Rationing Care by Driving Doctors Out of Practice

The discussion about rationing health care is not new. In fact, in my memory alone it is almost 30 years old

I learned about how costs in health care are shifted and rhetoric is used to mask the issues when my marketing company worked on the messaging for one of the first HMOs in the country in 1980. HMO used to mean Health Maintenance Organization. We thought if we kept people healthy, we could lower costs and increase quality of life. We were a bunch of dedicated people trying to encourage prevention. Our second in command had a degree in public health and was committed to wellness and prevention.

Our message about taking responsibility for your health immediately got translated by others as "rationing" and "lack of choice about your doctor" -- by other insurance companies wishing to preserve the status quo and charge higher premiums -- and we became, by necessity and by virtue of our own success in attracting employers to our original model, a public company that did something we never intended to do, we gave up the prevention concept. All the original people with the mission and vision left, and the money men still run the company, which has been merged into a much larger company.

We were defeated because HMOs were seen as "rationing," meaning denying care. But every insurance company now rations care way more than we did.

Although the American insurance giants would like you to believe it does, Canada does not ration care. My son-in-law's mom has breast cancer. She lives in a small rural town in Canada. After she was diagnosed, she was given access to specialists in Montreal immediately, and taken there for treatment. No waiting. At least no more than an American would have today getting access to a surgeon. She is now on a clinical trial. She has no medical expenses.

My daughter lived in Amsterdam for three years. She could walk down the street into the doctor's office and get seen immediately, and she had no medical expenses. Yes, the Netherlands doesn't pay for exotic things like in vitro fertilization, but she had no problems with access or rationing of essential medical care. And no medical bills.

But never mind the patient. What about life under the American system for the doctor? Here's something most Americans don't get: providers (doctors and nurses) are leaving the current system in droves. That's why there's no access to care. The docs hate the current insurance system (not the MEDICARE part, because MEDICARE pays quickly though low) but because it takes them 90 days and a blizzard of paperwork to get paid when they bill an insurer. Cash flow issues are driving them out of business, which means it is more difficult here to get in to see a dermatologist than, say, in Canada.

Banks, which used to look upon physicians as cherished client, won't lend to them anymore. The reimbursement is too slow and too unpredictable. So the banks won't finance the docs who are coming out of school. They can't start practices. The old cottage industry of medicine, where doctor and patient had a relationship, is gone.

It may not appear to be gone in your individual case, but in the aggregate it is gone, and when your doctor retires or goes out of practice or drops your insurer in disgust, it will be gone for you, too.

I'm 68. I am the widow of a doctor. I worked for an HMO. I've seen it all historically, and I know where it's going.

Don't let reform go down. Rationing will happen with or without it. At least with reform you may be rationed by an objective committee, rather than by having the last doctor in your town go out of business.

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Comments

[KenKo]

Francine, thank you for the insights and your validation of our Canadian health care system. Too many Americans are needlessly scared off systems like ours by the sound of the word "socialism" without looking into why so many industrial countries adopted them. My partner who works in an US insurance company is also disgusted at the levels of complexity that insured "consumers" have to endure to get approval for health care. I think that's the crux of the problem. In Canada, we have patients but in the US, you have consumers. As long as health care is seen as a commodity like eggs or cars instead of a public good, there will be no doctor-patient relationship. On the bright side of this debate, as least Americans have shown us debates can be passionate because you do care about the issue. Up here, it's difficult to have debates like these without accusations of being radicals. In the end, I do hope your country is able to offer affordable health insurance to those who cannot currently get it. That in the end is everyone's goals.

[francinehardaway]

But guess what? The Canadians are also considering re-vamping their system and opening it to competition for public dollars, judging by an article I read in the Vancouver Sun, because they are short money to fund the system just as a we are.

[nomoron]

I've been working directly with patients for more than twenty years and I think the problem will be much worse than simply rationing care if reform is not inacted. I can't tell you how many times I've encountered physicians so frustrated with the current system they don't hesitate saying if they had it to do over again they'd never considered medical school when considering a career. It's pretty clear that without reform the people can count on a system in which insurance doesn't exist, medicare and medicaid are bankrupt and the only people with access to healthcare will be those with the resources to pay up front. The rest of us will be out of luck. This is what's most disturbing.... There are so many people out there who lack the insight to understand these things will come to pass, yet are so scared of change they don't realize they're fighting against their own interests. Unfortunately there seems nothing anyone can say that'll change these folks behavior.

[valboski]

social security
medicaid/medicare
cash for clumkers
us postal service
amtrak
All operating in the red, broke and sucking on the public teat...let's add to it!

[johnashman]

I'd really love to know how many of these 'clunkers' were even in use before being traded in. Were all these people sitting around waiting to buy a new car, but, shoot, they were short $4K? I mean, if your car is a 1970/80s POS, is it because you didn't have an incentive or because you just plain can't afford a new car or don't have the credit? And is $4K suddenly going to give you good credit or the rest of the money? I doubt it. I would love to hear the stories of how normal people played the government by dusting off grandma's car and pushing it into a dealership. There's no way there's no monkey business going on.

