Comments on: Report on Dr. Oliver Fein’s talks in Huntsville, Feb 2010 http://northalabamahealthcareforall.org/2010/02/report-on-dr-oliver-feins-talks-in-huntsville-feb-2010/ Health Care for All Sun, 07 Mar 2010 16:29:55 +0000 hourly 1 http://wordpress.org/?v=3.0.1 By: Pippa Abston, MD, PhD http://northalabamahealthcareforall.org/2010/02/report-on-dr-oliver-feins-talks-in-huntsville-feb-2010/#comment-9 Pippa Abston, MD, PhD Sat, 06 Mar 2010 23:02:17 +0000 http://northalabamahealthcareforall.org/?p=377#comment-9 Dr. Goldstein, former president of MASA, came to Huntsville to present an opposing view to Dr. Oliver Fein, president of Physicians for a National Health Program, on February 27, 2010. Many of the points both doctors made were similar-- they both want improvements in quality, cost and access. Unfortunately, the reasoning Dr. Goldstein used had some significant errors that I want to be sure to present here in detail. 1. The number of insurers is the "cart, not the horse." The solution for cost is to avoid unscheduled visits, unnecessary ER visits, and unnecessary hospital care, and for access to solve problems of physician distribution in rural areas. Response: the number and type of insurers is actually a major problem for both cost and access. Because private insurance involves a much larger overhead than a public insurer like Medicare, and because doctors have to spend so much on multiple complicated billing procedures (every insurer has different rules), up to a third of our health care money is being wasted on administrative costs and profit. If we were able to take that wasted money and use it for actual healthcare, we would be able to pay for the uninsured to have access to physicians and to improve the coverage given to the currently insured. Patients in rural areas are more likely to be living in poverty and more likely to be uninsured. Because this severely limits physician income in those areas, it is one (not the only) factor that discourages physicians from moving to rural locations. If patients in those areas had insurance, at least rural physicians could be promised a fair salary compared to their urban counterparts. It is true that physician distribution (urban versus rural) continues to be a problem that both sides agree must be addressed-- but that should not prevent us from doing this relatively simple thing to guarantee access to physicians already in practice. 2. "All ER patients have to be seen. That is the law." Response: that is a falsehood. The law says they must be screened and only treated if they have an emergency. Dr. Goldstein is right that some patients get labeled incorrectly as an emergency so that the ER can get paid and to prevent lawsuits, but that is definitely not always the case. As a practicing pediatrician, every week I have patients come to the office who were sent over by the ER and not seen there due to the problem being non-emergent. The ER will also NOT screen and treat you for chronic illnesses. You can't go to the ER and say "everyone in my family has high cholesterol (or diabetes or breast cancer) and I need to get checked." They won't do it. They will treat you after you have a stroke that could have been prevented with earlier medical care. 3. Physicians can't get paid for preventive counseling, so they don't do it. Response: that is not true. There is a time factor built into the office visit codes so that if a physician spends more than 1/2 the visit counseling or coordinating care, the payment for that visit goes up. It is true that the counseling and cognitive work is not paid fairly in comparison to procedures, but it is a lie to say it isn't paid for. 4. "Why do we care who makes the profit?" It doesn't matter who profits from healthcare spending-- only the quality of care counts. Response: it matters very much who makes the profit! With so much profit going to administrators who aren't adding quality to healthcare, the money we have left to pay for access and quality is limited. If that money now going to profit insurers were going to pay healthcare providers, we could afford more and better care. It also matters if physicians are inappropriately profiting from self-referrals to physician-owned facilities. The profit motive is known to affect clinical decision making and adversely affect the quality of care. 5. Public insurance would ruin the doctor patient relationship. Response: at present, private insurers are destroying the doctor patient relationship, by interfering with the treatments physicians can offer patients, by arbitrarily limiting physician panels so that patients who change jobs have to change doctors, and by requiring copays and deductibles that discourage patients from seeking needed care. If we had a single public insurance for all patients, you could see any licensed physician you wanted to. Physicians would be put back in charge of deciding how to take care of their patients according to the best evidence. 6. In rural areas, physicians are content to be paid on a barter system. We should be free to adjust our charges and accept alternative payments from the poor, and that would solve their financial barriers to access. Response: this is just not true. Poor patients in rural areas who can't afford care usually just don't get that care. And before insurance contracts that prohibited variable pricing, the poor still did not have enough money to pay for care. A physician might be able to waive an office visit fee, but she probably can't provide a free mammogram, surgery or chemotherapy. Physicians are often charitable and kind, but not enough to pay for everyone who needs care. 7. Competition is the answer. Response: we already have multiple examples of competition, and it has only served to increase the cost of medicine. In areas with multiple insurers, insurance is not cheaper. In areas with multiple hospitals, huge amounts of money are wasted on duplicating services and competitive advertising. As Dr. Fein said, if you don't like the medical care you receive, you can't return it the way you could a pair of shoes. And competition ,even with transparency, will not help you make the right decision when you are seriously ill and need urgent medical care. Dr. Goldstein did make some very good points, which made me wonder if he could be interested in universal single payer insurance after reviewing the facts. He admitted, with refreshing honesty, that he didn't know all the facts about single payer. He said that the practice of medicine and business was incompatible and that medicine is a profession. He said everyone should have health insurance that is meaningful, and that physicians should always be the patients' advocate. He said every bit of money we can save counts. And he said we need to develop a flexible system with a long-term view. What we can say to Dr. Goldstein and other conservatives is that we agree on those goals! And we have the facts in hand right now to show that a universal, not for profit, single payer, improved Medicare for All would meet every one of those goals. Dr. Goldstein, former president of MASA, came to Huntsville to present an opposing view to Dr. Oliver Fein, president of Physicians for a National Health Program, on February 27, 2010. Many of the points both doctors made were similar– they both want improvements in quality, cost and access. Unfortunately, the reasoning Dr. Goldstein used had some significant errors that I want to be sure to present here in detail.
1. The number of insurers is the “cart, not the horse.” The solution for cost is to avoid unscheduled visits, unnecessary ER visits, and unnecessary hospital care, and for access to solve problems of physician distribution in rural areas.
Response: the number and type of insurers is actually a major problem for both cost and access. Because private insurance involves a much larger overhead than a public insurer like Medicare, and because doctors have to spend so much on multiple complicated billing procedures (every insurer has different rules), up to a third of our health care money is being wasted on administrative costs and profit. If we were able to take that wasted money and use it for actual healthcare, we would be able to pay for the uninsured to have access to physicians and to improve the coverage given to the currently insured.
Patients in rural areas are more likely to be living in poverty and more likely to be uninsured. Because this severely limits physician income in those areas, it is one (not the only) factor that discourages physicians from moving to rural locations. If patients in those areas had insurance, at least rural physicians could be promised a fair salary compared to their urban counterparts.
It is true that physician distribution (urban versus rural) continues to be a problem that both sides agree must be addressed– but that should not prevent us from doing this relatively simple thing to guarantee access to physicians already in practice.
2. “All ER patients have to be seen. That is the law.”
Response: that is a falsehood. The law says they must be screened and only treated if they have an emergency. Dr. Goldstein is right that some patients get labeled incorrectly as an emergency so that the ER can get paid and to prevent lawsuits, but that is definitely not always the case. As a practicing pediatrician, every week I have patients come to the office who were sent over by the ER and not seen there due to the problem being non-emergent. The ER will also NOT screen and treat you for chronic illnesses. You can’t go to the ER and say “everyone in my family has high cholesterol (or diabetes or breast cancer) and I need to get checked.” They won’t do it. They will treat you after you have a stroke that could have been prevented with earlier medical care.

