The House


Are Doctors the Real Problem?

The villains in the battle over health care reform in the U.S. are obvious, right? The insurance and pharmaceutical companies are not-so-quietly lining the pockets of their corpulent, greedy CEOs, who sit in corner offices adorned with centuries-old pine wooden desks and golden toilets, while doctors, patients, and businesses small and large are getting squeezed dry. But real reform requires a less one-dimensional examination of the industry, one that reveals a much more systemic assortment of maladies plaguing the system as a whole. President Obama has made prevention a pillar of his health care reform plan, suggesting patients' poor diets and exercise habits are partly responsible for the astronomically rising costs of care. (According to the National Coalition on Health Care, health care spending represented 17 percent of the country's gross domestic product in 2007, and is expected to reach 20 percent or more in the next eight years, and yet U.S. health care is ranked 37th by the World Health Organization.) Rush Limbaugh, he of the beer belly and hunger for prescription drugs, mocked Obama's assertion, inanely postulating that it's not the overweight or physically unfit who are the biggest burden on health care, but the physically active, who, he says, sustain injuries that cost taxpayers millions each year. And they say laughter is the best medicine.

A few months ago I made a rare trip to my primary care physician. His office is a veritable hole in the wall, with a sign on the window of the front desk that reads, "Do not ask how long the wait is or how many people are ahead of you." He overbooks his schedule, no doubt to make as much money as he can; I waited two-and-a-half hours to see the doctor despite having scheduled an appointment. After a tirade about how changes in the system have forced him to refuse patients who don't have coverage or who simply can't afford to make their insurance co-payments, he informed me that it would likely be over a week before my HMO approved his referral for a CT Scan. In the meantime, he sent me for lab work.

When I received my blood results, I noticed that one of the tests my doctor ordered wasn't performed. I called his office to ask him about it, and was told that "everything is fine" and that if I wanted to talk to the doctor, I should make an appointment. I insisted but was again refused, so I hung up.

I eventually went for the CT Scan and received a call from my doctor's office several days later once again telling me that "everything is fine," but that the doctor wanted me to stop by and pick up a new script for additional lab work. After waiting for an hour and a half, he told me that one of the tests he ordered wasn't performed. I informed him that had he taken my call two weeks earlier, he would have known that already, and that perhaps the CT Scan, the necessity of which he fought with my insurance company about, might not have been necessary after all. He explained that he prefers to talk to his patients face to face and told me not to worry about the co-payment, which I had no intention of paying anyway. It occurred to me that, co-payment or not, he was planning to submit this "follow-up visit," consisting of a gratuitous thermometer in my mouth and a brief conversation that should have taken place over the phone, to my insurance company for reimbursement.

Judging by the overall conditions under which my doctor practices, his actions might simply be a necessity of survival—having been fought tooth and nail by the insurance companies to do what he told me loves to do: practice medicine. And as someone who despises how the health insurance industry operates, I can certainly empathize with his plight. But not when it's at the expense of his patients' financial and medical well-being. More importantly, I couldn't shake the feeling that I was being made an accessory to insurance fraud.

I've been following the health care reform debate closely since I began paying for my own policy out-of-pocket several years ago, and while I've heard lots of buzz terms being tossed around (efficiency, waste, choice, competition, public option), I've rarely heard anyone in the mainstream media discuss the role health care providers have played in the crisis. Even Obama, who received a tepid response from the American Medical Association last month, has been loathe to criticize doctors. And then I stumbled upon an article in The New Yorker (not exactly a bastion of the mainstream) by Atul Gawande, a surgeon at Brigham and Women's Hospital and a professor at Harvard University, that sets out to find an answer to why the health care costs in a poverty-stricken Texas bordertown are some of the highest in the nation despite having state-of-the-art technology and facilities.

One of the factors Gawande examines is the profit motive of providers, who enjoy kickbacks for admitting patients to hospitals and, presumably, referring them to specialists and other agencies. In some cases, doctors are even paid a percentage of the profits from tests and procedures performed at what are called physician-owned hospitals. Doctors in the small town in question were prone to "overutilization," ordering procedures that, among other things, serve as a preemptive defense against malpractice lawsuits, and performing unnecessary surgeries when lifestyle changes and pain management would be just as effective—and cheaper. It's possible that a significant number of "unnecessary" tests would rule out more serious conditions, and therefore reduce the number of more invasive (and expensive) procedures that may have been performed based on less accurate testing. But how many doctors who view their practice as a profit-based business feel compelled to order unnecessary tests simply to pay for the cost of running their business?