[doe26]

Just something to think about.... a quick news report on NPR the other day reported a nostalgic car group successfully lobbied to exclude cars 1984 and older from the clunker program because they are considered "classics" and because those used parts were in demand by repair/refurbish shops. An estimated 5 million of these vehicles are still registered with the DMV yearly.

(Also,Review the clunker program, the vehicle must be driveable)

The program was an incentive program...I doubt the greasemonkey teenager, minimum wage low income working single parent, and fthe future collectors/used car lot owners who are most likely the owner of these vehicles, even considered the clunker program an option to them.

Ask the 1350 GM workers being called back to meet the clunker demand and the 2 jobs to every auto worker job that supports auto manufacturing if they think it's "monkey business." They don't care....they're back to work and back to paying taxes on those paychecks.

[RadCenter]

You obviously have no rational response to the actual points raised by the poster, so by all means continue to spew the latest Fox News talking points; it makes you appear oh-so-clever.

[Akira Hirai]

The root cause of so many of the world's problems can be traced to ignorance and intellectual laziness (including the big ones like poverty and peace).

People hear words like "rationing" and automatically assume (or are told to assume) that it is a bad thing, without taking the time to understand exactly what it means. If only more people would take the time to read and digest information like "Why We Must Ration Health Care" in the NY Times (http://bit.ly/tvc3q) we would be able to have more meaningful discussions about how we solve our problems.

Alas, a Global Campaign to Eradicate Ignorance is going to be 1,000,000x more difficult than the campaign to eliminate polio.

[johnashman]

Yes, however, the government is naturally not good at growing services at lower costs like the private sector is. Look at any monopoly or government agency. Has the post office ever been able to lower the price of its service like other companies? How long has it been operating in the negative? Why can't it simply switch to 3, 4 or 5 day delivery? Do we NEED mail every day? What about M/W/F? Instant profitability! BUT, the government is too slow. Need another example? Why do schools let kids out at 2:30 or 3:00 every day when there are no parents home? Well, because they need to go home and feed and milk the cows, of course! That is how slow government reacts sometimes. Medicare costs are doubling every 4 years. It's a single payer system. How can it not control costs? What happened to the magic wand?

So, if people readily hear the word rationing and are scared by it, it's because government has *always* fallen short of its promises and has been unable to control costs. I can count on FedEx. But the government? Not so much. Don't blame the people for healthy skepticism.

[Akira Hirai]

Wait - you're arguing that the private sector got healthcare right? You're happy with what you have now? Other nations are achieving better health outcomes (the U.S. ranks #37 - http://bit.ly/wWEj3) while spending less per capita (the U.S. spends most per person - http://bit.ly/191Ssg). And you're happy sticking with that? Do you work for the insurance industry or something?

As for the postal service, you're perfectly welcome to offer a private alternative to the USPS. If you (or UPS or FedEx) can deliver a letter between ANY two addresses in the U.S. in a few days for less than the $0.44 charged by the USPS, I'll gladly use you. Does the USPS contain inefficiencies? Sure, just like any large organization, public or private. It does run at a slight loss, but as a percentage of revenue, it's pretty small - close to break even. All things considered, it's a pretty amazing organization.

Also, just why is it necessarily bad for certain services to be subsidized? Your interstate highway system don't turn a profit. Neither does the military, or law enforcement.

And finally, I have no idea how you can claim Medicare costs are doubling every 4 years. Medicare cost increases have been comparable to private healthcare - either a little higher or lower, depending on whom you ask, what you measure, and how you measure it (here is one of many sources: http://bit.ly/pfvpH). But it is certainly not doubling every 4 years.

[francinehardaway]

Yes. I am a person who believes in a certain kind of rationing -- if you don't take care of your health, the system will not bail you out: i,e, smoking, obesity, etc.

[S1m0n]

It can be hard to see a dermatologist here in (parts of) Canada, too. On the whole, doctors like to be in cities. Or doctors these days are much more likely to have wives (actually, husbands; more women graduate from med school than men) who have careers, and whose job prospects are better in cities than the sticks.

So if you live a long way from a teaching hospital, it's harder to find a specialist you don't have to travel to. If it's an emergency, that'll happen, as the woman with breast cancer discovered when she was flown to Montreal for treatment. Where things get sticky is in the middle ground, where it's not an emergency, and where you'd like to see a specialist but you're not sure you want to badly enough to travel for it.

[Bluesue]

In the U.S. it is also difficult to find doctors in rural areas. Some rural communities have paid for a person's medical training in return for them practicing medicine in that community for a period of time. My community isn't exactly rural but is a small town. I had a female doctor at a medical practice associated with a large medical center. However, she recently left for the Boston area. She was the only female doctor in that practice and when I asked why she said in the case of female doctors, there's very little job opportunities in a small town for their husbands.

I have to see an dermatologist for a skin issue on my ear. First, there are no dermatologists within a 50 mile radius who participate in health insurance. Therefore, I will have to pay a higher deductible and co-payment and a balance since the cost will be more than the approved usual, reasonable, and customary fee. Second, as a new patient, after calling around I learned I have to wait 8 to 12 weeks for an appointment.

I also had to wait 6 weeks for an appointment with an ophthalmologist when my optometrist saw my eye pressure was elevated. The opthalmologist diagnosed glaucoma.

The Republicans like to pretend our health care is instantaneous.