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Cover Stories | Jan 2010

My Vision for US Health Care

KERRY K. ASSIL, MD

It is somewhat naïve of society as a whole and the medical community as a sector—maybe even narcissitic—to cast medicine as a golden goose that must be harnessed or rationed, lest society suffer unduly. Health care is by no means the single most important requirement for any society. It might not even rank among the top 10. Food, water, shelter, clothing, transportation, electricity, and telecommunications all rank ahead of health care in terms of importance. If any of those necessities were cut off or inappropriately rationed, our society would rapidly devolve into chaos.

Since entitlement programs were established, the US health care system has taken a sideways path. Trying to remedy that by further adding entitlement programs to the current system (and mandating that providers must accept whatever compensation is awarded) will not solve the current problems.

If further limitations are imposed upon the medical industry’s free market forces, the United States’ position as a leader in medicine will vanish. Pharmaceutical and manufacturing industries in this country will not have sufficient profit margins to meet the costs of research and development, and foreign manufacturers and pharmaceutical companies will take their place. The steady influx of patients worldwide into the United States to obtain health care underscores the quality of medical care in this country, yet we envy other models.

The current US system is one in which legislation has made it harder for market forces to settle in and properly reform health care delivery. Although legislation can spawn artificial economies for periods of time, artificial economies cannot sustain themselves. All artificial economies, as Karl Marx ironically pointed out, crumble because they are not driven by true economic principles.

If we allow proper economic principles to work their way back into health care delivery, much of our collective anxiety regarding reform and the cost of sustaining a particular system would quickly dissipate. Of the estimated 10% to 15% of our uninsured citizens, some choose to be without insurance. What are we prepared to do as a society on behalf of those without health insurance who want and need it? Let’s deregulate. We should provide a basic minimum level of coverage for all, while allowing providers to set their own incremental fees (just as with food, shelter, and other “essential” sectors).

Imagine if the government did not dictate a single price for cataract procedures and instead provided a nominal payment toward all cataracts and surgeons could set their incremental fee as they saw fit (providing they could justify their fees to their patients or third-party private insurers). Every person would be covered, and the government would save substantially on overhead. The cost of third-party private insurance would simultaneously drop, as a portion of the cataract fee would already be covered. Fewer—but more health-conscious—consumers would seek supplemental private insurance, thus reducing the need for third-party insurers (who could also allow surcharging). This concept could be applied across the board to all medical specialties as well as to the pharmaceutical industry.

The system I am proposing would cover everyone and be based upon the fundamental principles that made the United States great. Before Medicare, there was an unwritten code of ethics among doctors to provide 20% of their services in the form of charity. Nearly every day in my practice, I take care of uninsured individuals. Part of the reason I can provide free care is that I charge an appropriate fee for other services and reallocate some of those resources.

Kerry K. Assil, MD, is a specialist in cataract and refractive surgery at the Assil Eye Institute in Beverly Hills and Santa Monica, California. Dr. Assil may be reached at (310) 453- 8911; kassil@assileye.com.

MARK H. BLECHER, MD

One way or another, everyone—even the uninsured— gets health care in the United States. They just do not get it in a way that is costeffective or that produces the best outcomes. People without insurance, or who lack good insurance, wind up in ERs with advanced disease that could have been treated more effectively and more cheaply earlier. To those who argue that it is not society’s role to provide health care for everyone, I would say that the reality is it already does, and we already all pay for it.

If we are already spending all of this money, let’s do it better and maybe save money. I believe that everyone has a right to health care and that the government (as it already does) should provide it to those who truly cannot afford it. A plan should be constructed that includes routine basic preventive and interventional care that is age appropriate for the patient. Preferred practice patterns already exist for all of the medical specialties and can be used for this purpose. Next, let’s place a fair value on that care based on realistic costs and actuarial research. This would be a basic, bare bones health plan. Everyone would be required to carry it as a benefit of employment, a private purchase, or a package from the government, provided the individual met appropriate criteria. The cost would be the same nationwide for everyone no matter who was paying. That is the principle of community insurance: to achieve the lowest costs by sharing the risk. Healthy people would need to participate as well to lower the average cost and because, if they suddenly and unexpectedly became ill, they would access the system anyway. Again, this is a bare bones plan. People might then buy additional coverage as they wished.

As a part of this basic plan, I believe there needs to be coverage for catastrophic care. No one should be forced into bankruptcy by necessary health care. Everybody in this country now receives catastrophic care. The cost of treating uninsured individuals with heart attacks or cancer, for example, is covered, whether through higher insurance premiums or taxes. Again, preferred practice patterns could be used to guide appropriate care.

