Saturday, October 3, 2009

Health Care Reform - An Educated Response

This article is well worth the time it takes to read it. I only wish our Congress would do so.

Gerald E. Harmon, MD, FAAFP: Health care reform

Congress and the Administration consider and pass hundreds of pieces of legislation and rulings annually and it is intriguing to note what captures the most attention of the media and the electorate.

We are quite used to our political leaders addressing international relations, national defense, etc., but we always pay the most attention when the legislators discuss very personal issues such as changes in taxes, changing and expanding the role of the federal government, or changes in health care.

Health care reform actually covers all these issues -- it affects our taxes, it potentially greatly expands the role of the federal government, and it sure is very personal.

So no surprise that everyone gets nervous and quite interested in Congress as they consider changing the system. And the need to change the system is undeniable -- the current course is not sustainable financially.

The real problem before America right now is how much of the system to change immediately (if any) and how much change needs to be incremental with significant discussion and debate and a realization of the short and long-term effects of our actions.

If there were enough resources/money available to cover our needs and commitments we would not be having the current debate.

However, we have a "perfect storm" of conditions moving us inexorable to reconfigure the health care industry in America.

We have an aging population demographic, a marked reduction in the primary care infrastructure of our system, an epidemic of unhealthy lifestyles highlighted by obesity and inactivity, and what can only be described as overconsumption if not exploitation of existing health care funding.

If those storm conditions were not bad enough consider that we find ourselves in a huge economic downturn so our resources are even more strained with an increased demand for capacity that does not exist.

What can we do quickly now and more deliberately later? There are some pretty straightforward answers that have been studied and proposed by smart people for many years and I think they deserve serious attention.

Even using the most favorable budget numbers from the Congressional Budget Office the leading proposals from Congress (HR 3200 and the Senate Finance Committee wording) increase the tax burden on Americans by almost $1 trillion-this change itself is unsustainable and cannot be seriously supported by our voters.

Let's take smaller bites at this apple and work at a viable solution over time.

For instance, it may be a "bridge too far" to attempt to provide universal coverage for all uninsured citizens -- many of the 47 million number that are frequently quoted as being uninsured would remain without viable health care funding under almost any legislative proposal now before Congress and yet the expenditures would be hundreds of billions of dollars for little gain.

We can, however, provide advanceable, refundable tax credits to families and individuals who meet economic criteria such as 400 percent of the Federal Poverty Level, and allow those credits to be used to purchase health care coverage.

Estimates are that we could reduce the numbers of uninsured by as much as 20 percent using this straightforward method and yet the overall impact on taxpayer obligation would be minimal.

We must face the fact that expanding health insurance for folks will not necessarily increase access to care.

Our nation has allowed our Primary Care safety net (family physicians, internists, pediatricians, obstetricians, etc.) to suffer marked reductions in staffing and we find ourselves critically short of those professionals.

Massachusetts many years ago expanded health care coverage to all its citizens and found the state unable to provide even minimal primary care for those newly covered.

Many of the bills currently in Congress pay lip service to more primary care doctors but really offer no meaningful resourcing to achieving the goal, instead using nondescript terminology such as "quality improvement" and "pay for performance" to indicate that providers can be enticed to enter primary care fields with the expectation of higher rewards somewhere down the line of government funding.

Furthermore, we can make health care insurance more affordable if we allow transparency in policy pricing and coverage across state lines and allow high risk pools that provide coverage for pre-existing conditions to be formed nationally-this has been done in 35 states successfully with funding for the pools from multiple sources, including fees on insurance providers and agencies that market in the states.

And if we allow federal anti-trust relief then health care providers such as physicians and hospitals can openly market their prices to the consumers and the health insurance companies and allow free market pressures to drive many prices down.

Currently, it is against federal law for individual doctors, practices, or hospitals to have even informal discussions about fees so there is little change of competition for market share or reduction in costs to the consumer.

And although many in Congress and the President have openly spoken against true Medical Liability Reform it cannot be denied that a large amount of our health care resources are devoted to what we call "defensive medicine" where testing and investigation and even some treatment is driven by the fear of litigation rather than by a clearly defined benefit for the patient.

Existing federal law mandates medical care and evaluation for patients who present to our nation's emergency rooms yet it does not resource that care nor does it provide any liability relief for any subsequent allegations of bad medicine or even unpreventable bad outcomes in an imperfect system.

Some reasonable estimates of the cost of such truly unnecessary medical care run as high as 180 billion dollars annually.

Even if we saved only half of that amount we would realize a savings of 900 billion dollars over the next decade if we considered real liability reform efforts such as medical courts, loser pays, etc.

Eventually we can enact some of the more far-reaching ideas contained in the draft legislation from Congress and the Senate-such things as mandated Electronic Medical Records, as Comparative Effectiveness Research, and rewards for health lifestyles and preventive medicine.

And we certainly need to address strategies to strengthen the existing Medicare program including the Hospital Insurance Trust Fund and the Supplementary Medical Trust Funds that resource Medicare A (hospital inpatient) and Medicare B and D (doctor and outpatient charges, durable medical equipment, and pharmacy) commitments respectively.

All of the considerations outlined here have been touched upon in some form at town hall meetings, in editorials of leading newspapers, and in many Congressional hearings and committees.

The current health care "crisis" did not occur over a short period of time but rather over decades and the crisis deserves a measured attempt at management and reconciliation, not a hastily configured attempt at a long-term fix such as currently proposed by the Senate Finance Committee (that chaired by Senator Baucus) or by the 1000+ page House legislation known as HR 3200.

Let us take an incremental approach that will not markedly expand the role of the federal government and that will reduce health care expenditures in the short term while establishing qualified studies and commissions/committees to seriously address long term solutions bereft of traditional partisan politics that serve only those currently in power.

My patients -- my American colleagues and taxpayers-- deserve such a measured and thoughtful approach.

Let us not allow the mantra of "never let a crisis go to waste" to force bad legislation upon us.

Gerald E. Harmon, MD, FAAFP, Pawleys Island

Past President, SC Medical Association

Member, Council on Medic

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