The Japanese spend less on health care, but twice as much as Americans on food...
...But how long can this system go on unchecked...
...The only one that's worse for filing claims is Medicare, with its threats of hideous retribution for making the error of assuming that the fee schedule means what it says, and that the physician can charge more for a complex case...
...Costs are costs and must be passed on to the paying public," he says...
...Barnes, your glittering generalities discredit you...
...I agree with him on having patients pay a deductible...
...And while malpractice judgments need to be limited, doctors ought not be freed from threat of lawsuits...
...So will medical technology...
...Those Socialized Medicine countries you attack (Canada, Great Britain, Germany, and Japan), as imperfect as they are, possess a better attitude toward patients than the average U.S...
...Extra years of residency should provide for only a small differential in payment...
...My wife and I have four children (ages 22, 18, 11, 8), so I've seen firsthand how innovative technology aids safe childbirth...
...That would redress one wrong by creating another...
...Wait a minute, doc...
...God willing, someone will read it before the healthcare system is faxed to hell in a hand-basket...
...Too many U.S...
...The umbilical cord, it turned out, was wrapped around the child's neck...
...Believe it or not, there are still very responsible people in our society who refuse to receive services they cannot pay for...
...On health-care costs, I don't have the answer yet for Stanley Budner...
...TAS, May 1993), including the expectation that whatever changes (reforms) are brought about by the Clintons will probably make things worse, his conclusion that there is no crisis in American health care is flat-out wrong...
...This represented a blessing for the afflicted, and, to use an abused word, an investment for society...
...For more than twenty years, the cost of health care, with occasional dips, has far exceeded the rate of inflation, and will continue to do so as far as the eye can see...
...On Medicare, he says it doesn't cover all patient costs...
...What do you call a system that allows companies to become self-insured and then limit maximum benefits to $5,000 for chronic medical conditions...
...In fact, I infer that Dr...
...The client had a thin scar on the forehead and no neurological symptoms except a desire to sue the owner of the gym where the accident happened...
...For these patients, there will neither be recovery nor a return to normal life even though the costs of their treatment keep mounting...
...But surely he realizes that eventually the bills have to be paid...
...Surgical and medical specialists who provide "procedures" are paid exorbitant amounts of money on a per-hour basis...
...He concedes that the uninsured get high-quality care...
...So much for encouraging people to care for the elderly...
...And who decides which doctors should be defrocked...
...I therefore offer the following suggestions: 1. Develop a single-payer system...
...Should health care be different, with technological advances curbed...
...Care cannot be given away free forever," Dr...
...Hillary Clinton...
...Well, they are...
...Dr: Hunter declares: "Let physicians enforce and limit treatment according to scientific studies, unencumbered by patient demands and threats of malpractice...
...If patients deserve compensation for time lost, that's one thing...
...While seeming to disagree, Dr...
...Lack of primary, preventive care for chronic conditions results in patients being admitted to intensive (expensive) care units with life-threatening asthma attacks, heart attacks, drug overdoses, and a host of other conditions...
...It is one thing to pride ourselves upon drastically reducing the level of pain, illness, and premature death among people, another to pursue deathlessness, forgetting—even as death stares us in the face—that there is, as the Preacher said, a time to die...
...We waste health care resources in this country like we waste everything else...
...What do you call polls that indicate 40 to 50 percent of physicians would not enter medicine if they had it to do over...
...Tom Brokaw recently profiled the Temple University Hospital emergency room...
...It just has nothing to do with access and quality...
...Hunter wants more primary-care doctors and fewer specialists...
...And it is not something of which we should necessarily be proud...
...It's not...
...Cost-shifting may not be the best conceivable system, but it's hardly so egregious that it warrants scrapping our entire health-care system...
...Hunter's biggest gripe is that some doctors and hospital officials make too much money and primary care practitioners too little...
...How's that going to improve health care...
...Barnes wrote...
...These patients receive treatment with few questions asked...
...ED...
...A lawyer called me once, and was highly indignant that I would not order an MRI scan on a client who had suffered an injury to the scalp when the handles of a weight machine came off and struck his head three years previously...
...Get the premiums for every single citizen to a manageable level...
...Hunter actually goes along with some of my points...
...He complains about "our society's addiction to the latest technology...
...It's paid for through cost-shifting...
...But that is not the whole story...
...True...
...I'm sorry it took so long, but the bottom line is that the patient got treatment...
