The Five Dirty Words of Health Care Reform
As a practicing physician for 30 years, I can readily testify that health care is in need of repair. It now appears that we as a society are finally ready to attack the problem in a meaningful way. I am fearful, however, of the way in which the present debate is being framed. Words matter, and when I look closely at the language of health care reform I see many problems. To make the health care debate honest and sensible, we need to remove what I would call offensive language. If we could just remove five words — five dirty words that are actually just misleading vulgarities — then the health care debate can truly begin.[IMGCAP(1)]StakeholderThe word “stakeholder— is invoked at the beginning of every meeting on health care reform, punctuates the start of every Congressional committee meeting and is flashed like a picture of a grandchild at every press conference. However, most of these so-called stakeholders are pseudo-stakeholders. Megalithic hospital conglomerates, auto manufacturers, the government, or, God help us, health insurance companies are not stakeholders. There are only two real stakeholders in health reform: the patient and the caregiver. All health care funnels through them. They are the most important part of and the final common pathway for all health care delivery.When you hear or read about yet another meeting of stakeholders, realize that 90 percent of those in attendance do not care for the sick and will never be at the bedside of a sick patient. The present health care system is rife with profiteers who view health care as a good business investment. Fancy hospital rooms, MRIs, endless billing codes, e-prescribing, new computer systems, etc., are all peripheral to the real business of healing. We must get the pseudo-stakeholders out of the way.The most dangerous pseudo-stakeholders are health insurance companies. They restrict patient access and try to regulate physician behavior, yet provide no value to the patient or caregiver. What do the insurance companies do except take profits and deny patients treatments and access while drowning the physician with paperwork and meaning codes for diagnosis and treatment? Do they make us safer or healthier? Almost no one believes that. A recent USA Today/Gallup poll asked Americans who they trusted to make health care changes, and physicians were ranked the highest while only 4 percent trusted the insurance companies. If 96 percent don’t trust you, you are not a stakeholder; you are dangerous. If we protect and preserve the special intimate relationship between the ill patient and healer, we will go a long way to “fixing— the health care system and cutting costs. Coverage Coverage is not care and should not be the goal of health care reform. Just ask the vast majority of Americans who have insurance coverage but who are not able to get access to medications, procedures or their caregiver of choice. Many studies show that even patients with coverage are paying increasingly high deductibles and percentages of charges for less care, less access and increased hassle. A Consumer Reports investigation revealed that insurance plans are so riddled with loopholes, limits and exclusions that if a patient falls seriously ill they are often left with crushing medical debt even though they have coverage. Coverage has become less for more — less care for more cost. Forcing the insurance companies to lower their premiums will not solve the problem. They will only pass the loss on to patients by providing even less service. It has become fashionable for pseudo-stakeholders in the health care debate to offer coverage as a promise to the uninsured, but in reality, “coverage— is a cruel joke. Health care is broken, (and not just its cost), and year by year it gets worse, even for those with coverage. The delivery of health care has become increasingly impersonal, at times even heartless. Physicians are allowed less time with patients because they must maximize profits for their megalithic corporations. Insurance companies prefer to pay for tests and procedures and not for thought and compassion. Nurses are replaced by aides to maximize hospital profits, and more time is spent in documenting billable activities than caring for patients.We all know that the bicycle is broken, but the best answer we hear from pundits is coverage for the uninsured. So, for you poor folks without insurance, we are going to spend a trillion dollars to give you the same broken and dangerous bicycle we already have. Real solutions require honest language. Coverage is neither the problem nor the solution. It is the wrong answer to the wrong question. Yes, we want all people to have good medical care, but subjecting those without coverage to a tragically faulted insurance system is almost callous. Provider and Consumer Provider and consumer are the most subversive of the five dirty words. When we fall ill — and most of us will — if we are consumers instead of patients, then we are doomed. Patients have anxiety, are fragile and suffer, but a consumer is merely part of a simple business transaction. The major transaction is the exchange of money, not care. And of course the provider delivers a service, a diagnostic and procedural code that is then sanctified by the insurance company so the all-important money exchange can take place. The compassion, the shared understanding, the human touch that a physician must give, these are not covered in the consumer-provider code book. The patient-physician relationship is special and the bond developed