Archived Reform Thoughts

3/20/2013 Bitter Pill

I highly recommend this well-researched article by Stephen Brill in the March 4 issue of Time. It’s a powerful indictment of the health care industry, from hospitals and their fantasy “chargemaster” bills to the mega-business that is health insurance and big pharma. Told through the personal stories of ordinary citizens, Brill does a great job of exposing the rationalizations of these industries in overcharging all of us, as individuals purchasing health care or as taxpayers who are increasingly on the hook for this particularly American form of corporate greed. He applauds Medicare’s function in providing health care without hassle to millions of seniors, and notes its cost efficiencies, low overhead and tremendous bargaining power in keeping health care costs low and holding providers accountable for quality of care. His only complaint is that Medicare is not further empowered to negotiate for drug and equipment prices, thereby allowing these manufacturers to charge us the highest costs in the world. What Brill misses however is the obvious conclusion: we need to adopt his recommendations for an improved Medicare for all, one that would cover basic services from birth to death.

That’s why the majority of physicians and US citizens now favor single payer, that is, Medicare for all. We need to give Medicare the full power of its size to demand lower prices for everything, not just doctors and hospitals, but medical devices and drugs, and put it to work for all of us. As every other nation in the developed world has demonstrated, embarrassingly, before us, not only can we cover everyone, we can do it cheaper, and better than we’re doing now.

I don’t know about you, but as a patient and a physician, I’m tired of being pushed around by health insurers and pharmaceutical companies. Yes, give me Canadian health care! Or the UK, or German, Japanese or Swedish! Give me the French system, or the Swiss. When are we going to say enough to a process that serves only the stockholder and not the patient? Whatever serves to profit the business, takes away from the patient. Watch for the stories I have seen in upcoming posts (they’ll be in ‘A Day in the Life’ section of this website).

7/6/2012 ACA (Affordable Care Act) Update

Okay, you’re living under a rock if you don’t know the Supreme Court (for whatever reason) upheld most of the health care act. Here’s my take on the fallout:

  1. With or without the act, we are a long way from the kind of health care reform our nation needs to rein in spending and to improve quality of care.
  1. For those of you complaining you don’t want to pay for care for “all” let me remind you, YOU ALREADY DO. You are simply paying for it in the most expensive way imaginable, through the use of the emergency room—the only health care “right” we Americans have. The question is not whether to provide care to everyone, but how to do it cheaper, and better.
  1. Which leads me to this: we need to stop trying to reinvent the wheel and get over ourselves enough to realize we could pick from a cornucopia of ideas already tried and in-process in other countries successfully doing way better than we do, for a lot less money. Our arrogance is heading us for bankruptcy.
  2. Obamacare is Romneycare on a national level. Neither party has advanced anything close to cost constraints, or complete coverage. How sad. I’m tired of Republicans saying Americans don’t want universal health care (polls show the majority of Americans do, including doctors), and I’m tired of Democrats suggesting Obamacare is it (it isn’t).



  1. Expect to spend more out-of-pocket for everything health-care related every year until we fix this, and to give up more of your income to premiums (you never see this income because your employer takes it out, so you have no idea how much higher your income would be if our costs were say < $4000/ person per year—where most other developed nations are–, instead of >$9,000/yr – current, and rising, US costs. And they’re living longer. And healthier. I’m not making this up.)


  1. My advice: don’t get sick.



Health care costs rose 113% and wages only 34% in the past 10 years according to recent data released by the Kaiser Foundation. While we are distracted by the size of the deficit, and dismal employment rates, the elephant in the room responsible for a major degree of both problems is our soaring spending on health care. Until we address this our economy will at best tread water, and at worst, sink from the weight of the cost of health care to business and private citizens. Seemingly the US response to major issues is guided only by crisis. What will it take I wonder?

Polls clearly show the majority of Americans favor health care provision for all. Clearly, world data show at least a dozen other countries providing health care to all citizens with better results and at much lower costs to all, including to business. Though some large corporations have recognized the need to fundamentally change health care payment and delivery in order to thrive in the world economy, most business leaders have been reluctant to call their conservative leaders to the table. Change is not only possible, it is mandatory to U.S. success at home and abroad.

Vermont moves toward single-payer model: Employers, patients, providers and government are likely to reap savings of up to 25% while maintaining the coverage we insist on. See this article by William Hsaio, PhD. in the New England Journal of Medicine, Mar 16, 2011:

2/4/2011   A Prescription for Health Care Reform: Fiscally Conservative, Socially Responsible, and Evidence-Based 


Long ago I abandoned attempts to convince people that health care is a right: because if you already believe this, I am wasting my time and, if you don’t believe this, there is probably nothing I can say to change your mind. So let’s move on. I propose that it doesn’t matter whether you believe health care is a right or not: health care reform, in a manner that covers everyone, is still in your best interest, no matter your financial, health, or insurance status.


Contrary to the chest-thumping, pseudo-patriotic rhetoric popularized by some in the media and echoed by the uninformed in daily conversation, the United States does not have the best medical care in the world. But we could. And even more to the point, considering how much we spend on health care, we should. Quite simply, excellent care is being stolen from us and every sector of the system is to blame: from insurance companies who profit by denying the very care they promise us in insurance contracts, by big pharmaceuticals who convert our need for medicines into record profits used to steer our politicians, by physicians who practice defensive medicine based on a malpractice system that functions more like a lottery than a just process of weeding out incompetence, by patients who expect every test to be done, every specialist to be consulted, just because they have insurance, by families unwilling to face end-of-life decisions for their loved ones forcing physicians and hospitals to practice aggressive medicine right up to the moment of death, by our government that continues to put pressure on individual physicians and hospitals to tighten costs, but refuses to negotiate with medical equipment and drug suppliers to lower costs, by the media who have abandoned in-depth analysis of the issues in favor of sound-bite reporting.

