- The Washington Times - Saturday, May 16, 2009



Politicians tell us that it is the uninsured in our country, 44 million, who stress our health care system to the breaking point. They receive no preventive care, pay no insurance premiums and access the system when it is too late. This is why health care has to be reformed.

I have been a physician for more than 30 years, and it is painfully obvious that health care needs change. But I see it differently: When you walk a day in a doctor’s shoes, you may see why.

Early in the morning, in the driveway of any of our nation’s hospitals, you could see patients who were just discharged taken by wheelchair to their waiting cars. Some - who had major surgeries just 24 or 48 hours earlier - were barely able to stand or walk and were certainly not able to care for themselves.

Hospitals decided that further inpatient care was not cost-effective. The government already determined insurance reimbursements on which the actual cost of care for any of these patients had no bearing. Instead, payment was prospective, predetermined even before they were admitted.

The benchmark was called a Diagnostic Related Group, which essentially corresponded to a hypothetical patient with the same diagnosis. Furthermore, payment for care of this imaginary patient covered the most minimal utilization of resources possible. So, in efforts not to lose money and maybe even make a profit, hospitals became more economical by limiting the use of resources to the shortest possible time. Afterward, care would still be delivered, but by cheaper caregivers in cheaper facilities, most often by a patient’s family and in a patient’s home.

We, your doctors, knew that the risk of overlooking complications was greater after patients went home than if they stayed a day or two longer, but still, we bought into this new economy. It was a false economy, though, because the re-hospitalization of only one patient with a totally preventable postoperative complication at home could easily wipe out the entire savings from every discharge that day. One way to reduce this risk and these costs was to increase prospective payments to allow a day more in the hospital, but instead, politicians decided to reduce only the costs by simply denying payment for totally preventable complications.

Later in the day, by spending a few short minutes at the service counter of any pharmacy in the country, you might see a senior citizen picking up a prescription that was filled every month for the last couple years.

Today, however, his Medicare health-maintenance organization (HMO) concluded this medication was no longer cost-effective and dropped it from its prescription plan. To condition doctors to prescribe only those drugs the Medicare HMO deemed cost-effective, politicians have determined that doctors who complied will be paid more than doctors who used discretion when prescribing what they deemed genuinely the safest and most effective drug for the actual - not a hypothetical - patient. Politicians called it “payment for performance.”

Finally, if you were like a fly on the wall in any doctor’s office watching patients enter, one in particular would catch your eye. She was a patient for years. However, after presenting her insurance card and casually commenting, “We changed insurance at work last month,” the receptionist politely told her, “I’m sorry, but the doctor isn’t part of this health plan’s network.”

Now, realizing that this office visit was not covered by the usual $15 co-payment, she angrily stormed out.

Walking out was exactly what the health plan wanted. It was determined to keep this patient inside their network. That way, it was confident that all her doctors were conditioned to the economics behind hospital discharges or prescription drugs.

However, what if she got sick and did not fit the standard profile for the hypothetical patient with that illness, and what if her doctor was so conditioned by the health plan that he could no longer tell the difference?

So, you see, none of these observations escape doctors. All involve patients with insurance who pay premiums and get preventive care. Not only that, but they also get all their care at a discount because venders who participate with insurance offer discounts. The 44 million uninsured are not a major factor in these costs - not really. It is just wrong for our country to have any uninsured.

The uninsured do not get free care either. They pay out-of-pocket, and furthermore, they get no discount. This is the status quo, and when you add skyrocketing operating expenses for doctors and hospitals - not the least of which are medical-liability premiums - you will find that these are the reasons hospitals cut services and doctors do what it takes to survive.

Health care needs to change. However, health reform that only addresses the uninsured without fixing the status quo will guarantee that either the health care system goes bankrupt or - worse yet - becomes totally ineffective.

Howard Smith is a practicing physician, an associate professor at George Washington University, a consultant for FairCode Associates and a health policy adviser for Plexus Consulting.

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