demands mutual trust, respect and compassion. I have cared for thousands of patients in my 30 years of private practice, but never once have I cared for a consumer. When health care became a huge profit-making business, those who made the profits had a stake in painting health care as just another business exchange. It lowers the consumer’s expectations, limits the provider’s obligations and helps the bottom line. According to Standard & Poor’s, profits at 10 of the country’s largest publicly traded health insurance companies rose 428 percent from 2000 to 2007.What does the medical insurance industry provide for these increasing and distasteful profits? In our present insurance system, physicians often have to call an insurance company to obtain “authorization— for a state-of-the-art treatment. Even if I know from my 30 years of experience that it is the best and most appropriate medication for my patient, I am required to justify it. My first contact point is often someone with an extremely low level of medical sophistication. They may even mispronounce the medical terminology. At best I get antagonism and double-speak followed by a maze of appeals; at worst I am told that the patient must first fail on or have negative side-effects from cheaper, older and often less-effective medications before the patient can receive my selected treatment. Even then, the patients may have to pay a substantial percentage of the cost. Is the nonprofit medical world any better? Well, at least for Medicare, the answer is usually “yes.— The voice on the other end of the Medicare line is often friendly and they are not making more profit by rejecting my request. QualityQuality has many connotations, and not all of them are offensive, but often in the course of the health care debate “quality— is used in a boorish and rude manner. Is there a problem with quality health care in America? That is a complicated question, but with a few years and a thousand or so practicing medical specialists around the world, we could form a reasonable debate about health care quality. But health care delivery is the real problem. Health care media pundits, shunning complexity, highlight isolated measures like infant mortality or the number of MRIs ordered per thousand patients and conclude that America lacks quality health care. Quality in this case is merely a code word for money spent. I believe that American health care is the best in the world, but that is debatable. However, there is no doubt that the delivery system, with its interference by profit-making stakeholders, degrades health care’s effectiveness and increases its cost. Infant mortality is a complex social issue, and the health care system is no more responsible for it than it is for the high incidence of divorce or starvation in the inner city. If the debate is really only about cost, then don’t use quality as a smoke screen.PreventionLast, but certainly not least, is my favorite word: prevention. It has become like the words “wind power— are for the energy crisis. Unfortunately, prevention will not be the savior of our health care cost crisis. In fact, as any doctor will tell you, if you die suddenly of a myocardial infarction at 55, you will cost the system a lot less money than if you live 30 years longer and die of the diseases of aging. Trust me, you are going to die. This is a sad fact. Preventive care and emphasizing good health behaviors are important, but emphasizing preventive care as a cure-all for health care costs and our broken system is nothing more than obfuscation. For many people, more than 50 percent of their lifetime medical care costs are spent in the last year of life. Preventive care is good, but we will still eventually get ill and die. Although we should continue striving to improve the quality and healthy times of every American’s life, we will not save health care costs or fix the health care system by having more preventive care. Certainly, we need to perfect the compassion and care at the end of life as well, but I believe we stand a better chance of reaching those goals if we get the profit-makers out of medical care. Once we understand and remove these five dirty and misleading words from the health care reform debate, we can replace them with a few meaningful words to help guide the reformers: CourageFrom our lawmakers, we need courage. The health care profiteers are some of the richest and most powerful institutions in the country. Their lobbyists are everywhere. They make the tobacco industry look like paupers, and it took decades for us to begin to restrict that lethal chemical. We need the courage to confront the pseudo-stakeholders and remove them from the debate because we will all one day be patients. The special interests have controlled medicine for too long, and they must be removed from the debate just as they have been in the rest of the civilized world because they are not part of the medical relationship.TrustWe must trust physicians. When we are sick, we place ourselves in the hands of our physician, literally entrusting him or her with our lives. Yet, the health profit industry has been relentless in its attempts to destroy that special patient-physician relationship and to wrestle away any control the physician might have on the delivery system. And they are winning. Insurance companies require physicians to document the most menial of interactions, and to explain any deviations from their rigid and ill-informed ideas about therapy. Insurers institute therapeutic restrictions based on cost, which they justify with often poorly