Posted on November 6, 2009

ER doctor analyzes health reform debate


By Dr. Michael T. Rey
Asheville (N.C.) Citizen-Times
Oct. 23, 2009

This country needs radical reform to fix a health care system that currently encourages poor-quality medical care and costs too much. A universal single-payer system would put the focus back on patient care, where it belongs, and reduce costs.

In my 30 years as an emergency room physician, I have seen the quality of patient care plummet as a result of a lopsided reimbursement system. Family physicians and general internists cannot make a living providing basic health care unless they cram more patients into every hour, spending less time with each. Other doctors can make a very good living if they are “procedural specialists” (doctors who treat a few medical problems, in a limited anatomic area, and do so using a diagnostic or therapeutic tool).

This happens, in part, because billing codes favor “doing” over listening, talking and thinking, even when the “doing” has no proven medical benefit. An example is the “vertebroplasty” procedure that has proliferated recently, in which a physician injects glue into a patient’s spine to bond vertebral compression fractures. A Mayo Clinic study published in the New England Journal of Medicine questioned whether vertebroplasty works, yet this lucrative procedure, performed by orthopedic subspecialists, attracts more and more doctors, while the number of general orthopedists, surgeons, internists, and family practitioners declines.

Third-party payers (health insurance companies, preferred provider organizations and HMOs) have tried to improve efficiency and increase profits by controlling the behavior of doctors and nurses, rather than by reducing paperwork and redundant documentation. Thus, under the current system, doctors focus on producing patient records that are designed less to document important clinical events or enhance patient care, and more to maximize revenue and reduce liability. Nurses spend less time at patient bedsides and more time at computer workstations. Medical conferences now allocate large blocks of time to coding and billing strategies.

Each insurance company has its own forms, fee schedules and documentation requirements, resulting in wasteful duplication of effort. Out of every health care dollar, a cut must go to the transcription service, the company that assigns billing codes and makes sure the physician’s documentation supports the codes, and collection services. Hospitals hire less clinical staff (nurses and medical technicians) and more clerical staff (billing, coding, and insurance collections experts). Entire floors of hospitals are devoted to appeasing the administrative requirements of hundreds of third-party payers.
Forcing doctors and nurses to focus more attention on record-keeping, coding and reimbursement does not promote good patient care, and is not cost-efficient. A single-payer, public plan would eliminate wasteful administrative requirements and ensure that economic factors unrelated to patient care no longer drive health care decisions. Physicians and nurses should do what they do best and continue putting the needs of the patient above shareholder and institutional interests. We can afford quality health care but only if we eliminate the middlemen.

The need for universal care is undisputed — our nation already acknowledges that no one should suffer pain, disability or death as a result of being unable to provide proof of ability to pay. The federal Emergency Medical Treatment And Labor , passed in 1986, requires all hospitals and ambulance services to provide care to anyone needing treatment.
Having acknowledged the principle that everyone is entitled to care, we should now fund that care. Like automobile insurance, health insurance must be required, available and affordable for everyone.

Some opponents of health care reform argue that taxpayers will have to pay too much for a single-payer public plan or see it as a “government takeover.” They forget that most health insurance is already government insurance. Medicare and Medicaid payments provide more than half of the average hospital’s revenues. Few of those who heckle the president at town hall meetings will refuse Medicare insurance when they turn 65.

Our nation can no longer afford to accept the propaganda of third-party payers, who claim that a free-market model is appropriate for health care. Their free-market model has resulted in a slow but unrelenting decline in the quality of medical care.

Dr. Michael T. Rey lives in Waynesville. He is a board-certified emergency physician and fellow of the American College of Emergency Physicians. He has practiced in Western North Carolina for 27 years.