Physician Rethinks Healthcare System. Single Payer Our Only Choice

Summary of Weekly News June 5, 2009  

Rachel Maddow discusses the eight Third Rail statements made by President Obama in Egypt. http://www.msnbc.msn.com/id/26315908/ 

Less consumer Spending and Less Credit Cards Indicates Slow Growth for Economy in 2009 By LOUIS UCHITELLE

Published: September 18, 2008

The latest outgrowth of the housing crisis, the breakdown on Wall Street, threatens to gradually corrode economic activity on Main Street, mainly by disabling the credit on which so many everyday transactions depend — but also by frightening people. ... http://www.nytimes.com/2008/09/19/business/economy/19econ.html?_r=1

Bail-Out of Mortgages Planned Soon Edmund L. Andrews ... While details remain to be worked out, the plan is likely to authorize the government to buy distressed mortgages at deep discounts from banks and other institutions. The proposal could result in the most direct commitment of taxpayer funds so far in the financial crisis that Fed and Treasury officials say is the worst they have ever seen.

Senior aides and lawmakers said the goal was to complete the legislation by the end of next week, when Congress is scheduled to adjourn. The legislation would grant new authority to the administration and require what several officials said would be a substantial appropriation of federal dollars, though no figures were disclosed in the meeting. ... http://www.nytimes.com/2008/09/19/business/19fed.html

Investors Skeptical on Stock Market Rebound, Peter Garnham Financial Times June 1, 2009 The majority of the world’s leading investors do not believe the recent strong performance of stocks and other risky assets is sustainable ... 

Leverage Creeps Back onto the Radar Gillian Tett FT 6/2/09  Michael Hintz, a former Goldman Sachs trader who co-founded CQS sees modest shift in increasing use of leverage.

Those Who Know Her Said Sotomayor Rose on Merit Alone NY Times Michael Powell and Serge F. Kovaleski ... The Manhattan district attorney Robert M. Morgenthau, who recruited her from Yale Law School, said the comforts of corporate law held no great attraction for her. Her striving to make a difference was partly due to her life long diabetes I. Because of Sotomayor’s superb academic credentials and recommendations, the Republicans tried very hard to keep her off the Appeals Court appointment because they were afraid she was Supreme Court material which is obvious now. Peter Baker NYT  Sotomayor spent a lot of time on supporting diversity struggle. 

Jim- Judge Mayor is truly an outstanding candidate for the court who may be able to speak to Kennedy to bring him over to the good guys and gals. The conservative court members show quite clearly that genetics and experience has shaped how they make decisions. The huge number of 5-4 decisions indicate that everyone is shaped how they think by forces they cannot necessarily control. Sotomayor realizes that she gets over-emotional on Latino equity issues so she sometimes bends over backwards too far.

Your are What You Eat Holds for Cows Too! NY Times Leslie Kaufman June 5, 2009 Methane output dropped 18% when fed plants like alfalfa and flaxseed--substance that, unlike corn or soy, mimic the spring grasses that the animals evolved long ago to eat. Corn fed cows need to be treated with hormones and antibiotics to keep them from getting sick. The cows are healthier and coats shinier. Methane has 20 times more global warming effects that carbon dioxide. Eat cow belches out 400 lbs of methane each year. 

President Obama Wrote Letter to Congress on Wednesday that He Strongly Favors a Public Insurance Option-- NY Times Robert Pear and John Harwood Fri June 5,2009

Physician Rethinks Healthcare System. Single Payer Our Only Choice Daily Kos June 4, 2009 http://www.dailykos.com/storyonly/2009/6/4/738944/-A-physician-comes-out. 

... How About Medicare as a model?

Medicare was a deeply flawed system from the get-go because the insurance companies were able to force their will on Congress to make Medicare greatly dependent on the insurance industry -- most people do not realize that even plain ol' fee-for-service Medicare is administered by private contractors, {updated: who have been given a great deal of latitude in interpreting and implementing the regs put forward by the Centers for Medicare and Medicaid Services (CMS). And because Medicare only covers 80%, that still gives the insurance companies a large role in selling supplemental insurance for the other 20%; insurance that a significant minority of seniors cannot afford. Patients without a supplemental policy are almost never denied care, and it's providers who are stuck covering the difference.} And of course, Medicare Advantage is simply managed care, except that for the insurance companies, it's EVEN MORE PROFITABLE -- in fact, under the current system, they are guaranteed huge profits, while providers are often in the red for every Medicare patient they see, and patients and their physicians have to put up with all the administrative burdens that are part and parcel of managed care.

There continues to be tremendous concern about the way Medicare is structured. Part A and Part B are financed entirely separately. Part A covers inpatient hospital care, and Part B covers outpatient care given by physicians, and has grown tremendously in recent years as outpatient care as taken over much of the care that formerly was done in hospitals. Yet, current law mandates budget neutrality for Part B (only), so that as the volume of care has grown, a very badly flawed formula called the Sustainable Growth Rate requires draconian cuts in physician reimbursement in the face of ever rising costs of providing care, causing an annual crisis in Medicare funding. Congress to date has refused to fix this, as it's become a useful political football, and there is much hand-wringing about where-oh-where the money would come from. So, we have annual emergency fixes. In fact, average reimbursement for regular Medicare is currently slated to by slashed by 20.5% in January, 2010. Congress will almost certainly not allow this to happen -- it would destroy Medicare almost over night. But needing an annual emergency fix for cuts based on an obsolete formula that everyone agrees is wrong, but nobody will fix, is an insane way to run a health care system. I mention this primarily to explain perhaps the foremost source of physician apprehension about single payer -- if Congress cannot even muster the political will to fix SGR, how in the world can we rely on Congress to come up with a single payer system that works? But ...