understood and inadequate data. Do you want your physician spending his time thinking about the complexities of your illness or documenting meaningless drivel to the insurance company? The insurance industry operates under the philosophy that if it is not documented in the chart, it didn’t happen. In what other important situations is this concept allowed? Imagine a 747 pilot who, instead of flying the plane, would be forced to document his thinking moment by moment to the airline passengers’ insurance company, which is composed of non-pilots. How worthless is this act in a time of crucial decisions? When did the documenting become more important than the result? At least half of my solo practice medical costs are from documenting, coding, billing and pleading with insurance companies to allow me to care for patients. Entrusting your life to your physician yet making him acquiesce to the demands of a pseudo-representative/insurance company makes no sense.ImaginationWe must think creatively not only about potential solutions but deeply reflect on what the real problems are. Cost is not the problem but only a symptom of a deeply flawed health care delivery system. When pain is the symptom, you don’t just treat the symptom but search for the underlying cause. If the underlying cause is left untreated, it could be fatal. We must think outside the box or it will soon become a coffin. We need to risk asking some basic questions. Can we allow the profit motive to control the most precious quantity we have — our health? How much health care is enough, or too much? What elements of the current health care system should we preserve, and what should we eliminate? Do caregivers and hospitals, and megalithic health care corporations earn too much? Should we subsidize all health care training and then demand subsequent service? How can we allow the health insurance industry to step between the sacred patient-caregiver relationship? Is the rest of the civilized world wrong in supplying health care services? These are a few of the initial questions we must ask, and we must be open to creative answers. ProtectionThe first priority in reforming the health care system must be to preserve and protect (and in some situations resurrect) the patient-caregiver relationship. It is the final common pathway of all personalized compassionate health care delivery. Caregivers are the best advocates for the ill. They have lived within the world of illness for most of their lives and can guide us out. We have developed too many surrogates for compassion, and too many substitutes for true healing. Hospitals undergo expensive remodeling that allows family members to spend the night with their sick relatives. At the same time they cut back on nursing staff and decrease the interaction that the staff has with the patient. Is this progress or a sad commentary on the kinds of wrong solutions the current health care system offers to the growing problem of the large, dangerous, impersonal hospital? When my patients have a successful hospital experience they talk of compassionate staff, not hospital facilities. Healing is a one-on-one relationship and we must protect it. PatienceNow that we are finally taking on the problem of health care delivery, there seems to be a motivation to get it out of the way in a matter of months. Although we must not abandon reform and it must be painfully comprehensive, it needs to be complete — not just a giant expensive bandage. Tragically flawed bills that are filled with the five dirty words, the wrong words, have already passed some Congressional committees. In their present form they provide no real change of direction. People say that health care reform will fix the economy, that it will fix General Motors, and that it must be done by August or September. Don’t be swayed by those arguments. Health care reform is too important to be left to pseudo-stakeholders like insurance companies, it is too important to be rushed. Yes, the bloated overweight health care system is failing. The patient has been deteriorating for decades. The prognosis is grave and without change probably terminal, but the right solution will take time and the right vocabulary. Like the severely obese patient who has decided to change, he now wants to lose all the weight in a few weeks. We must keep his motivation but adjust his expectations. More than anyone in health care, caregivers want the system fixed, but it must be done thoughtfully and with full reflection by the real stakeholders. True reform will be painful to everyone except, we hope, the patient. For years, this faulty system has pulled us away from our primary goal, which is caring for the sick. Healing and ministering to the sick does not require coverage, or consumers and providers. It does not require billing codes, or e-prescribing or the million other financial and bureaucratic annoyances caregivers are asked to perform. Doctors routinely perform these tasks because we must, but it has taken us away from our true mission. Now is the time for real change. Help us change.When you become ill, as most of us will, we caregivers will do all that is humanly possible to minimize your pain and suffering and, if possible, to return you to health. If we have no cure, we will give compassion and guidance to help you deal with your infirmities. And if there is nothing further that we can do, we will be at your bedside, holding your hand. And that is one place your health insurer or coverage provider will never be. Cody Wasner is a doctor and president of the Oregon Rheumatology Alliance.