Dr. Wisor's Manifesto on Health Care Reform
Dear Patients and Family Members,
The following information represents my opinions and views regarding the current debate regarding the future direction of health care reform. As a preface, I am compelled to report that while currently in a private practice setting, I was also a prior service military medical officer in the US Army, and as such have therefore spent my entire adult existence serving others in a relatively apolitical state. Most recently, given the White House’s insistence that my fellow medical practitioners and I are not doing an adequate job, I am compelled to justify my existence. And, despite the suspect veracity of extreme political agendas gone amuck, I am morally obligated to leave the comfort of my uninvolved state, and sort through the political hand wringing, media reporting and self-serving web postings of too oft ill-informed or agenda supporting misinformation.
This manifesto in no way represents the views of any of my fellow physicians or colleagues at Capitol Spine and Pain Centers. The views expressed below are solely mine alone both as a concerned citizen and practicing doctor. You may choose to take them with the proverbial “grain of salt”. If I insult anybody’s delicate sensibilities or political affiliation, for that I do not apologize. The ramifications of the high stakes games of political poker currently being played in Washington are enormous and as such requires that each concerned individual become as informed as possible.
Over the past several weeks I have been listening to many opinions or “sides” in the debate. I have also participated in a recent White House national call for practicing physicians, as well as Congressman Tom Price MD’s (R-GA) call with The Physician’s Council for Responsible Reform (PCRR), which I am currently a consultant for. The following topics, as far as I can glean, are the most contentious issues that divide the sides in regard to reform.
1. Over-utilization:
White House Position: Doctors have vested financial interests in procedures and as such, have been profiteering in the excessive ordering of tests and medical procedures. President Obama sited in several town hall meetings examples of doctors performing foot amputations and tonsillectomies more often than clinically necessary out of financial gain. Further, he has often sited numbers (with no rebuttal from the medical community). as examples: doctors receiving $30,000 for performing a foot amputation. (It should be noted that actual Medicare reimbursement for physicians performing such procedures ranges between $700 and $1000.) Further, President Obama has implied that most doctors own imaging centers and labs, and therefore order way more tests than medically necessary for the financial gain of fees for performing unnecessary tests.
Dr. Wisor Position: A very low percentage of doctors actually own imaging equipment or have any vested financial stake in the ordering of expensive and often unnecessary tests. The vast majority of physicians agree that over ordering of expensive tests is often performed as a result of practicing defensive medicine (i.e., fear of medical lawsuit in the event that they are missing a very rare and unlikely medical condition.)
2. Malpractice Reform:
Studies indicate that anywhere from 10% to 30% of all imaging or laboratory testing are ordered practicing defensive medicine which would equate to hundreds of billions of dollars that could be saved on unnecessary waste. Thus, most doctors agree and insist that malpractice or tort reform is absolutely crucial to dramatically reduce over utilization!
White House Position: President Obama has looked at states such as Texas that have placed caps on malpractice and his position is that he does not want to interfere with the patient’s ability to be fairly compensated in the event of malpractice. Howard Dean has been quoted as saying they are “scared to death” of the trial attorneys lobby.
Dr. Wisor Position: Malpractice reform is at the very heart of significant societal savings. Malpractice attorneys take cases on contingency (collecting anywhere up to 50% of any settlement or judgment) and thus a plaintiff has no financial disincentive to litigate a case no matter how trivial (or “no skin in the game” as it is often referred to). Often times doctors are forced by their malpractice carriers to settle cases even if they believe that no wrong was done or the standard of care was not breached as is often much more expensive for the insurance carrier to litigate the claim until completion. This results in doctors practicing with a defensive mindset to cover their basis for potential litigation even when their clinical judgment suggests otherwise.
At the end of the day when the dust settles, most physicians believe that President Obama is still a lawyer at heart and will desperately strive to protect the special interests of trial attorneys and their vast lobby so that they can continue to make a good living off of tort settlements of malpractice cases that often never get to trial for the doctor to defend him or herself. This frustration for physicians is why most will not support reform that does not reform this system as well. Further, as a previous doctor in the Army, it should be noted that when a soldier, family member or retiree accuses a Military Physician of malpractice, the case is immediately dropped from the physician and shifted to the US Government as the Defendant. These cases conclude much quicker and typically with much smaller judgments than the private practice world today. There is no justifiable reason why tort reform could not follow these similar models.
3. Aging Population:
White House Position: None identified.
Dr. Wisor Position: Healthcare reform dates back at least as far as President Truman. One has to ask oneself, why all of a sudden is there a state of emergency in regards to reform? The reality is that Social Security’s financial insolvency as it applies to the shear volume of baby-boomers is well known, but there is a literal tsunami of baby-boomers heading into the Medicare system in the very near future. And unfortunately perhaps, the dilemma facing every American today is reflected in the age-old expression, “our virtue is our vice”. Because--despite the rhetoric spewed from all corners of the political arena debasing the most successful fifty years of continuous medical and pharmaceutical advances in the greatest health system in the free world--there is undeniable evidence that as a result, Americans are living longer. This is a glowing success story for both science and capitalism intersecting to bring cutting-edge medical advancements and technology to the citizens of this great nation especially knowing that there has been no vast improvement in overall lifestyle as people on average have more obesity and diabetes than ever before. Sadly, in its current state however, as with Social Security benefits for an exponentially growing pool of retirees, it is a recipe for fiscal disaster as there are more “outs” than “ins” in a closed financial system. This is the same fundamental flaw that causes the collapse of any Ponzi scheme such as run by Barry Madoff. Eventually if growth or contributions from the bottom of the pyramid cannot support its top, the infrastructure implodes. Currently, (as documented in The Health Services Research, 39:3, June 2004) America spends more than any comparative nation on health with approximately $316,000 per capita lifetime expenditures on women and $268,000 on men; the bulk of that fundamental difference is owed to women having a slightly longer life expectancy than men.