...General internal medicine, family practice, and, pediatrics are the cornerstones of this reform...
...This is certainly not an exhaustive proposal...
...I understand Ross Perot is responsible for the computer software that runs Medicare and Medicaid, and that was sufficient reason to vote against him in 1992...
...Why is it a "typical conservative, Republican, arrogant American attitude" to note that our doctors are the envy of the world...
...We have health-care problems, but this isn't one of them...
...Limit awards to actual damages...
...Please stay tuned...
...Until recently, the great triumph of public health and medicine was the preservation of life and health—primarily in the very young, to a lesser extent in adults—so that they could live out their lives normally...
...I got a letter from Medicare stating that a family doctor should not bill for anything of more than intermediate complexity...
...That will be no help in treating serious illness...
...People, including me, like new technology because it saves lives...
...The cost-shiftine of the current systern is ill-conceived, politically motivated, and downright dangerous...
...As a primary-care doctor who still takes some Medicaid patients, I can tell you reasons why many doctors will turn them away—payment averaging less than ten cents on the dollar, tedious paperwork, a labyrinthine bureaucracy, and one of the worst claims-processing systems I have ever suffered through...
...We have come right back to the crux of the problem: everyone gets care, but no one wants to pay for it...
...All you have to do is show up with child in tow...
...The Japanese have nothing on us in this area, Barnes...
...I'm happy to deal with them...
...Users of the system need to have some direct responsibility or we will create a system where everyone satiates himself on health care without ever having to accept any personal responsibility...
...The sad fact is that we won't be able to make everyone healthy at the lowest possible cost unless we can reform society into a peaceful collection of wine-sipping, non-smoking joggers who fervently believe in childhood immunizations, wearing seat belts, monogamy, and vegetarianism...
...The corollary is that older citizens who have insurance are increasingly subsidizing the care of, these "young and uninsured" patients as well as all the cost-shifting between Medicare, Medicaid, and managed-care discounts...
...must increase its number of primary-care physicians...
...Mark McLaughlin Ocean City, New Jersey What a wonderful article about health care Mr...
...just a little "tinkering" will do...
...Hunter has tales of woe...
...It's consumer choice...
...I have not heard from the patient or his lawyer since...
...But to have reams of paper consumed by lawyers, insurance companies, and health care providers to spend months wrangling over what was a direct result of the accident or injury and what was "pre-existing" is wasteful—and very expensive...
...Yes, uninsured people do get health care through emergency rooms...
...I have not touched on medical education payment, issues surrounding long-term care, physician-credentialing and continuing education requirements, and other significant elements of health care...
...The neat thing about advances in medicine is that eventually things get cheaper—polio vaccines instead of iron lungs, acid-blocking medications instead of stomach removal...
...To return to Barnes's argument: •"American physicians, with a universe of modern technology at their fingertips, are the envy of the world's physicians...
...Yes, we need these people...
...Susan K. Reynolds, M. D. St...
...We cannot blithely dismiss these expensive problems as non–health care issues...
...Costs are costs and must be passed on to the paying public...
...Make sure that every citizen has a deductible as part of the package...
...But health care won't get that much cheaper...
...Walter R. Hunter, M. D. Denver, Colorado Fred Barnes replies: Being called arrogant by Dr...
...Pay us for our time and watch how we respond...
...Now for one of the most jealously guarded secrets of health care: many insurance executives and hospital administrators are paid inflated salaries, while primary-care physicians continue to lose out...
...Hunter is like being called chronically late by President Clinton...
...Ninety-nine percent are eligible for Medicare...
...Develop guidelines for basic services coupled with expanded medical research on clinical-outcomes data so we physicians know what does and does not work...
...Some parents just don't bother to take their children for immunizations, even when the health department sends a van to their neighborhood with workers who pile out and beg the people in the apartment complex to send out the kids for their shots...
...The uninsured tend to be young, thus healthy...
...3. Build health care on primary care...
...How long can taxpayers foot the bill for patients like the AIDS patient Barnes discusses who "sometimes . . . had so much medicine we had to throw it away...
...Louis, Missouri I read with bemusement Fred Barnes's "What Health-Care Crisis...
...Birth was induced...
...The only difference between men and boys is the price of their toys...
...What do you call a system in which it took me a week to find a nursing home willing to accept a dying diabetic patient because reimbursement from Medicaid would not cover the costs of her care in her terminal state...
