Specialist Q&A
Friday, July 24 2009
So, then, what ought to be the last post from “Putting Patients First“: the specialist panel’s Q&A.
Ms. Blakey began in a manner similar to her questions for the primary care panel: ‘Any comments regarding the speakers – anything for the blog?’ Dr. Wes asked why Congress is not reading this bill (which has a pretty simple answer: they hardly ever read big bills at this point in the process. If you have six hours to kill, ask my mom the banking lawyer about Congress’s reading of the USA PATRIOT Act). Dr. Herndon asked why Congress was not listening to the CBO about cost expansion (presumably in reference to Doug Elmendorf’s recent statements). Dr. Rich said that the most disturbing thing is that Congress is allowing itself to be irrelevant, and that he doesn’t see the representatives doing their jobs. Kim said that she no longer felt so bad about her ‘head spinning’.
Ms. Blakey asked, what about government-run health care? Kim responded that overt rationing is transparent. If overt rationing is going to happen, it has to be transparent. Kim explained that she talked to Anthem/Blue Cross, and they won’t cover insulin-dependent diabetes at all; that’s a form of rationing, and the American people won’t stand for it, and won’t allow it to get to the same point it is in Canada. Dr. Rich agreed that the mentality is different in the US. He pointed out (contra Robert Goldberg’s horror flick) that 70 to 80% of Canadians like their system. He said ‘the rest die anyway and don’t get to vote’. But, said Dr. Rich, the US is already dangerously close to attitude of the European countries. Dr. Herndon added that Americans think health care is a right, and are not willing to pay for it (able and willing are two different problems, my friend). Dr. Wes said it was time to “go red” – doctors have their patients’ ears, which scares the hell of out Congress. Dr. Wes said doctors should mobilize their patients, get them to call Congress at a grass-roots level.
Ms. Blakey then asked, ‘of the public plan reimbursed at Medicare rates, would that discourage doctors from practicing medicine?’ Dr. Rich said yes – that having 70-80% Medicare patients in your practice means you are going broke. Doctors will retire or doing something else. Dr. Herndon pointed out that Medicaid pays even less. Ms. Blakey remarked that ‘patients really end up at the bottom of the totem pole’. Kim replied that nurses would have the same problem, including nurse practitioners. Dr. Rich also pointed out that Medicare rules mean it takes enormous effort to avoid a ‘fraud rap; the regulations are fundamentally indeterminate, and shedding that burden is a huge advantage for providers who don’t accept Medicare. (I don’t doubt this for a moment.)
Ms. Blakey then asked for one or two things that would radically change health care? Dr. Herndon suggested a single insurance form. Dr. Rich said that PCPs need to drop off the grid, and offer care for money. This will help create awareness of doctor/patient privilege. Dr. Herndon pointed out that in Massachusetts, doctors must participate in Medicare to get a a license (the people of Massachusetts are no doubt victims of the archaic notion that being granted a license to practice medicine comes with some duty or obligation to society.) Dr. Rich asked whether our laws will allow patients to spend their own money on health care, and said he would not be surprised if the bill would be interpreted as requiring single-payer. (I’m not sure exactly who was doing the interpreting in his statement; the courts, or the GOP? It’s not surprising that the Hebrew Bible is interpreted as requiring the Roman Catholic Church, but I think we have to admit that’s not what the authors had in mind.)
The next questions came from the audience. ‘Do you feel health care is a privilege or a right? How would you ensure Americans get equal access?’ Dr. Herndon said he believes health care is a right, but that the question can’t be resolved before August 8th. Kim said that health care is just; it’s just that we all have access to an equitable system. (In this, I totally agree with Kim. I think this is perfect statement of principle where it comes to health care. Our disagreement, I think, is in the implications and consequences of this principle.) Dr. Rich allowed that while he is fairly libertarian and fairly conservative, he does think health care is a right – because we are all paying for it. As a Medicare recipient, Dr. Rich’s health care is subsidized by everyone. Since we’re paying for his, he feels we ought to have access to our own health care. Dr. Wes said that physicians have a moral obligation to serve every patient who comes to them. He said that he has worked in government health care (in the Navy), and he knows it can work. But there is a very different mindset in the government, and doctors are not incentivized. Government health care can work, just not efficiently or quickly. As for rights, Dr. Wes said he would prefer not to get into that. Doctors have an obligation. (This question, in my view, showed each the panelists at their very best. No other question in this panel was as connected to the theme of the event – ‘patients’. It was worth the whole morning to hear them talk through this one question.)
