As stated earlier, I am a physician and I am in private practice. My specialty is plastic surgery and my practice now consists largely of elective procedures that are performed in my own accredited facility and the majority of these procedures are not paid for by third-party health insurance providers. This makes my practice, my business, largely true fee-for-service in its structure. This also makes me somewhat more fortunate than many of my non-cosmetic surgery performing colleagues because I often do not have to rely on third-party, health insurance companies to pay me somewhere between one-tenth and one-quarter of what I might bill for a particular service and also have to wait 3-4 months to receive this greatly reduced reimbursement.
As fortunate as I often consider myself, this in turn has had a negative effect on plastic surgery as a whole. Many of my non-plastic surgeon colleagues are often doing plastic surgery procedures that they are ill-prepared to perform in hopes of capturing some of this true fee-for-service brand of medicine. This in turn leads to more patients suffering the consequences of bad plastic surgery, more lawsuits and therefore higher liability costs … even for highly (properly) trained plastic surgeons. Once again, others in turn end up bearing the costs associated with this increased liability.
Although it appears that I have digressed into a more specific scenario related to my own specific specialty of medicine, I bring this to light only to ponder the question: Why is it that other healthcare providers would assume the risk of providing a service that they were not trained for? The answer, unfortunately, but true, lives in the financial gains that are seemingly possible when one becomes a true fee-for-service (cosmetic surgery model) provider (i.e., cutting out the third-party payor).
Much of what is discussed by our president and many healthcare reform supporters is how competition will bring down the costs of providing healthcare by adding the “Public Option.” I am certain that cutting out third-party payors (as much as possible) would not only drive the prices of care downward, but it would also drive the level of care upward. Doctors would get back to providing better service because they would now be directly competing for patients and the revenue associated with caring for them instead of getting the same adjusted flat fees that are dictated by the handful of third-party payors available. In other words, providers could charge the patients less and yet more goes into their pockets instead of the insurance companies. I’ve seen it and live it firsthand.
What is also being sorely left out or not discussed is what I believe to be one of the root causes of rising healthcare costs: The lion share of rising healthcare costs are directly related to liability coverage. Hospitals, physicians and insurance companies all have higher rates to cover out of control, frivolous, and overexposed costs related to legal expenses and potential liability that in most instances is completely unwarranted. Built in the fees that are almost directly related to the rising expenditures of liability coverage cost that are all passed on to the consumer (i.e., the patient). Hospitals charge more (oftentimes 10-20 times the actual costs). Physicians are forced to charge more, order more testing and obtain more unnecessary consultations for more specialists to protect themselves. Health insurance companies charge higher premiums, cover less per procedure, and cover fewer procedures overall. Malpractice insurance rates are exorbitantly high across the board even when physicians prove a good track record. All too often, the physicians that are not racking up malpractice claims are paying for the few providers that are allowed to continue to practice poor quality unchecked.
So, how do we create a system that has meaningful tort reform and still protects the patient’s from bad practitioners?
1. There needs to be incentives or rewards for doctors that are providing good service by lowering malpractice premiums and raising reimbursements for years of good service.
2. We must find a way to enable doctors to better police themselves. Some of these things are already being done (e.g. CME requirements, safety record reporting, review panels with objective criteria).
3. It is imperative that we have meaningful disincentive for frivolous suits (i.e., patient’s paying minimum attorney/court fees, the loser in a lawsuit being forced to pay court costs and possibly doctors out of pocket revenue costs for lost working time).
4. Maybe the government should be offering a public/government controlled option for malpractice insurance instead of, or in addition to, healthcare insurance.
In addition to decreasing healthcare costs through meaningful federally based tort reform, what we have failed to remember is that at a very root level, the great majority of doctors/healthcare providers have the inherent need to give of themselves in their service. They want to give care not money. The reformed healthcare system needs to make donated hours of service more readily available and easier to perform. If a healthcare provider is worried about the high costs associated with liability, how can they provide service at low or no cost to the patient? There must be a way of leaving the associated liability for a provider that is willing to give of their time and service. On a similar note, there must also be a way that doctors are able to more freely cross state lines to practice medicine, which in turn would make it easier for them to donate service and time. It is absolutely ridiculous that a doctor can more freely practice in a Third World nation than a nearby urban area or neighboring state.
Along those same lines, it has become increasingly clearer that the medical profession has become less desirable for our young people to pursue as a career. The medical profession in this country has had a long history of attracting the brightest and most motivated students that enter college. For the last 30 years there has been a gross maldistribution of physicians of all specialties placed geographically around the country after they have finished their medical training. This has left many urban and rural areas grossly underserved. Furthermore, in that same time span, there’s been a major shift of prospective doctors training in areas of specialties and fewer medical students are becoming well-needed primary care physicians. To compound the problem even further, the students that are typically entering into more specialized practices of medicine are at the top of their class and the primary care physicians are more and more coming from the bottom to middle of each medical school class. As of the last 10 years, medical school enrollment has been decreasing as it has become a less desirable career choice. It is not hard to understand why these trends are occurring. College and medical school tuition rates have risen astronomically, postgraduate residents work long hours and usually get paid less than minimum wages. When physicians and surgeons complete their training they are often getting paid less, they’re earning potential has been greatly reduced and they are often leaving their years of training grossly in debt. Certainly, one solution that should quickly be entertained is the possibility of enticing some of our brightest high school and college students to pursue a career in medicine by offering tuition in exchange for years of healthcare service in underserved areas when they first leave their resident training program. The armed services have been instituting programs like these for many years.
Finally, none of the above nor any of the healthcare reform proposals, already on the table, will matter if there aren’t dramatic changes in the way the average American leads their life. Let’s face it, we wouldn’t have the most up-to-date screening techniques, the best trained healthcare professionals and the most technologically advanced treatment methods if it weren’t for the simple fact that so many of us require this care in the first place. The average American continues to eat foods highly saturated in fats, consume too many calories per day, smoke cigarettes, don’t exercise and are often overexposed to the sun. Unless we change our life styles, the cost of healthcare will always remain high. Somehow, we need to educate our parents and children earlier on the practices of healthy living. Somehow, we need to create incentives for people to refrain from smoking and live at a normal weight for their particular height. There are businesses that are already instituting these policies internally. Tax incentives could easily be created for individuals and small businesses to achieve these goals.
I understand more than the average American how complex the issue of healthcare reform truly is, and I also know that in addition to many of the plausible ideas that are being floated at this time, the major healthcare reform boat is being entirely missed if these basic tenets aren’t included. I’m not sure if reform of our healthcare system needs to be overhauled in its entirety at one time and I’m not sure how we go about choosing which problem needs to be rectified first. I do know that our country is in a world of hurt economically and that our financial woes as a whole cannot be mended if changes in our health-care system are not included as a part of the cure. I am a deeply concerned American citizen that just happens to be one small cog in the delivery of medical care as well as one who has employees and a family that all participate in the system as it exists today. Nobody considers changes without considering how stressful they may be as they evolve into their new way of doing things. It will be difficult. There will be wrong turns. The only thing that makes it somewhat more comforting is that knowing these changes are mandatory. We must do something.
Share your thoughts on healthcare reform by e-mailing Scott Becker (sbecker@mcguirewoods.com) or Rob Kurtz (rob@beckersasc.com).