Doctors in the U.S. perform more operations than doctors in any other country in the world, and there's no evidence to suggest that we're any better off because of it. (The U.S. ranks 45th in life expectancy, below Cuba.) And the cost of certain procedures—like CT Scans, for instance—is also more expensive, but that doesn't mean the quality of care or the accuracy of the results is any better. Due to subsidies, the equipment required for a CT Scan reportedly costs 40% less in a third-world country like India than it does in the U.S., and the average cost of one contrast scan here could pay for dozens of similar tests in Mumbai. So what accounts for this discrepancy?

The U.S. is a nation filled with the best and brightest physicians and technicians who have attended some of the most respected and expensive universities in the world. The cost to our providers is bound to trickle down to their patients. But radiology isn't brain surgery; the cost of interpreting a CT Scan simply doesn't justify the exponential cost incongruities being shouldered by Americans. Technical and professional fees are part of the problem, but that doesn't explain how the cost of a test like a CT Scan varies so wildly in the U.S. (The fact that one has to "shop" for the best deal when it comes to potentially life-saving tests is obscene, but that's a whole other topic.)

One factor might be that the cost of treating the uninsured—or the underinsured, which was the subject of a front-page article in The New York Times last week—is built into the cost paid by those who can afford to pay. The radiology clinic where I had my CT Scan offered to drop off the contrast fluid I had to drink prior to my test and gave me a ride to and from the clinic on the day of my test. This was a service provided by the clinic and wasn't billed to me or my insurance (I know because I asked—twice). It was generous and helpful, especially since I'd never been there before and don't have a car, but they no doubt offer this "free" service to all of their patients, not just those who are insured. Someone has to pay for it. A country with 45 million uninsured is bound to see its health care costs skyrocket.

Universal coverage isn't feasible if large segments of the population are being priced out of the market. Blatant profligacy within the system, specifically of the variety Gawande has unearthed, means that prices won't be dropping any time soon. But ironically, it also means reform isn't a hopeless venture. Taking care of everyone doesn't mean the country has to go bankrupt or that we have to saddle our grandchildren with even more debt. If we're indeed wasting money, and that's recognized as a reality on both sides of the aisle, that means at least one buzz term, "efficiency," truly is the key to reform. Obama may be pointing one finger at the overweight, but as Gawande shrewdly observes, "the idea that there's plenty of fat in the system is proving deeply attractive." We just need to admit who the fat ones are.

Changing the culture is essential to solving the problem. Defensive medicine costs tens of billions each year. And doctors whose focus is not on patient care but on money—whether it's profit-motivated or simply a matter of survival—might not even realize they're part of the problem. The discussion draft of the House bill provides incentives for accountable care organizations, which are comprised of doctors and specialists who collaborate in networks—not for profit or kickbacks, but for results. These kinds of networks would purportedly discourage profiteering by changing the way doctors get paid through Medicare—paying physicians for results, not the quantity of service. Policymakers close to the bill say the details—how or if those changes are going to happen—haven't been worked out yet, but what Congress seems to have realized is that Medicare is a barometer for the entire health care industry. As Medicare goes, so goes the nation.

It's easy to blame one part of the system for the failure of the entire thing. But like the human body itself, health care is made up of the symbiotic relationship between separate but inextricably bound parts: providers, insurers, and patients. The House bill looks at the issue of reform from both sides: reforming delivery systems—how doctors are paid to create incentives for efficiency and quality—and adding a public plan to keep costs to consumers down. And while those goals might prove to be tricky (The Washington Post reported this week that a panicked health insurance industry is in full-on lobby mode, which means that even if a bill passes, it will likely be watered down), it's still only one part of the solution.

Legislating cultural change is an essential component to reform, and while that's likely to prove even more difficult, there has been some progress. At the beginning of the year, lawmakers introduced the Physician Payments Sunshine Act of 2009, a bipartisan bill that failed to make it through Congress two years ago but which, despite even stricter regulations, stands a better chance in the current economic and reform-happy climate. The legislation would amend the Social Security Act, requiring transparency in the relationship between physicians and pharmaceutical and biotechnology companies. The bill is currently under review, but even if it fails to pass a second time, the pressure has already forced companies like Pfizer and Merck to voluntarily disclose the amount of money they're spending on things like consulting gigs, speeches, meals, and gifts—and to whom.

Additionally, nonprofit organizations like Area Health Education Centers are taking steps to offset Pharma's influence on physicians. It's a little disturbing to think that your local doctor's office could be serving catered sandwiches for pharmaceutical reps who are hoping to peddle their latest inventions to the community via your family doctor, but that's exactly what's happening across the country. Doctors shouldn't have to choose between what's in the best interest of their patients and what's in the best interest of keeping their practices in business. And we shouldn't have to worry that our doctors aren't on our side.

This blog entry was originally published on Slant Magazine on the date above.

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TAGS: atul gawande, ct scan, rush limbaugh, the new yorker









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