Saturday, July 28, 2012


. I am a practicing MD for last 30 years and seen lot of changes. I feel that there are ‘problems with the current health care system and we can do a lot to fix it provided concerned parties are willing to do it. I do not believe that the change in the law that just was approved by the high court will do anything to cut cost as it is more based on ‘belief’ than reality or the understanding of the system .I hope that republicans can come out with a plan and not just oppose present one . Please read the outline of some thoughts.

-The presumption that ‘insurance companies have failed’ is to put blame at wrong place.  The insurance company collects the premium, spends it on expenses for running the  business (advertising ,agents, commission, salaries etc) and medical expenses. If the expenses are more, premium goes up.   To state they have failed is naive. This can be compared to going to buy a shirt. The final cost of the shirt that the retail store will charge is based on acquisition cost plus overhead plus profit if any of these things go up, and then cost of the shirt will go up.

In our office my young secretary , under 30 years of age cannot get insurance for 8% of her salary.(as required by new law ).Health Insurance costs $3600 for a young patient like under 30 years of age with no major medical (preexisting ) problems.. This is higher than 8% of average salary. If healthy person is ‘subsidized’, who pays the difference? The cost will not come down even if everyone buys or is forced to buy.  

-Fairness. If I exercise, eat properly, stay healthy, why should I be ‘penalized’?  Having a medical disease is not always one’s fault. But to have same premium for everyone irrespective of medical history, is unfair to those who work hard to stay healthy. In the existing system, we do subsidize. The ‘family coverage’, in which 2 adults and children are covered, does not cost 3 or 4 times that of individual coverage. But there is going to be a limit as to how much a healthy person should contribute to the coverage for people with serious health issues.

-Health care cost is a square. To reduce cost all sides must be reduced. These sides are providers, recipients, drug companies and lawyers. The cost goes up due to lack of controls and fear of malpractice. The waste of resources is seen daily. I have seen 12 -14 CT scans brain being done on one patient in a span of 8 -10 months. This may be because of lack of understanding on part of MD and ‘demands’ on part of the family.

     The cost of health care has increased due to greed, ignorance, malpractice, new technologies and treatments.

     Greed is on the part of the physicians, patients and the hospitals. There are family physicians who are doing cardiac stress tests, sleep studies, echo cardiograms, which they are not well trained to interpret. Since the reimbursement for the nuclear stress test has gone down, more cardiac PET scans are done. Now a days hospitals ‘own’ doctors’ practices. These hospital owned physicians get more money from insurance companies and Medicare, than independent physicians. The hospitals get more money for the same tests done in an office by a physician. Hospital-employed physicians get higher compensation as office is considered an extension of hospital. Why is there a difference for the same tests?

New drugs and new technologies. In 1980, we did not have MRI, PET scans, Stents and many other drugs , including drugs for HIV. Today, the  ICD  ( implantable defibrillators )costs $29000 plus hospital cost(probably another $20000) , PAH (pulmonary hypertension) treatment with drugs costs $50,000 a year. One tablet of a drug called Tolvaptan costs $300. This is used for low salt in blood.

      DME (Durable Medical Equipment) is adding to expense. These is use of oxygen , mobility  scooter ,home health monitors, treatment of sleep apnea with CPAP etc are all expensive and there use is on rise .Unless we decide to change the ‘rules’ as to who is covered and how much, cost will continue to rise. There is no way to reduce premiums, no matter how many more healthy people buy insurance  

 My suggestion is to divide the population into several groups.

Group one- Individuals in the lowest socioeconomic group who cannot afford any premiums and have no resources – will receive Medicaid.

Group two –Individuals in this group will be those who do not qualify for Medicaid and cannot afford any premium either because their income is slightly higher than allowed by Medicaid or have assets that are higher than allowed by Medicaid will be in this group. These are ‘True indigent patients. The society takes care of them, provided

 1) One and All medical providers i.e. all physicians, all the hospitals, all the radiology clinics, all labs, and all other health care provider, will participate.

 2) Patients cannot sue.

3) Providers will get ‘tax credit’ for the services .This could be as little as 10% of Medicare allowable charges.

Group three -People who can’t afford regular insurance but do have some money to spend on their own health care. These patients could  be the young people who do not have major medical problem, but want to have some coverage to cover for major health care related expense They should buy ‘high’ deductible policy and get tax credit if they have to spend more than certain amount. e.g. If they have $5000 deductible policy and have to spend $10000, then will get some tax credit for the amount that they spent .

Group four -The people who can afford regular insurance policy will be in this group.

Group five -The Medicare population will be in this group.

Group six -There should be higher deductible for expensive procedures-ICD, bariatric surgery for older patients .The cost for certain procedures is so high that we cannot cover it fully. We as society have to decide if these high ticket items should be covered at what cost . One suggestion could be ‘higher’ deductible for them. It could be age related or health care related.

  Lastly the ‘Cookbook’ medicine in certain situations will reduce cost; this has been tried in certain situations. What tests get ordered and get covered will be based on age of the patient, his medical history and his physical examination. If this approach is followed then the MD cannot be sued.e.g size of nodule in lungs seen on the CT scan and frequency with which the CT scan needs to be repeated.





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