Health Care--Who Controls Your Choices?

Who makes your health care choices--you, your doctor, your insurance plan, or your government? Who should make such choices, and who should pay for the delivery of the chosen services? In truth, each of the four entities I mentioned above plays some role in the delivery of health care in America. Today marks my first effort at discussing the state of health care delivery in the United States, and it's my opinion that the critical question is the one I asked at the beginning of this paragraph. Who should be paying for the array of wonderful and advanced treatments available to us?

Our society has come to accept the notion of health care as a "right," and that it should be available, at least at a basic level, for everyone regardless of their ability to pay. This principle collides, however, with the inconvenient truth that someone must pay. As a provider, I wouldn't be in business very long if I did not pay my staff and my office rent and insurance and all the other expenses associated with a medical practice, not to mention that I would like to provide for my family. The tension evident in today's system results from the fact that the users of a given service, poor or not, are largely removed from directly paying for that service. This divergence drives up the costs of care and the demand for services.

For the vast middle class in America, the linkage between a health care service and its cost is lost, and the result is greater demand at greater cost, and ultimately more limited choices. The schism that I'm talking about has come about because of the huge and intrusive role of third-party payors--insurance companies and government--that has developed over the years. I can give a multitude of examples, but I'll be brief to try to illustrate my points. For every service or good you can think of, there is a balance between supply and demand, and cost is the expression of that balance. Assuming you're not on food stamps, who pays for your groceries? You do, of course, as you do your phone bill and your car payment and whatever else you buy. Now, again assuming you are part of America's great middle class, how did you choose which car you drive? The answer is that you bought the car you wanted, that fit your needs, and that you could afford. No one expects to pay their employer or the government a monthly premium, and to be given a choice of three different cars to pick from every March. And if my absurd illustration were true, I'll assure you that not only would your car choice be limited, it would be more expensive, as well. Competition is a potent motivator, and innovation is its result.

Apart from emergency care, my illustration above is as equally applicable to health care services as it is to car purchases or haircuts or groceries. Unless our current system changes, patients will in the future have vastly greater restrictions placed on them with regard to choice of doctors, hospitals, treatments, and medicines. We are already seeing examples in physician provider panels, and in medicine formularies that pay for only one drug, if any, in a given class. The bureaucracy chooses which medicine to pay for, and which physicians to contract with, and those choices are driven by interests that are often at odds with the patient's best interests. Physicians, for their part, have little incentive to openly publish their fees or compete for patients based on convenience issues such as flexible appointment availability or timely message return. Employers, saddled with the job of picking insurance options for their employees, are left with a responsibility and cost they'd rather not have, but which has developed because of a longstanding tax loophole which favors employer-provided health insurance. Human nature can't be legislated, and those who pay the bills will always control the process. My fear is that the precious doctor-patient relationship is at risk from these outside forces.

One ridiculous and disingenuous proposal before Congress now is to have the federal government "negotiate" drug prices with pharmaceutical companies. This means price controls, and I can't think of a more effective way to dry up the basic research that leads to breakthrough treatments, which now routinely cost one billion dollars or more to bring a single drug to market. Certainly it's not fair that we are the only major Western nation without price controls, and the result is that we wind up subsidizing new drug development for these socialized countries. But the solution is not to do wrong just because everyone else is. I am armed today with a potent arsenal of drugs which are effective treatments for hypertension, diabetes, and heart disease, and many of these drugs did not exist 13 years ago when I entered private practice. Lives are being saved today because of the existence of these medicines. Instead of beating up on Big Pharma, lots of folks need to give them a word of thanks, and we should let our congressmen know how we feel, as well.

Nobody wants to hear doctors poor-mouth about money, but the truth is that primary care physician incomes are down about 9% in inflation-adjusted dollars over the last 10 years, and Medicare reimbursements are on track to be reduced even more drastically in years to come. Let's say you're a doctor with a full practice, and Medicare reimburses you only about 60% of what a private insurance plan would for the same service. How anxious would you be to fill all your slots with Medicare patients? Not very, and therein lies a substantial looming problem for everyone nearing the age of 65. Reimbursement is better with private insurance than with Medicare, but the same issues are in play, just delayed a little bit.

I'm a board-certified internal medicine specialist, and I deliver what I believe to be excellent care for my patients. Yet, I'm only a participant in three of the four available Blue Cross plans in the area, for example. Why am I not part of the fourth? It has nothing to do with my qualifications, but is because I was unwilling to provide my services at the price Blue Cross offered for that particular insurance plan. Meanwhile, I provide exactly the same services for Blue Cross patients in the other three plans, for a fee that I find acceptable. Blue Cross, and employers, you see, are driven by different motivations than patients themselves might be. Why should the employer or the insuror determine whether a patient can see me? I submit that the cost, quality, and choice available to patients would be greatly improved if the patients were more directly responsible for the cost of their care.

How might this be accomplished? One solution is being implemented now in the form of high-deductible health insurance plans coupled with health savings accounts. These programs are relatively new but are already transforming the health care delivery dynamic. The problem is that these plans are not nearly available enough to make a dent in the overall system. If these plans were more widely used, patients would likely become much more savvy consumers of health care dollars, and doctors would ultimately be forced to compete for patients much more directly in terms of transparency of cost, availability and convenience of services, and patient satisfaction indices. In my own new solo practice, I'm trying to implement some of these protocols, but in many ways I'm swimming upstream with my efforts. In any case, it's not just my solution, or anyone else's solution, but a multitude of solutions that will fit the needs of a diverse America. This is the vision I have for health care in America, with the patients and their doctors driving innovation.

Sure, patients may not immediately see the problems with third-party payors as I see them, and indeed these problems have developed gradually over the last 50 years. Nevertheless, the predicament is real and worsening, and I pray for wise leadership to bring us to sustainable long-term solutions. The surest path to success will be one in which the individual patient maintains maximal control over his own health care decisions, and that recognizes that it is the payor who has the control. I've chosen to be a solo practitioner for the freedom and flexibility that are its fruit, both for me and for my patients. I believe that people will value what I have to offer. On a broader scale, I hope Americans will continue to have a rich array of health care options in future years. It's not a given that we will.