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“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Tuesday, September 22, 2009
    My Take on Healthcare Reform

    You knew it was coming.

    I don't really have the time or, at this point, the functioning thought processes to give you a heavily-researched, well-worded essay on the pros and cons of government health care. I'll just give you a few points that have occurred to me as a primary care physician. When it comes, and I have no doubt it will, a government funded health care program will fail unless a few points are straightened out first.

    Before such a program is implemented we need more primary care doctors. There is a huge shortage of primary care providers in this country. There are a lot of reasons for that; compared to the specialties primary care is poorly reimbursed and involves much longer hours. We also get most of the scutwork - jury duty excuses, disability paperwork and Pay for Performance. This last issue is huge, but that's something for another post. The reason I say we need more docs in primary care is that in order for a huge unwieldy national program to work it has to be implemented at ground level. We are ground level.

    Medicare has a big problem, and that problem is that no one doctor is in charge of the patient. In other words, it isn't uncommon for me to see patients who float from doctor to doctor, go off to see specialists, get tests and get their meds changed, and then turn up on my doorstep completely unable to tell me what type of test they had done or what the specialist's take on it was. Now, many times the patient does have a PMD, who does call the shots and is aware of everything, and that's great. But too often that is not the case. Before instituting a national plan I think the federal government should run Medicare more like an HMO, in that every patient needs to get a PMD to coordinate workups and testing.

    Another problem with Medicare is that the government is slashing reimbursements to doctors and has been doing so for years. This means that a lot of doctors are now no longer accepting Medicare. These patients either need to pay cash, have a fallback private insurance plan or find a doctor or clinic who will agree to see them. This problem is not going away any time soon, and no proposal of which I am aware has addressed this issue, either.

    Another issue is that there has to be tort reform. That could mean malpractice capping, or it might mean mandated arbitration. Did you ever wonder how Kaiser keeps its rates so low, or how the VA program holds its costs down? The answer, my friend, is arbitration. Before suing you must go through meetings in which both sides try to reach a compromise. I'm not claiming it's perfect or the best way to go, but I am saying that in order for the President to even come close to meeting his wild claim that a national health program wouldn't cost the country any additional money, something has to be done about runaway malpractice rates.

    People will need to get used to waiting and being told "no." There's going to have to be a huge cultural change in the U.S. before the public will be happy with national health care. What do I mean by that? I'll give you a few examples. I have a British friend who lives in Brighton, but grew up in Nottingham. When she first moved to Brighton she couldn't find a doctor to take her, as all the medical practices were full. Yes, full. For over a year, if she needed to see the doctor, she had to travel to her MD in Nottingham. In case you are wondering, the two cities are 150 miles apart. She told me this story as though it were nothing unusual, and I'm sure it wasn't. The big, dirty secret about nationalized health coverage is this: just because you have insurance, it doesn't mean you'll get a doctor. As I said above, if there aren't enough docs to go around, the situation hasn't improved. Also, I accompanied her to her doctor's office the day she had an appointment for a Pap. Five minutes later she was back in the waiting room. You aren't going to have a chance to spend time with your doctor or to get many questions answered, if this is anything to go by.

    "But what about physicians' assistants or nurse practitioners?" you might ask. "Can't they handle basic health care?" Yes, they can; but NPs and PAs are nobody's fools, either. Most of them get specialty jobs too. They work with plastic surgeons or orthopedic surgeons, or in outpatient oncology programs (most of my aunt's care is coming from NPs and PAs right now; she sees an MD only once a week). That means you're still SOL when it comes to finding a primary care provider, MD or otherwise.

    Let's talk about wait lists for other stuff. Mammograms, for instance. The reimbursement for mammograms is minimal and it comes with a high malpractice risk. This means there's a shortage of radiologists who are willing to read them and there's a shortage of facilities providing them. When every woman in America over the age of 40 gets insurance and runs to the phone to schedule a mammogram, what do you think is going to happen? You got it. Say hello to six month waits for mammograms.

    None of this is to say that people shouldn't have access to insurance, or that coverage should be predicated on their having a job. It shouldn't. And insurance companies should not be allowed to deny policy coverage to someone with diabetes or other chronic illness who's trying to buy a plan. I don't have a suggestion for a workable national insurance plan, though I wish I did. I'm just pointing out that it isn't going to be all rainbows and unicorns once everyone has insurance.

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