Each of these problems needs to be addressed to achieve excellence and manage costs. I would like to raise the discussion on health care policy to the level of the evidence as I describe what the best health care system in the world might look like. As a physician I rely on research every day to take the best care of my patients. You wouldn’t expect any less; in fact you would sue me for less. I am therefore appalled to see how the research on health care policy has been mostly ignored in our debate. Ignored by politicians, ignored by the media, ignored by physicians, ignored by our president, and as a result, ignored by patients. Because the evidence clearly points to harm, we no longer rely on leeches to cure illness, yet there was a time when this was considered state-of-the-art; the evidence is every bit as clear that we cannot rely on our current health care system to provide quality care at a cost we can afford. We must abandon it.

Our national conversation has been hijacked by powerful organizations that have no vested interest in your individual health whether you are lucky enough to have insurance or not. As a physician who swore an oath to heal, I can no longer stand by and watch my patients be so utterly harmed by a system that is dysfunctional at best, barbaric at worst.


There are no lobbyists in my pocket. My perspective is only that of a physician who is intimately engaged with patients and policies, administrators and insurers, hospitals and governance. From the front lines of health care, I would like to humbly offer you my hand…walk with me through the minefield that medicine in America has become. But more importantly, don’t rest. Don’t…until all of us have access to basic care that’s affordable. To do any less puts each of us increasingly at risk to a future in which, to paraphrase, “I have met the uninsured, and it is us.”


Stay tuned…

Complexity Is a Waste of Time (and therefore money)


The new ICD-10 is out–and over a 1000 pages long. This is the book we doctors are forced to follow when billing for our services. It is a list of diagnoses and conditions we must adhere to when trying to justify our importance to patients and more critically to their insurers so that we can be paid. It weighs in at several pounds but its value is inversely proportional to its size: it does nothing to improve patient care, and less than nothing to keep down costs–in fact because it takes an inordinate amount of time to use this garbage doctors have less time to actually take care of patients and are incentivized to extract as much reimbursement from better coding from this time-consuming process as they can–which inevitably leads to higher medical costs. Duh.

Just one more example of how unecessarily complex our health care system is–could we please just take care of patients?

Let me give you an example. When I admit a patient to the hospital with pneumonia I am not allowed to simply write a diagnosis of pneumonia, the liklihood of how and where it was acquired denoting an assessment of the risk and severity of it, and also of the indicated treatment. To be paid the best level (which matters very much to my employer if not to me) I have to write what kind of pneumonia it is, for instance, due to gram positive or gram negative bacteria. I have to write this even though I don’t know, and will never know, what kind of bacteria it is. This is because we don’t sample lungs for bacteria – it’s dangerous- too dangerous to risk. So we guess. No matter what hoity-toity medical center you go to – we always guess at the cause of pneumonia. In fact the pneumonia may not be bacterial at all – it may be viral- and which is even less easy to identify than bacterial. But still we are forced to adhere to this guessing game of what specific kind it is to be paid. Stupid, just stupid because it doesn’t serve the patient, it doesn’t serve the doctor. It just serves the insurance company. Bravo American health care.

Advice to New Doctors


There is no doubt that the business of medicine has changed in the thirty years I’ve been in practice, just as it did in the thirty years before that, and the thirty years before that. What hasn’t changed is the ability, and the privilege, of a physician to deliver excellent care to his or her patients, with compassion, dignity and respect. In fact, over time these qualities have become even more important to my patients, for whom such care stands out more than ever.

National health care does not frighten me; I believe dumping the insurers is the only way to place the patient and the primary care physician back at the center of health care. The insurance industry, after all, is not in business to serve the patient (nor us), but the stockholder. Every dollar in the shareholder’s pocket is another dollar taken at the expense of the patient’s health. I have spent plenty of time arguing with private insurers on the phone to get my patients what they need, something I have never had to do with Medicare. Further, the data are clear on two points about Medicare: it is the most cost-effective and quality-driven insurer out there; it could be even more so but for lobbyists and the politicians beholden to them )which is almost all of them).

“Cookbook medicine” has been the bogey man since I was in training, so I am rather inclined to roll my eyes at the same paranoia spouted today. There is too much to know for any of us docs, I don’t care how dedicated you are, to keep up with everything every day. Particularly in family or internal medicine. While I certainly do practice medicine on individuals, I take very seriously the data that helps us identify what works and what doesn’t, what’s harmful and what is not. Algorithms and reminders help to make our care idiot-proof, and allows us to spend more time with our patients.

Lastly, I work with a lot of new graduates in my current field of hospital medicine (I had my own private practice for > 20 years), and find them to be just as dedicated to patients as anyone I knew at OSU 30 yrs ago. About the only difference in the past 15 years is the zeal with which most of the new grads, out- and in-patient oriented, get consults. This is the place where I think we need to get back on track with education: our patients do not need more specialists—they need fewer. They don’t need more testing, by and large they need less, and better directed evaluation and treatment.

My advice to new docs is to go out there and be the best doc you can be with each patient every day. Find joy in your work—if you do that, no change in health care policy can take it away. Know when to play by the rules and when it’s worth trying to break them. Stand up for what you believe in, not just on media sites, but in conversations—let people know what you know. Learn the data on health care policy and become an advocate for all your patients, not just those who can pay you (you may want to check out if you’re looking for data). Good luck, and may the force be with you…!