...What do I say to patients with insurance who refuse appropriate medical tests and treatments for fear their insurance will be canceled if they submit claims...
...There is one involving money and what it is buying us as a nation...
...The Denver Post notes that a third of every dollar spent on hospital care goes to subsidize Medicare/Medicaid and managed-care insurance contract discounts...
...As he reported, many inner-city emergency rooms are going out of business because they are losing millions of dollars in uncompensated care...
...Hunter contends further that we "aren't dealing effectively with serious illness in this country...
...Put all medical malpractice claims under binding arbitration of panels of physicians, health care lawyers, and responsible, knowledgeable public watchdogs...
...I'm a big fan of the medical profession, but please give patients a say...
...I don't think an attitude makes up for inferior health care, however...
...There is simply no justification for the discrepancies in payments to physicians under our current system...
...No amount of hue and cry from conservatives can alter the fact that the current system cannot be maintained...
...Now, however, the bulk of health-care funds is increasingly being spent on treatment of patients in the last year of their lives, e.g., the elderly dying of strokes, cancer, heart failure, and other degenerative diseases of old age...
...And if certain doctors cannot rise to the occasion by taking primary care responsibilities in return for topnotch reimbursement incentives, get them out of medicine...
...Hunter's detailed response and the honest differences it expresses...
...In addition, our society's addiction to the latest technology, and our incessant need for immediate action have certainly contributed to the high cost of health care...
...Look who's talking...
...Sorry, doctor, but that's the arrogant conservative position...
...What a typical conservative, Republican, arrogant American attitude...
...And what of the uncompensated care physicians provide in the office...
...This system has one virtue: it works...
...Does Barnes believe hospitals can indefinitely provide $10 billion in uncompensated care in addition to these subsidies...
...Barnes seems to be one of those conservatives who wants to pretend everything is basically fine...
...Primary-care practitioners suffer, when virtually everyone agrees that the U.S...
...Get non-medical payers of health care out of the system...
...For every person seen in the emergency room, there are countless others who do not see physicians for chronic conditions because they have no insurance and not enough money to pay...
...But that's the point: untreated chronic problems can become acute problems, and very expensive ones...
...He complains ittook a week to find a nursing home for a Medicaid patient...
...The system worked...
...Yes, it is high-quality health care...
...It's their bodies and their bucks...
...Care cannot be given away free forever...
...It has been bipartisan pandering to senior citizens that has allowed Medicare to become the most massive entitlement program in this nation's history...
...This same market, remember, created the greatest health-care system in human history...
...A hundred and fifty dollars to a physician for a forty-five-minute visit is cheaper than a five-minute visit and a $1,500 MRI scan...
...It was Republican appointees to the Health Care Financing Administration (HCFA) and Health and Human Services who gave us the incredibly complex and very expensive rules and regulations of Medicare, Medicaid, OSHA, and CLIA (Clinical Laboratories Improvement Act), which have made physicians' lives a living hell...
...But that is one of our problems: we as Americans think everything is "serious" and have failed to differentiate serious conditions from benign nuisances...
...It has been Republican administrations that have driven up health costs through ridiculous Federal Trade Commission regulations that spawn three hospitals in one city to duplicate services...
...HMOs and "managed care" have done little to lower health care costs while putting patients on an assembly line...
...Protect patients, but stop pandering to America's trial lawyers...
...That's 'simple: Tell them to take the tests if the tests are medically necessary, and worry about the insurancelater...
...Maybe that's so by his yardstick...
...Now, Dr...
...They rely on our health-care system only for life-threatening conditions...
...This gives them, as he says, "some direct responsibility" for their own medical costs...
...2. Develop significant tort reform...
...Stanley Budner New York, New York . . . . Mr...
...It applies to any citizen of the world regarding any commodity we Americans have available...
...In fact, we aren't dealing effectively with serious illness in this country—largely because we have perverted the meaning of the word...
...Hunter mounts a large-scale assault on cost-shifting, the practice of covering the cost of caring for indigent patients by spreading it among those who have insurance and can afford to pay...
...There is waste in American medicine, and a lot of it occurs because the technology is available and it's fun to use it...
...I think not, and Freddy agrees...
...That's circular reasoning in the best political fashion, since even the government's own experts now concede Medicare doesn't cover the costs of care...
...Barnes cites, of all things, an "enlarged prostate" as an example of serious illness...
Vol. 26 • August 1993 • No. 8