The question that begs to be answered is with so much money being spent on healthcare, why are private payers such as BlueCross/BlueShield and United Health turning profits while the government-run payer system Medicare is destined for bankruptcy? The answer is simple; for Americans reaching age 65, Medicare absorbs (and most private insurers divest of) people who retire from their employment driven health plans. Some may have you believe that it’s an evil conspiracy of the vast insurance empire that causes the conundrum. Unfortunately, over half of the average lifetime medical expenditure per citizen is spent during the Medicare years after age 65, and further, more than one-third in the remaining years after age 85. Thus, more people are living longer and it comes at a tremendous governmental and societal expense. And, with further scientific advances in the treatment of chronic diseases such as heart disease and cancer, life expectancy will undoubtedly continue to rise in years to come. So, while sweeping reform and a complete systematic overhaul seems to be the popular answer for those with an underlying agenda, the reality is that we as a society would be much better served by tackling specific issues regarding the care of elders and more specifically, addressing and debating the fiscal and moral dilemma of how we treat the terminally ill. In our current health system, withholding expensive and often ineffective treatments, is too often confused with “playing God.”
4. Rationing of Care:
In May of 2008, after suffering a seizure while walking his dogs at his home in Hyannisport, it was determined that, at the age of 76, Sen. Edward Kennedy was suffering from a terminal brain tumor, or malignant glioblastoma. The diagnosis was rendered at Harvard’s prestigious Mass General Hospital not only through routinely acceptable MRI, but also through a more sophisticated confirmatory neurosurgically-guided stereotatic brain biopsy. Despite what would unarguably be the commonly accepted recommendation of supportive care from the oft-touted nationalized health care programs of England and Canada, and the starkly grim statistics of his advanced age and a less than 8% two-year survivability rate, he went on to have a technically advanced and elective neurosurgery at Duke University Medical Center. His follow up treatment plan also included comprehensive radiation and chemotherapy regimens.
Thus, any realistic cost saving healthcare reform will have to center around rationing care during the greatest expenditure of our healthcare dollars, which typically occurs in the last 6 months of our lifetime. The undeniable but often unspoken reality is with the baby boomer generation entering their senior years, a government run single payer system (such as those currently in England, Canada and Sweden) will have to include significant plans to ration care during end of life illnesses. Currently, John Mackey (CEO Whole Health Foods) published a letter quoting that 830,000 Canadiens are waiting to be admitted to a hospital or get treatment and according to the Inverstor’s Business Daily, 1.8 million people in England.
5. Health Savings Accounts (HSA’s) or Personal Wellness Accounts:
White House Position: Nearly 47 million people are without health care in the US. Currently, employer health insurance is fully tax deductible, however individual health insurance is not.
Dr. Wisor Position: The government uses “health care” interchangeably with “health insurance”. The reality is that any uninsured patient can walk into any ER in the country and get the most sophisticated care in the free world. With that said, insurance companies, despite their vast complexity and market dominance, add very little value to American health care. Unlike other forms of insurance, such as auto or home, health has become the primary payment vehicle for nearly all medically related expenses. This model makes no inherent sense. If you doubt this premise, ask yourself the last time you used your homeowners policy to buy groceries or your auto policy to get a tune-up? The reality is, young Americans need catastrophic insurance, which pools risk among otherwise similar healthy people in the rare event that a trauma or unfortunate disease develops.
Currently, it is estimated that the average American who begins work for $30,000/year at the age of 22, retires at 65 and dies at 80, will have contributed approximately $1.77 million dollars to employer provider health care plans. If this money was invested in a rollover accounts (much like Roth IRA’s) rather than given to insurance companies who dispense these premiums to pay for medical care through convoluted reimbursement decision trees, with left-over’s used to produce CEO bonuses and shareholder profits, it would be available for use when we reach our elder years and need it most. Further, the money spent during the younger and healthier years would be done with real concerns for costs. This would discourage over-utilization of health services that the minority of consumers employ because they currently only have only small co-pays to concern themselves with and see it as some “use it or lose it benefit”. People would begin to ask themselves, “How much is this care or medication costing my account” and “is this service or treatment really worth the return on investment?”
6. Physician Primary Care Shortage
Currently there is a well-documented shortage of primary care physicians to provide preventative medicine and basic health care. With the addition of 47 million more people to care for, the chasm will widen.
White House Position: Physician Assistants (PA) and Nurse Practitioners (NP) and other health care physician extenders will be able to make up the difference for the under served.
Dr. Wisor Position: PA’s and NP’s can play a pivotal role in health care. The US Army utilizes PA’s and nurses to provide primary care not only in garrison, but also on the battlefield to meet the shortage of doctors who volunteer for service. Unfortunately, my experience in the Army is that because these physician extenders have less formal clinical training (such as residency and fellowship training) they tend to order more expensive labs and imaging studies out of a fear of missing clinical conditions. This form of care will therefore cost the system more in the long-term.
In conclusion, I believe it behooves us to move forward only after comprehensive and thoughtful discussion and not in a hurry so as to push forward an underlying political agenda. Every citizen shares the responsibility to become informed and involved in this potentially monumental change, as it will eventually affect each and every one of us at some point in our lives.
I hope this helps you stimulate dialogue with your family and congressional representative in what will undoubtedly be interesting months ahead.
Best in Health,
Douglas Wisor MD