I must emphasize that I am arguing for the provision of only the most essential parts of health care to everyone. There should be a free market for supplemental insurance and premium care. Finally, the costs associated with the basic and catastrophic plans should be national, not determined on a state-by-state basis. This plan can be delivered by private insurance companies or government agencies or both, as is now the case. Private enterprise can add to the basic plan if desired.

Currently, there is no free market in health care, no transparency in costs or services, and no incentive to provide the most appropriate care, only the most complete care. We can do better

Mark H. Blecher, MD, is in private practice in Philadelphia. Dr. Blecher may be reached at mhbmd@earthlink.net.

STEVE CHARLES, MD

Although Americans typically prefer to blame others (eg, large companies, technology) for their problems, I believe the true cause of the current health care crisis is consumer demand. An addiction to food, smoking, drugs, and/or alcohol drives approximately 75% of the cost of health care. Obesity can lead to type 2 diabetes, myocardial infarction, and stroke. Smoking raises people’s risk of developing cancer, heart disease, stroke, pulmonary disease, and macular degeneration. The abuse of alcohol can result in liver disease and a higher risk of automobile accidents.

Whereas the premiums for automobile insurance rise after someone has an accident, the premiums for health insurance are the same regardless of whether or not the person is obese, smokes, or is a substance abuser. The health care system I envision would promote personal responsibility for health. Specifically, it would provide financial incentives for healthy behavior (eg, tax breaks on the purchase of health insurance and gym membership as well as enrollment in programs for wellness/prevention, weight loss, smoking cessation) and penalties for unhealthy behavior (eg, luxury taxes on alcohol, tobacco, and gambling). The basis for these determinations would be the results of an annual physical, which would include testing for drugs and tobacco as well as an analysis of the patient’s medical record for evidence of unhealthy behavior.

My system would also address end-of-life care, which constitutes a significant fraction of the cost of health care in the United States. Hospice care is a compassionate alternative, and the emphasis would be on the quality rather than the duration of life.

A goal would be to reduce costs through efficiency. Medicare funds and higher insurance premiums pay for the acute care of uninsured individuals. Preventive and wellnessbased care for the insured and uninsured would decrease expenses. Treatment protocols as an integral component of point-of-care electronic care software would reduce mistakes and the duplication of services while making treatment more efficient. My system would also include an expansion of Medicare. Although most physicians opposed the program at its inception, Medicare is a relatively good payer and has overhead costs of approximately 3% versus 30% to 40% for managed care companies, because they pay taxes, dividends, higher salaries, and bonuses with those salaries.

Steve Charles, MD, is a clinical professor of ophthalmology at the University of Tennessee in Nashville, and he is an adjunct professor of ophthalmology at Columbia College of Physicians & Surgeons in New York. He is also an adjunct professor of ophthalmology at the Chinese University of Hong Kong. Dr. Charles may be reached at (901) 767-4499; scharles@att.net.

JOHN F. DOANE, MD

I believe that the only financially sustainable health care would be directed and paid for by the individual. Anytime a third party is involved, the cost of processing, managing, and implementing the plan will dwarf the cost of providing care to the patient. By design, a socialized system— governmental or private—becomes fiscally inefficient. If an organization or government sets up a pool of available services with no direct controls of cost responsible to and determined by the recipient, demand will inevitably outstrip available resources. The system will then require greater financing in the form of additional taxation to increase services.

Is there a role for health insurance? I believe it should be reserved for catastrophes. To my mind, one of the biggest failings in the United States’ delivery of health care services was the socialization of the payment of said services. With the advent of Medicare in 1965 under the auspices of President Lyndon B. Johnson, the estimates have been off by a factor of 10. So much for predicting intermediateand long-term health care costs. Richard W. Fisher, the president and CEO of the Federal Reserve Bank of Dallas, has remarked that, in order to “cover the unfunded liability” of the Medicare program today for an infinite period, “you would be stuck with an $86.6 trillion bill,” which is “more than six times the annual output of the entire US economy.”1 He also noted that “Medicare was a pay-as-you-go program from the very beginning.”1 I do not believe that the United States can afford to support the system financially, and this sentiment does not take into account the changes that may be wrought under President Obama.

