The Conundrum of Health Insurance

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability—taken from the Hippocratic Oath.

When the Obama administration began pushing for the passage of the Affordable Care Act (ACA), the claim was made that the Act would make health care better and more affordable for everyone. Since health care costs are now responsible for about 17.8 percent of the Gross Domestic Product (GDP), the goal of decreasing costs makes sense. However, the claim that increasing the number of people covered by third party payers would lead to a decrease in costs was difficult to understand.

It is obvious that something has to be done to reign in the cost of health care in America. Health care costs were $3.2 trillion in 2015. This comes out to about $9,990 per person in the country. Despite the implementation of the ACA, the percent of GDP paid for health care has actually gone up; it was 17.4% of GDP in 2014.

Under free-market principles, costs will depend on what people will be willing to pay for a product that they desire. If the costs for health care are paid by someone else, it is reasonable to assume that market principles may not apply. If someone gets sick, they will want their doctor to do whatever is necessary, or not, to get them well. With this model, the only ways to decrease costs are to pay less to those that are providing the health care service, or restrict what will be paid for on the front end.

Unfortunately, health care has been mostly a fee-for-service model since the mid 1960’s. By doing more, the physicians were paid more. It has been estimated that one third of the procedures and one third of the tests were unnecessary; eliminating the incentives to doing tests and procedures will lead to significant cost reductions.

One of the most significant consequences of the ACA is that it forced more physicians out of private practice and into the employment of hospitals and clinics. As salaried employees, they are less likely to order unnecessary tests or do unnecessary procedures since their income will no longer depend on what they do; unless their contract has incentives for doing more and ordering more.

To contain costs, it would be a good idea to prevent the employer from coercing the provider to do more procedures and order more tests by tying remuneration to services billed. I’ll bet Congress can do that under its Commerce Clause powers. They could easily do this by capping payments based on the disease entities being treated. This would incentivise the providers to follow best practices and even look for better ways to care for chronic conditions in hopes of keeping the patient out of the hospital where costs are high.

A return to free-market principles also makes sense for the purchase of health care insurance. Letting people shop for the coverage they need for their family, without artificial goverment requirements for coverage that will never be used by that particular buyer, will lead to a decrease costs for the insurance and make it more likely that more people will be covered. Even young and healthy people should be willing to buy coverage for the possibility of a devastating injury or early onset cancer so long as the premiums are reasonable. After all, most people are willing to buy other forms of insurance such as auto, homeowners, and life even though they are unlikely to ever get a payout.

Patients with pre-existing conditions may have to pay more so there may need to be some premium support from the government. No one should ever be denied coverage no matter what their pre-existing condition is; this part of the ACA should be kept no matter what the new plan is.

Allowing people to buy insurance across state lines and keep insurance when they change jobs would also lead to a decrease in premiums and deductibles which would increase the number of people buying the health insurance.

Even with the return of free-market principles in the health insurance market, there will still be some patients, not covered by Medicare and Medicaid, who will still not buy insurance. However, these patients will still need to be given care if needed. After all, this is America!

For people who are not covered by Medicaid or Medicare and who do not have their own health insurance policy, there are safeguards already in place to make sure that they will be cared for in an emergency. Under the Emergency Medical Treatment and Active Labor Act, anyone presenting to a hospital that takes Medicare must be given an emergency screening exam and if that exam reveals an emergency medical condition, stabilizing treatment. By the time the patient is stabilized, the physician-patient duty will have been established so that further care must be provided under the State’s laws dealing with medical malpractice and the requirements of the various licensing bodies and specialty boards. Patients without coverage will be responsible for the costs, but it is unlikely that hospitals and providers will ever be paid.

Let’s not forget that most physicians in America who have graduated from American medical schools, have taken the Hippocratic Oath. Under this oath, they have sworn to do no harm and to take care of people regardless of their ability to pay. The physicians I know take this oath very seriously—I actually have a copy of the oath (written in the original Greek language) hanging on my office wall.

Couple the increase in people with third party payers along with requirements placed on the health care providers, the foundation has been set to decrease payments for health care itself. The added requirements of electronic health records (EHR), complex forms for billing—which led to the necessity of hiring knowledgeable coders, and the increasing complexity of health care laws relating to fraud, privacy, and proper documentation, all made it more difficult for the health care providers to maintain their incomes. It is now estimated that physicians spend 50 percent of their time filling out forms for billing and for performance measures which are required under the law. There must be some relief for the providers who are being squeezed from both ends or we are heading towards a perfect storm where we will not have enough health care providers to care for the ever increasing influx of patients.

For the people now on Medicare and Medicaid, let them keep that coverage but increase the number of providers willing to take care of those patients by allowing for tax write-offs for the cost of care not covered by the Medicare and Medicaid payments. Write-offs should also be allowed for patients without any coverage. Allowing for these write-offs will likely make the care less costly as the providers would be more willing to compete for these patients. There will need to be a bureaurocracy in place to adjudicate any discrepancy in the costs claimed and the write-offs allowed, but these discrepancies should decrease as more data on costs accrues over time.

Another way to help decrease the costs associated with health care is to require that those writing the laws be subject to the same laws they are requiring for everyone else. Since we are a nation of laws where everyone is supposed to be equal under the laws, this should already be in effect; for some reason that I have never understood, this is just not the way it is.

by Darryl S. Weiman, M.D., J.D.

Professor, Cardiothoracic Surgery, University of Tennessee Health Science Center and Chief of Surgery, VAMC Memphis, TN

MORE ABOUT THE AUTHOR: Darryl Weiman is a featured expert in on February 17, 2016. 