Stories: patients

There are untold numbers of stories. One I heard just this morning, from a construction supervisor who is doing some work for me. His former employer went out of business. He has tried to convert his previous plan -- offered by the dominant, integrated system in our state -- into a family insurance policy. But this hard-working laborer has had two compressed vertebrae. Not even a chronic illness! So? Presto -- he's uninsurable. When he questioned this, he was told, "Sorry, that's our policy."

Stories: physicians

Physicians and their employees spend inordinate amounts of time fighting with multiple insurance companies, each of which has myriad sets of rules that vary with different policies. It is absolutely impossible for physicians to keep all of the rules and restrictions straight, even with computerized records. And patients wind up paying the price, when their care is denied "because your doctor didn't prescribe an approved medication" or "your doctor forgot to get prior authorization". Even incredibly conscientious physicians who try their best, and who are willing to fight with insurers on their own time, can't keep up with this.

So, Single Payer?

Single payer health care might mean the death of private medicine in this country. It would likely mean that the clinic that my family member spent an entire professional career proudly building using loans that the clinic's physician partners took out on their own risk, would go out of business, because unless reimbursement rates were substantially increased above current Medicare rates, medical practices, even successful group practices, that are not owned by huge corporations or integrated systems that can take advantage of tax scams like those described above and preferential pricing only available to hospital owned practices -- will not be able to stay in business.

But you know what? Private, independent medicine is being slaughtered now. It's going extinct. And with its loss, an important part of what in the past made American medicine so vital, so personal and of such high quality will disappear, too.

That may be the price we have to pay. I have concluded that it's time to get private insurance out of the business of running and paying for health care, even if we were able to get every man, woman and child a health insurance policy, especially when insurance is used, as it often is now, as a way for huge corporations to gain a stranglehold on markets, and take all choice away from patients. Even if it means that many of my colleagues, including in my own family, wind up having to sell (probably at a substantial loss) what they've spent their lives building.

You see, while I understand capitalism, I also firmly believe that in an enlightened, wealthy society, we really have to do what does the most good for the most people. And if we believe that health care is a right and not a privilege, polishing the edges of a system that is rotten at the core will never get there.

I say this knowing that the overwhelming majority of physicians whom I represent at the AMA are vehemently opposed to the concept of single payer health care. Some of the opposition is not rational, but much of it is. If single payer were implemented poorly, it could turn our current system into something even worse.

Coming Out

So, I'm "coming out". I will say it: We need a true single-payer system in this country, but unlike Medicare, it has to done right. If it's done via insurance contractors, with all the control given to powerful hospitals and integrated systems, we will continue to have a disaster, perhaps worse than the one we have now, with the same disconnect in the marketplace that we have now between purchasers and users of health care and all of the upside-down incentives and rewards that have so perverted our current system.

We have to copy the very best of successful systems elsewhere. We have to make sure that physicians who have invested their careers and risked their own finances in developing practices are not destroyed. As a country, the last thing we an afford is to force physicians in their 50s into early retirement -- we already have severe shortages in many specialties and geographic areas, so a "tough shit" attitude about physicians is in NOBODY'S best interests. We need the input from the people who actually understand and provide health care in designing and running the system.

IF single payer were done right, the extinction scenario for practices not owned by huge conglomerates might not come to pass. In fact, it's possible that the opposite would be true. But that would take a huge amount of political will. More political will than we have ever seen to date from the likes of Harry Reid and Max Baucus.

I'm looking forward to the discussion I'm hoping this diary will generate -- especially from you physicians lurking out there.

* * * * * *

UPDATE (midnight MDT): I posted this diary right before going to dinner with two physicians I respect greatly -- the major topic of discussion was health system reform! -- and returned home to find this atop the Rec List. Thank you all for the incredibly gracious comments, and even more for the excellent discussion. I hope you'll forgive any comments of mine below that aren't as clear or as concise as they might be after two glasses of wine.  :-)

But most importantly, I really have a renewed sense of optimism that we can all work together to bring about meaningful reform.

I'll be attending the annual meeting of the AMA in Chicago that starts a week from now. I'm sure that health system reform will be topic #1 for the entire meeting. I'll be happy to provide updates.

And -- go get 'em nyceve!!

UPDATE (Friday morning) -- I must mention Paul Krugman's column today on health system reform, entitled Keeping Them Honest. Two guesses on who "Them" refers to:

... let me offer Congress two pieces of advice:

1. Don’t trust the insurance industry.
2. Don’t trust the insurance industry.

I can't think of a better possible way to close this diary.

• * * * * *