3. Physicians can’t get paid for preventive counseling, so they don’t do it.

Response: that is not true. There is a time factor built into the office visit codes so that if a physician spends more than 1/2 the visit counseling or coordinating care, the payment for that visit goes up. It is true that the counseling and cognitive work is not paid fairly in comparison to procedures, but it is a lie to say it isn’t paid for.

4. “Why do we care who makes the profit?” It doesn’t matter who profits from healthcare spending– only the quality of care counts.

Response: it matters very much who makes the profit! With so much profit going to administrators who aren’t adding quality to healthcare, the money we have left to pay for access and quality is limited. If that money now going to profit insurers were going to pay healthcare providers, we could afford more and better care.

It also matters if physicians are inappropriately profiting from self-referrals to physician-owned facilities. The profit motive is known to affect clinical decision making and adversely affect the quality of care.

5. Public insurance would ruin the doctor patient relationship.

Response: at present, private insurers are destroying the doctor patient relationship, by interfering with the treatments physicians can offer patients, by arbitrarily limiting physician panels so that patients who change jobs have to change doctors, and by requiring copays and deductibles that discourage patients from seeking needed care. If we had a single public insurance for all patients, you could see any licensed physician you wanted to. Physicians would be put back in charge of deciding how to take care of their patients according to the best evidence.

6. In rural areas, physicians are content to be paid on a barter system. We should be free to adjust our charges and accept alternative payments from the poor, and that would solve their financial barriers to access.

Response: this is just not true. Poor patients in rural areas who can’t afford care usually just don’t get that care. And before insurance contracts that prohibited variable pricing, the poor still did not have enough money to pay for care. A physician might be able to waive an office visit fee, but she probably can’t provide a free mammogram, surgery or chemotherapy. Physicians are often charitable and kind, but not enough to pay for everyone who needs care.

7. Competition is the answer.

Response: we already have multiple examples of competition, and it has only served to increase the cost of medicine. In areas with multiple insurers, insurance is not cheaper. In areas with multiple hospitals, huge amounts of money are wasted on duplicating services and competitive advertising. As Dr. Fein said, if you don’t like the medical care you receive, you can’t return it the way you could a pair of shoes. And competition ,even with transparency, will not help you make the right decision when you are seriously ill and need urgent medical care.

Dr. Goldstein did make some very good points, which made me wonder if he could be interested in universal single payer insurance after reviewing the facts. He admitted, with refreshing honesty, that he didn’t know all the facts about single payer. He said that the practice of medicine and business was incompatible and that medicine is a profession. He said everyone should have health insurance that is meaningful, and that physicians should always be the patients’ advocate. He said every bit of money we can save counts. And he said we need to develop a flexible system with a long-term view.

What we can say to Dr. Goldstein and other conservatives is that we agree on those goals! And we have the facts in hand right now to show that a universal, not for profit, single payer, improved Medicare for All would meet every one of those goals.

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