Trauma On the Highway

“Listen to him. He’s a surgeon!”

Two quick statements and the chain of command was established.

I had been out of medical school for over thirty years and was a practicing surgeon at the attending level for twenty-five and yet, I had never had the “opportunity” to deal with an emergency outside of my hospitals or office until that night.

My wife and youngest daughter were with me in the car as we drove down the interstate on our way home from shopping. It was early in the evening but it was already dark. Traffic was moving briskly as it was well past the rush hour. Even though the speed limit was 65, most of the cars, including mine, were cruising along at about 70.

A dark object passed me on the right and by its lights I could tell it was a motorcycle. The outline of the rider dressed in black from helmet to boots could be seen as he weaved in and out through the traffic as if we were stationary obstacles in a course.

“What an idiot,” Kathleen said as she also glimpsed him as he zoomed by. I was a little less judgmental, “At least he’s dressed right for his activity.”

Our conversation stopped as traffic was picking up; in the darkness I am not as comfortable as I once was in driving on the highway at those speeds. My daughter, Millie, listened to her IPOD. About a mile up the road, I noticed that things were changing rapidly.

Red brake lights were coming on and progressing back towards us like a slow wave. In anticipation, I took my foot off of the gas and slowed down. Several cars were now pulling off to the left into the emergency lane and, as I passed them, I noticed debris on the road. Several of the cars were damaged. As I crawled by, it looked like a chain reaction fender-bender with three cars now lined up off the road with what appeared to be minor, although undoubtedly expensive damage.

Ahead, cars were coming to a complete stop. In my lane, cars were pulling to the right emergency lane and progressing slowly.

Shortly thereafter, we saw the problem.

The motorcycle was sprawled on the highway, separated from its jockey by about thirty yards. A small crowd was gathering around the driver and it appeared that they were trying to help him so that he could walk off and get out of traffic.

“I’m getting out!” exclaimed Kathleen. “They’re going to kill that guy!”

My stomach turned as she opened the door and jumped from my slow moving SUV. I was sure that some car behind us would not slow down and would wipe out my wife and several of the other bystanders.

I inched my car up to the crowd. I was hoping to act as a shield so as to protect my wife and the crowd as well as use my headlights so that we could better see what was going on.

“Millie,” I said, “I want you to lock all the doors after I get out. Don’t leave the car and I’ll be right up ahead if you need me for anything.”

I got out of the car, thus shedding my steel cocoon. Now I, too, was at risk. My daughter, obviously frightened, followed my orders.

Kathleen was rapidly gaining control of the situation. The injured rider was now back on the ground; Kathleen was applying traction to his head to try to prevent a severe cord injury which could occur if the neck was broken. She was also controlling a scalp laceration—which, by the amount of blood on the pavement—had been bleeding briskly.

As I did a primary exam, I was relieved to find that he was breathing well on his own. He had a pulse and he was alert enough to answer some questions. “What’s your name? How old are you? Where does it hurt? Do you have any allergies or medical conditions we need to know about?”

His head and left arm were hurting him.

My physical exam was inadequate, but it was the best I could do in light of no stethoscope and only the illumination provided from cars stopped behind us.

Two other samaritans joined us. They were nurses. I told them I was a surgeon. They had some rubber gloves which I put on. Unfortunately, it was too late for my wife whose hands and clothes were already soiled from her efforts to control the bleeding from the scalp.

A firetruck arrived and the captain directed it to pull up perpendicular to traffic right behind my car whose light we were still dependent on. Two ambulances came next. I directed the paramedics to immobilize the neck and back and splint the left arm. These guys were pros. They recognized that Kathleen and I knew what we were doing and they followed our directions. Within ten minutes of their arrival, the victim, now a patient, was bundled and ready for transport.

The police arrived and were re-directing traffic off of the interstate. They took our statements and started their investigation. With several damaged cars and a destroyed motorcycle, they had a lot of work ahead of them.

The nurses had chlorox wipes and Kathleen was doing her best to get cleaned up. We went back to our car where Millie let us in. Even in the dim light we could see that she was shaken.This was my sensitive child who epitomizes the saying that “still waters run deep.” It would be a while for her to absorb and reconcile the events of the evening.

The next morning, I made rounds at the trauma center and learned that the patient had started to seize shortly after arrival the night before. A CT scan showed a rupture of the frontal sinus into the front of the brain. He was now in the operating room undergoing a crainiotomy to repair the damage. He was destined to make a full recovery.

That night Millie wanted to talk; it was as if she was trying to come to grips with the facts that her parents were not strangers to dealing with life-threatening emergencies. On the one hand, she was in awe that we could deal with massive trauma and save a life, but, on the other hand, she was upset as the stress of the situation was overwhelming for her twelve-year-old self.

Millie was used to us being assertive, “bossy” if you will, within the confines of our family.

“Do your homework! Get off the computer. Turn off the IPOD. No TV!” These were the orders she was used to hearing and, rarely, were they obeyed on the first request. To have her parents actively take over a highway trauma scene with the police, paramedics, and firemen on site, and the people involved deferring to the commands of her parents was, at least eye opening, and perhaps, life-changing.

Millie is still Millie, but the incident led to some changes. She listens to us more closely and she is less likely to ignore us as we advise, request, order, and cajole. She knows we are her parents, but she now realizes that we are, perhaps, something more.

by Darryl S. Weiman, M.D., J.D.

Professor, Cardiothoracic Surgery, University of Tennessee Health Science Center and Chief of Surgery, VAMC Memphis, TN

MORE ABOUT THE AUTHOR: Darryl Weiman is a featured expert in on February 17, 2016.