A health system in dire need of reform

By Robert S. Kiefner, M.D.
Concord (N.H.) Monitor, Aug. 23, 2015

Through some mutation of American exceptionalism, we have come to believe that by spending more per capita on health care than any other country on Earth, we must surely enjoy the best health on the planet. Not so, not by a long shot.

The Affordable Care Act notwithstanding, the number of uninsured and underinsured in this country is still too high, accounting for thousands of preventable deaths each year. Also, more than 60 percent of personal bankruptcies are tied to uncovered medical expenses.

The cost curve has not been broken. In the health care barnyard, there are way too many piglets and not enough teats. The health insurance companies, plump from the ACA, are increasing premiums, co-pays and deductibles. The insurance industry has been calling the shots for years.

In an effort to offset future challenges to their oligarchies, they are pairing off in a frenzy of corporate promiscuity. Aetna is buying Humana, and Anthem is shelling out your premium dollars for Cigna. One can only hope that the Justice Department will pay close attention.

History has shown us that mergers, including insurance companies and hospital systems, have an annoying tendency toward increasing costs while decreasing access and patient choice. Physicians and their patients, pawns on the chessboard, may be forced to terminate longstanding relationships as mergers arbitrarily create new networks and dismantle others.

The for-profit insurance model is just plain wrong. Physicians and patients are too often befuddled and belittled by insurance companies in their pursuit of coverage for reasonable medical care. Even the smartest and most savvy among us have been beaten into submission by circuitous phone trees whose purpose is clear – abandon the effort to challenge the insurer or submit to exasperating appeals processes while your account goes to collections and your credit drops like a stone.

Big Pharma clearly has its sights on profit, not patients. It is one thing to spend billions of dollars for research on novel, lifesaving drugs. It is quite another to acquire rights to manufacture all forms of established generic drugs (such as colchicine for gout and doxycycline for infections), and to increase the cost tenfold overnight. New cancer drugs and new drugs for hepatitis C would seem to offer a breath of hope for cancer patients and those facing the uncertain prognosis of hepatitis C, until that breath is taken away by price tags in excess of $100,000 per year. Drug companies engage in this sort of behavior, well, because they can. Your money or your life indeed.

Pharmaceutical giants spend untold billions on direct-to-consumer advertising, imploring us to hound our doctors to prescribe some overpriced, marginally effective drug. Meanwhile, in the ultimate corporate welfare program, the government still cannot negotiate with drugs companies for reduced drug costs within Medicare Part D.

The health care free-for-all has led many physicians to misplace their copies of the Hippocratic Oath, which they so earnestly recited upon graduation from medical school. The changing economic landscape, combined with loss of autonomy, has too often led physicians to advocate on behalf of their corporate overlords instead of their patients.

How about a wag of the finger at our tort system?

Practicing physicians are haunted by the specter of a career-ending malpractice suit, ordering billions of dollars worth of unnecessary tests each year. In the world of “defensive medicine,” tests tend to beget more tests, adding to expense and the real potential for harm. Moreover, our tort system is an inefficient way of compensating patients who are harmed by the health care system.

Other players feeding at the health care trough include the vendors of electronic medical records. While a basic EMR can be of immense value to a clinician as a repository for information, the maintenance of an EMR requires substantial ongoing investments of time, money and personnel. EMRs have their origins as billing tools, and are too often crammed with details that do not pertain to care of the patient. Despite their high costs, different EMRs often cannot “talk” to each other, such that transmission of data is still at the mercy of a fickle fax machine and harried staff. To ensure that profits keep rolling in, the spending cycle for EMRs is just a few years, keeping providers and patients paying through the nose in the world of planned obsolescence of hardware and software.

Health care delivery has become, by intent, so complex that it has spawned a whole new cohort of health care policy experts and high level administrators, who project themselves as the only ones who can interpret the chaos, which they have conveniently created. This group includes architects of the ACA and an army of congressional lobbyists.

A friend of mine who works for the government within the Beltway reminds me that our nation is not held hostage by big government so much as big business, which runs big government for its benefit. Nowhere is this observation more salient than in the world of for-profit health care.

For real reform to occur, much advance work needs to be done.

First, we need to decide whether health care is a right or a privilege. If we choose the latter, forget about reform and continue with a profit-driven death spiral until we spend ourselves into oblivion. Should we embrace the notion that health care is a right for all Americans, the road to reform must first pass through campaign finance reform, repeal of Citizens United and dramatic reduction in congressional lobbyists. Our elected representatives need to work for us, not their biggest contributors.

We can build a not-for-profit system of health care that is publicly financed but privately delivered. Medicare should be improved, and applied to all (as in H.R. 676 currently before Congress). Overhead among the insurers is 20 to 30 percent, while Medicare overhead runs just 2 percent. No big-time advertising, shareholder profits, exorbitant CEO salaries. Just innovative, cost-effective, evidence-based, personal care.

We need to realign the health provider workforce to emphasize robust primary care, wherein primary care providers and their designated teams take care of their patients to the full limits of their training and expertise.

No mode of health delivery is perfect, but other countries are taking care of their citizens with better outcomes, improved patient satisfaction and lower costs with single-payer systems. Where there is a nonpartisan political will, there will be a way.

Robert S. Kiefner is a family physician and lives in Concord.