08/27/2012 10:29 am ET Updated Oct 27, 2012

A Real Health Care Debate

The health care debate has become surreal. Politicians talk about fixes that bear no relation to real world experience. This is not surprising when one considers that the medical profession has no essential role in the discussion.

I practiced community hospital anesthesia for 20 years before leaving the profession in 2000, but keep close contact with many of my colleagues. At the time I retired, Medicare paid me less per patient than it did when I started in 1980. During those 20 years, I NEVER submitted a bill to Medicaid because the compensation was so low that it wasn't worth the trouble to do the paperwork. Apparently, things have only gotten worse for providers, according to my friends.

Did you ever wonder why you have all those itemized costs on your doctor and hospital bills? It seems that you get charged for the doctor walking into the examining room, walking out, taking your blood pressure, hitting your knee with his little hammer, etc. Many activities are covered by different billing codes, and the compensation for each of those codes is so low that the only way to make seeing Medicare patients profitable is to bill for all those separate codes.

In my last year of practice, I was on call on Easter Sunday. An elderly woman was brought to the operating suite that afternoon with a broken hip. Because of her many health problems, she needed to be cleared for surgery by her regular internist. He was off, and we got his covering doctor. His response, "I'm not leaving Easter dinner with my family for $35. Do her tomorrow." That was in 2000!

Medicine in this country, while still the best in the world (don't believe the doctored statistics), isn't what it was, because you're going to get what you pay for. The discussion always comes down to the same issue of how to avoid gutting health care while relieving the crushing cost burden of a service that is both tech- and personnel-intensive. It is already more difficult to get doctors to take Medicare and Medicaid patients than it used to be. The response is sometimes the establishment of "mills" that crank through patients at breakneck speed, and with the expected results. The solution is not to reduce further provider compensation.
What to do? The solution needs to be radical and multifaceted. Tort reform should be a part of the equation, regardless of the path pursued. But since we've decided as a nation that medicine is a business, simple business principles might be in order.

Some time back, big retailers realized that they were paying distributors an extra cut to get product from manufacturers to their stores. Some smart guy realized that he could deal directly with the manufacturer and cut out the middleman. The distributor rapidly disappeared from the scene with no apparent harm to the retail landscape.

How are the insurance companies any different? In 2011 they reaped record profits providing what? They don't practice medicine, and will, in fact, find any way possible to keep you from getting access while thinking of any gimmick possible to hold off paying your bills as they gain interest payments on that held money. The fact that both parties embrace ideas that include these companies in managing Medicare is unfathomable.

Think of diverting all those billions in profits toward simply lowering health care costs. The replacement: consortia of doctors and regional hospitals that sell insurance directly to patients. They could be competitive, forcing down costs. The policies would have riders to care for people hurt or ill while traveling. Federal and state governments could take an oversight role to prevent gouging and needless duplication of services, rather than trying to figure out fee schedules that don't work. Medicare could be folded in by providing a voucher that pays the entire premium in the system the person chooses. Medicaid could be handled similarly. The system would be tweaked at intervals as results were observed. And the overall system would be non-profit. Pharmaceuticals could be included, as well. All this is actually being done in some areas of the country.

It still won't be cheap. onservative economist Eliot Janeway once pointed out that maybe medicine has to be as expensive as it is or you can't have the medical care you want. How much care we want is another discussion. But however much that is, it will be more if we don't shovel billions of our health care dollars into insurance company coffers and receive absolutely no value added to our health care in return.

The problem, as always, is the politics. What will counteract the lobbying dollars the insurance companies use to paper the offices of representatives of both parties, or the patently inane arguments made by both parties in the heat of election season? The solution presented here may not be THE solution, but the point is that we need to start thinking about truly innovative approaches to our health care dilemma, or we'll simply continue to get less care for ever growing costs.