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Rationing Care by Driving Doctors Out of Practice

09/05/2009 05:12 am ET | Updated May 25, 2011

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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