Enshrining the status quo...

We can tell a lot from the groups that have come out in support of the Senate's insurance reform bill and from those whose "opposition" is muted and disingenuous. The American Medical Association supports it, but threatens to withdraw support if the Sustainable Growth Rate formula isn't overhauled. Translation: We like the current dominance of fee-for-service reimbursement through third-party payors because it protects the incomes of most of our members who are specialists. We just wish the formula paid us even more.

The American Hospital Association supports it, but would also like provisions added that reduce the threat of Medicare reimbursement reductions for hospitals with high readmission rates. Translation: Like the AMA, we too like fee-for-service reimbursement based on volume of procedures and tests rather than quality. The system of disease focus rather than health focus serves us well as we're clearly in the disease business.

The Insurance industry publicly "opposes" the bill under the veil of "we care about our members - and think their premiums are going to go up." Simultaneously, they've quit spending much money or energy on stopping this thing, which they could clearly do if they wanted as a number of Democratic Senators are tied very tightly to the insurance lobby.

It's a classic and usually effective political strategy. They've set up the "I told you so defense" in advance so they can raise insurance rates after the no-preexisting conditions rules kick in. They then profit nicely from increasing premiums while the new laws force younger, typically healthier-than-average, and thus profitable people to buy insurance they previously decided they didn't need. Beautiful perfect storm. The Democrats provide the publicity cover, and the Insurance industry gets a mandate to take over even more of the health care pie.

Speaking of pies...by what logic does the growth of this pie slow under this plan? We provide more people with someone-else-pays-for-it access to a system still based upon doing rather than thinking, testing rather than listening, and treating rather than preventing. Any claims of cost savings are completely baseless...and cost containment is the whole deal. There's no reform without it.

Primary Care's Toxic Environment

In his blog (linked below), Dr. Richard Figaro captures the toxic environment that is killing primary care in this country.

Crocodile Tears Over Primary Care - Lamenting Primary Care

I agree with his points but wish he would emphasize that primary care doctors are not powerless. Patients respect and value what we do and in my experience will pay us directly for their care. Refusing to submit to the nonsense that DrRich describes in his blog is the most important step to keeping our costs low so the price of great care is accessible. See my practice website, www.poncepreventive.com, for specifics on how this can work.

Marital status needed to make an appointment?

Bizarre experience today as I again experienced as a patient the parallel universe that is healthcare in the U.S.

I'm turning forty this year so decided to make an appointment for a physical with my primary care doctor. I called the office and was told that the next physical available was at 3:30 pm six weeks from today. Not commenting on the lack of reasonable access, I asked if an early morning appointment was available so I wouldn't have to fast all day before my visit. "Why does that matter?" asked the receptionist. I can't imagine why it would be more unpleasant to not eat until 5:00 pm than to delay breakfast until 10:00 a.m. The receptionist couldn't imagine that either. She then informed me that the next morning physical available was in April. I'm an established patient of the practice that espouses access, quality, etc. all over it's website and they can't see me until April.

So I call another practice...a big one here in Atlanta with a strong, serious reputation. Access is better (three weeks rather than six until their first appointment), but the person on the phone proceeds to "get my information." Included in this antiquated process is the question "Are you married, single or divorced?" What? Why is my marital status the business of whoever answers the phone at a doctor's office? How is it relevant to my making an appointment with a physician? In addition, what if I were "none of the above"? I was tempted to say, "I'm a gay male previously divorced with six kids, now married in Massachusetts which isn't recognized in Georgia - so just call me single." Would have been great to hear the silent pause after that. Many of you know that I'm neither gay nor divorced and have two kids. I've only been to Massachusetts a couple of times in my life. The point is that the question would never be asked in any industry that treats clients like customers. It's rude - like a lot of healthcare in the U.S.

Thank you Senator Lieberman

There have been some good ideas and some horrendous ideas appear this year as part of the health insurance debate. Expanding Medicare was probably the worst apple that has fallen from the idea tree. It now appears we were one Senate vote away from significantly expanding the wasteful, bankrupt pyramid scheme that is Medicare. Senator Lieberman has shown real political courage this week and done the country a great service by halting the nonsense.

Medicare a "pyramid scheme"? This may sound harsh, but the fit is too tight to ignore. In a pyramid scheme, current benefits are paid to previous investors out of funds provided by current investors. That works fine until the number of new investors becomes insufficient to pay the current benefits at which point the scheme collapses. Hmmm...sounds like Medicare today to me. As the baby-boomers age and retire, the cost of their healthcare expands as the number of workers paying into the system declines. It would be hard to call this a pyramid scheme if it were just bad luck or circumstances, but we've known for decades that the demographics of the U.S. would lead to this. We just chose to do nothing about it.

We have a moral contract with our seniors to provide them with accessible, quality healthcare. Medicare is our very flawed attempt to honor that contract. The problem is that Medicare, like most health insurance, is procedure driven. Doctors and hospitals get paid more for doing than thinking, more for testing than listening, and much more for treating than preventing. The evidence is found in answers to simple questions: Is it easier to find a surgeon who accepts Medicare or a primary care doctor who accepts Medicare? Is it easier to see a nutritionist and have Medicare cover the $100 fee or have Medicare cover the thousands of dollars of cost when the preventable heart attack occurs? Does Medicare pay doctors for outcomes like the health of their patients or inputs like the tests and procedures performed? The answers to all of these questions are disappointing.

Expanding Medicare in its current form would quicken the already alarming reduction in access to quality primary care in this country. Doctors are leaving and avoiding primary care in droves. The administrative trivia imposed on primary care by the byzantine system of coding, justifying, and compartmentalizing care has made primary care a particularly unappealing professional choice. We need to create and finance a system that reverses the current incentives and priorities. Adding millions of people to a collapsing system looked for a week like a way to pass a bill, but the approach made zero sense if the goal is to actually reform the system.