The check and balance I envision for substantially curbing the cost of individuals’ health care is for patients to be responsible for their own care. In the system I propose, all costs related to health care would be tax deductible. All US citizens would have a health savings account, with unused funds rolled over annually and personal contributions tax deductible. Individuals could buy insurance from vendors across state lines to enhance competition. The government would revise tax laws so that people would not be forced to buy health insurance through their employer. Insured individuals would be permitted to negotiate the cost of goods and services they want directly with their providers, hospitals, and pharmacies. Moreover, my program would include massive state-by-state tort reform to eliminate the waste of tens of billions of dollars on defensive medicine, and it would repeal all limitations on balance billing by providers.

I believe that the system I propose would offer complete transparency. It would allow the free market to determine the value of goods and services, which have been massively overpriced for decades due to a lack of competition and of haggling between buyers and sellers. For example, several ophthalmic drops currently cost $50 per milliliter or $189,000 per gallon. Under my plan, patients—aware of this cost—might decide instead to buy a medication priced within their budget (say $1/mL, which would result in a 50X cost savings for one decision alone).

My program would also institute a total restructuring of the qualifications for disability as well as Medicare and Medicaid. I want to combat the fraud perpetrated by select recipients and the self-serving cottage industry created by unscrupulous physicians and lawyers that is funded by tax revenue. Only the truly mentally and physically disabled should be considered for benefits.

I believe that houses of worship and philanthropic organizations should play the role of social safety nets. Contributions to these groups should be 100% tax deductible to encourage concerned citizens to take care of members of their own community.

It is through responsible, individualized decision making— not centralized bureaucracy—that a nation’s health care needs can best be served in a financially based reality.

John F. Doane, MD, is in private practice with Discover Vision Centers in Kansas City, Missouri, and he is a clinical assistant professor with the Department of Ophthalmology, Kansas University Medical Center, Kansas City, Kansas. Dr. Doane may be reached at (816) 478-1230; jdoane@discovervision.com.

  1. Fisher RW. Storms on the horizon. Federal Reserve Bank of Dallas. http://www.dallasfed.org/news/speeches/fisher/2008/fs080528.cfm. Published May 28, 2008. Accessed December 15, 2009.


KARL G. STONECIPHER, MD

The chief components of my plan for health care are prevention and rewards for healthy behavior. In many cases of foreclosure today, medical expenses represent the straw that broke the camel’s back. I would like to see the creation of health savings accounts. Employers would put money into these accounts and would offset the cost in part by altering the insurance plans they offer to have high deductibles (eg, $2,000) to cover medical catastrophes. Employees would have the option of contributing to their health savings account pretax, and unused money at the end of the year would roll over automatically. Once they were fully vested, employees could take the accounts with them if they changed jobs. Individuals would determine how they spend the money in their health savings account. For example, if not needed for essential care, the funds could be used to cover LASIK, plastic surgery, or massage therapy. In addition, everyone would have the option of paying for additional private insurance.

Prevention must be the number-one goal. We need to emphasize healthy living for the younger generation so that these individuals make it a priority. Every doctor I know treats patients who do not make an effort to improve their health. Whatever health plan is ultimately adopted, it should include rewards for good health. After all, healthier people are less burdensome on the country’s health care system. As an example, we could tackle the three biggest health problems in this country: cardiovascular disease, diabetes, and obesity. With their income tax returns, individuals could submit a form from their primary care physician listing their body mass index, blood pressure, fasting blood sugar level, and blood cholesterol level. Individuals whose results fall in or below the normal range would receive a deduction on their income tax.

Critics of the current US health care system often point to other countries as examples of how to do it better. Those plans are tailored to suit other societies; they will not work here. Rather, let’s improve the system we have. The federal government already has numerous agencies dedicated to improving the health of the US population, including—but not limited to—the National Institutes of Health, the Centers for Disease Control and Prevention, the Centers for Medicare & Medicaid Services, the Indian Health Services, the Substance Abuse and Mental Health Services Administration, and the Department of Veterans Affairs. Often, these groups duplicate each other’s efforts. I would like to see a better-directed collaboration among these agencies with an emphasis on preventing chronic disease (eg, heart disease and diabetes). The effort would include the establishment of measurable goals to ensure that preventive health programs are working. The metrics would be derived from evidence-based medicine, and the reports would be regular.

Finally, let’s put the money that is being spent on negative advertisements about universal health care into a fund to cover care for the indigent. At least it would be a start toward a meaningful answer to health care reform.

Karl G. Stonecipher, MD, is the director of refractive surgery at TLC in Greensboro, North Carolina. Dr. Stonecipher may be reached at (336) 288-8523; stonenc@aol.com.

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