Then we got another question from the LaRouche crew, tying the Holocaust to with government-run health care. The panelists were abruptly dismissive of the question, and good for them. (The weird thing, is the LaRouche person felt like she was helping them – like they were all on the same side.)
Finally, Lisa asked her question, pointing out the extraordinary costs of her health care over the last year, and asking what the panel was offering for patients like her. Kim suggested that Lisa be given $1000 that the insurance companies then have to compete over.
Kim’s answer, in my view, was an optimistic and inadequate response. Lisa’s bills tabbed out at something like $50,000. No insurance company is going to compete over a $49,000 loss – except to see who can unload Lisa the fastest. I’m paying more than $5,000 a year for my health insurance; nobody wants my business. The whole problem with making insurers compete is that they will inevitably compete for the healthiest customers, and the sickest people will get the shaft. And nobody had a clear solution for that problem, apart from some kind of government program. Kim, Lisa, and I had a nice chat about this after the event ended.
Once again, I think the panelists ended up pushing back against the right-ward bias of the event. They made clear that some of the things that conservative politicians warn are signs of the apocalypse – like CER – are, in fact, sensible and reasonable ideas. That is evidence enough to me that they are thinking about these things, and not just parroting talking points. Much as we might disagree, there’s still the possibility here for a real and constructive conversation about health care reform. Whatever else it accomplished, “Putting Patients First” was not a substitute for that conversation – which is too bad, because it could have been.
Duncan, if this post doesn’t come through, would you please post it for me?
I saw Lisa’s post at her site and I completely agree.
I have rheumatoid arthritis. Used to have a good job with better, but not great, coverage and they were already moving to the high deductible plans as a choice, but it wasn’t one for me with a chronic condition. However the drug coverage was getting worse and worse. Had to quit that job and now have a crummy job. Had to wait a year to become eligible for insurance, only to find that I now would have to wait another 2nd year to have my RA covered because it was considered pre-existing since I couldn’t afford the COBRA coverage and had paid for my (severely cut back) treatment out of pocket. However, when I do get covered for it, the drug plan is even worse, and I’m scared to find out how bad the medical part will be. I make barely over minimum wage now and I won’t be able to afford even my traditional dmard under the new plan structure, much less afford to take the time off for needed surgery, or to afford my share of that either I’m afraid. I’m not happy with what I’ve got now, but I don’t know that anything under reform will even meet this current substandard. It’s unaffordable under either.
No one is really addressing all of us with chronic conditions and how to keep our costs down. They are not dealing with the high cost of even basic blood tests for monitoring (much less imaging or other technical monitoring), and definitely not of prescription drugs. And I take the crummy old, on-the-market-for-decades DMARDs and corticosteroids and NSAIDs. These are generics. They are not dealing with the cost of generics for seniors on Part D plans either, as we have problems trying to pay for my mother’s generics on her limited income also. These are outrageous costs that should not be so high as to eat folks out of house and home and utilities just to cover. I’m not a fan of Happy Hospitalist, but maybe some kind of bundling of fees for care, which could include drugs and monitoring tests for various conditions, might be in order. They need to revamp the payment structure and to be able to negotiate pharm costs way down. We honestly cannot afford to keep the fat profits that every player in the health care field seems to get at the expense of most docs and all patients.
Chelsea – thanks for your comments. I have similar concerns myself. I don’t think the reform bills currently in Congress are going to meet all your needs, but I do think they do two important things. First, the public option plus the generous subsidies should put a solid health insurance policy within your reach, and not dependent on your job. The downside is, those of us with insurance through your job might not be able to get into the public plan. Second, comparative effectiveness research is absolutely necessary, not just to rein in costs, but to make sure that sick people are getting better medicines as opposed to more expensive medicines. I think both of these steps, implemented properly, will help folks like us a lot. It won’t be perfect – just much better.
You are absolutely right in the conclusions that you have drawn. The problem is not those who are healthy and choose not to get insurance. While I believe that everyone should have insurance as illness is a step away from health I guess people are free to make bad choices.
My concern and the one that others have is what happens to those who have been ill and are unable to get decent coverage? The cost is exhorbitant and the coverage mediocre. No one wants to “compete” to cover those with chronic illness.
The rest of the world can cover their citizens, what stops us?