Surgeons Elgin Surgery Elgin Illinois

Healthcare Reform for Legislators
First Do No Harm

Joseph N. Michelotti, M.D., M.A., F.A.C.S.

Like a living person, healthcare is a complex system with millions of working parts.

The practice of medicine is fundamentally the art of diagnosis; the identification of a problem through analysis of its signs and symptoms. Our bodies are unimaginably complex with millions of working parts, so the odds of actually helping a patient will greatly improve if an accurate diagnosis can be made. Fortunately, when afforded an opportunity, a patient will very often describe his or her problem for the doctor, devoid of the medical terminology. Good diagnosticians are always good listeners. Of late, our elected representatives have had some opportunity to carefully listen for and identify specific problems with American healthcare, how it is delivered and how we pay for it.

Our current healthcare system is populated by suppliers, providers, insurers and consumers. What are the major problems that have been described with increasing frustration about each of these groups?
  • Suppliers. Consumers interact with suppliers mostly when buying medications and complain about inflated pricing, especially to fund expensive marketing to consumers who cannot directly purchase these potentially dangerous products anyway.
  • Providers. Consumer interactions with doctors and hospitals are usually on an ‘as needed’ basis. Instinctively, consumers want their doctors to pay attention to them and give them advice that they can trust. Patients do not appreciate conflicting interests that influence and distract physicians, such as business ventures with suppliers, insurance or employment contracts, or other referral agreements. As for hospitals, consumers absolutely hate the ‘$50 aspirin’! For the consumer, most hospital charges cannot possibly be justified, and the inflated pricing makes the patient a hostage of his insurance coverage.
  • Insurers. Consumers interact with their insurers most often and grievances are frequent. Insurance choices are limited and expensive, but perhaps the most common complaint is ‘paying for insurance and then not being insured’; that is, after an illness or injury strikes, insurance coverage is denied. Perhaps the provider is not “in the network”, or perhaps the insurer thinks the patient “should have known” the illness existed before the policy started. Insurance policies are incomprehensible and consumers feel defenseless.
  • Consumers. Finally, what do we consumers dislike about ourselves? Generally, it is the freeloader. Americans contribute generously to people in need, but we resent being forced to subsidize a private room with a view for a freeloader who perhaps might have made better choices. Alas, although we all dislike the freeloader, we will almost always become one if the opportunity arises.

Once a patient’s illness is correctly diagnosed, treatment (usually somewhat unpleasant) should target the problem with surgical accuracy to minimize collateral damage to healthy tissues. Because there is still much about American healthcare which is exceptional, low risk reforms that target specific problems with the current system will be more readily embraced.
Under the current regulatory scheme, consumers pay insurers, who pay providers, who pay suppliers. This has created a ‘disconnect’ between the pricing of healthcare and its value to consumers, resulting in our out of control “cost curve”. Consumers deserve to have more direct transactions with their providers and suppliers. It doesn’t take a brain surgeon to figure out that an aspirin cannot cost $50! Consumers need know nothing about medicine to make reasonable value judgments for themselves, the first of which should be the free and un-coerced selection of a trusted, independent physician for guidance. 

Our representatives should support the following reforms:

  • Reestablish the mutual trust of the doctor-patient relationship. Doctors paid directly by patients should be able to earn a good wage just for being doctors, making other sources of professional income unnecessary. All forms of fee splitting, kickbacks and other referral or self-referral arrangements should be banned.
  • Remove the legislative obstacles to Health Savings Accounts (HSAs). (Ideally, all physicians’ fees would be paid from HSAs.) HSAs also reestablish the direct transactions that will make providers and suppliers more sensitive to the value judgments of consumers. Insurers should reimburse consumers directly, with benefits that are predefined. Then, when consumers pay providers, providers will respond to the consumers’ perception of value, and price their goods and services accordingly. Inflated pricing will not be tolerated in a consumer driven market and the shock will ripple through the supply chain, finally “bending the cost curve”.
  • Current regulation allows an insurer to, in effect, practice medicine without a license. Effective legislation to reform ‘network’ exclusion and pre-existing condition contract language has been proposed* and is long overdue. Much has been said about increasing competition among insurance carriers. The government could encourage competition by simply allowing health insurance policies to be marketed across state lines, and ending the industry’s other anti-trust exemptions. Also, the tax code which penalizes the purchase of health insurance independent of one’s employer is unfair, and should finally be revised.
  • Medical advertising represents an enormous and unnecessary healthcare expense. Our 35 year experiment with medical advertising should end. Ban all direct-to-consumer advertising of controlled medical goods and services (defined as those goods and services which, because of their expense, finite availability and potential for harm, may only be dispensed by or under the order of a licensed physician for the treatment or prevention of an illness or injury). This alone would save many billions of dollars annually in hospital, pharmaceutical and physician advertising costs.
  • Although physicians traditionally offer safe and effective medical care to everyone regardless of their ability to pay, no market system can long survive by offering consumers who pay nothing the same goods and services as consumers who pay something. Patients who need or want medical care at no cost could be directed to teaching institutions (that may enjoy increased federal funding) where medical students and residents can provide services safely under expert supervision as an invaluable part of their training. Not fancy, but good care for people who need it.
  • The cost of defensive medicine far exceeds the cost of actual malpractice litigation. It is so insidious and ingrained into our healthcare system that providers often no longer recognize when they are practicing defensively. Caps on non-economic damages have been debated for decades, while other reasonable avenues for improvement are ignored. For example, the potential for litigation is a major obstacle to free clinics and charitable care. Providers who offer free healthcare should be able to do so under immunity agreements with patients. Some reforms can benefit both plaintiffs and defendants. Expert witnesses in malpractice cases routinely offer their narrowly supported opinions as widely accepted standards; and do so with utter impunity. Discouraging such misleading, self serving and patently false testimony with adverse actions through professional societies or state licensure boards would eliminate many groundless and futile trials without preventing meritorious ones from being heard or quickly settled. Many more suits could be avoided or settled if it were easier to recover court costs and reasonable attorney’s fees.
For 2500 years doctors have taught their students that it is always much easier to hurt patients than it is to help them. Like a living person, healthcare is a complex system with millions of working parts. I hope our representatives consider reforms that will target the perceived problems rather than just making things worse for all of us. Thank you.

* Illinois State Medical Society

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