Commentaries
by Cameron S. Schaeffer, MD
 Cameron S. Schaeffer, MD |
Read in order or click on to the title for direct access.
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A Few Words to Our Patients
We, the undersigned physicians of this community, are concerned that expansion of the role of the Government in our nation’s health care system will significantly harm our nation, our profession, and our ability to care for you. We fear that we are on a path well-travelled by other nations and with a destination so predictable that the journey need not be repeated. Despite its faults, America still has the best health care system in the world as evidenced by the hundreds of thousands of people who flock to this country every year for training and care; for critics to claim otherwise for political gain and without scrutiny is unconscionable.
We adhere to the following:
Privacy: Third party involvement in the doctor patient relationship is a fundamental violation of patient privacy and our Hippocratic Oath. Personal health information of the most sensitive nature already resides in the vast databases of insurance companies and governmental agencies. A centerpiece of proposed Government health care reform is the expansion of these databases, which are NEVER secure. We do not want your most personal secrets to leave our offices without your explicit permission.
Freedom: This Nation and its economy were founded on the right of independent parties to contract freely for goods and services in a competitive market, and this includes doctors and patients. Free markets lower costs and improve services. Goods and services are exchanged based on price, and prices for health-related services should be negotiated in advance of illness by insurance companies on behalf of their clients or by patients contracting directly with doctors and hospitals. Government price schedules have no market basis and often do not adequately cover physician costs, which is why many doctors do not accept Medicare and Medicaid. For markets to function properly, people must understand what they are exchanging. Our health care system woefully lacks transparency in price, cost, reimbursement, and quality of the services provided at every level. Reforms should empower all parties in the health care economy to contract freely, intelligently, transparently, and in good faith. No laws should deprive you of your freedom to determine what happens to your body.
Cost: The costs of Medicare and Medicaid are already staggering and unsustainable, and the Congressional Budget Office has stated that additional programs will incur more debt. Our debts, mostly carried by foreign countries, must be paid by our children or by devaluing the dollar. This course threatens our economy and our future as a Nation. The current payment schemes in our health care system are inflationary because patients and doctors have no disincentive to consume. Furthermore, as long as the Government and the insurance companies are paying most of the bill, they will seek to limit and ration care. Until we are incentivized to shop wisely as individual consumers caring for our own bodies, the problem will continue.
Insurance Reform: Insurance companies provide a necessary service, and we need fundamental insurance reform in this country. We can start by making health insurance about insuring risk of serious injury or illness, not a prepayment scheme for every sniffle. We have auto insurance for accidents, not oil changes. New private risk pools for individuals and not-for-profit insurance companies would enhance competition, i.e. improve services and lower costs. If insurance companies are required to accept all applicants, including those with preexisting conditions, they will create larger risk pools to manage the risk. The Government should not be allowed to “compete” because it is impossible to compete against an entity that prints money, does not have to collect premiums, does not have wellness programs, and does not pay taxes. Patients should be allowed to purchase health insurance across state lines like almost everything else that is sold in this country, and it should be tax-deductible. They should buy it as individuals for life, like life insurance, which makes it guaranteed, portable, and not subject to preexisting conditions. Freed of the need to provide health insurance for employees, employers will pay higher wages to stay competitive in the labor marketplace. Insurance companies need to improve transparency in physician contracts and quit playing reimbursement games with doctors.
Caring for the Uninsured: The Government cannot make uninsured patients disappear by passing laws. They are a societal problem. To ask providers to shoulder most of the cost of caring for the uninsured is unfair. The Government should allow providers to deduct some of the cost of caring for the uninsured from their taxes, like any other act of charity. Rather than create new programs for the uninsured, the Government could create a mechanism to allow immediate enrollment of the uninsured in Medicaid at the point of service. The insurance status and personal financial liability of these patients could be evaluated retroactively by Medicaid.
Malpractice Reform: The cost of medical liability insurance for physicians is high, and the cost of defensive medicine is real and enormous. Ultimately, these costs are paid by all of us. The utter absence of any discussion of malpractice reform in Washington is a disgrace and fundamentally dishonest. We believe that patients should be compensated for economic damages caused by medical malpractice, but we also believe that our legal system is a circus of blackmail and jackpots, disconnected from true medical malpractice and true damages. Furthermore, and cruelly, it takes years for deserving patients to receive compensation, long after they most need it.
Regulatory Burden: Our regulatory burden is onerous both in time and money, and it frequently contributes nothing of material value to you, our patients. We need relief from this burden to better care for you. Any proposed reforms should diminish, not expand, this regulatory burden.
Personal Responsibility: We all have a civic duty to buy “catastrophic” health insurance at the minimum, and those who cannot afford it should be subsidized, perhaps through taxes on unhealthy foods and non-essential purchases. Some people, particularly the young and healthy, choose not to buy any health insurance, even when they can afford it. These individuals must be incentivized to buy health insurance to spread the risk.
Wellness: Under our current system, patients have almost no financial incentive to lead healthy lifestyles. Mechanisms to incentivize wellness could be created, and patients who take care of themselves should be rewarded with lower health insurance premiums.
Professionalism: We are professionals, not commodities. Our training required years of dedication, and it came at a great cost, personally and financially. The assets of the businessman reside in his building and its contents; ours reside in our heads and in our hands. They belong to us, not the insurance companies and not the Government. These assets have real value, and we passionately want to use them to heal you when you are sick, on mutually agreeable terms. Any attempt to force us to work for the Government, without our individual consent, is a form of theft, a corruption of our relationship with you, and an assault on our professionalism.
Stand with Us: Send this essay to your friends and family. Send this essay to your representatives and tell them that free market principles can work in health care, just as they do in other service industries. Demand that they fix Medicare, Medicaid, and every VA Hospital BEFORE creating any additional programs. Demand removal of distortions in the tax code that promote health care inflation. Demand a national insurance market and the expansion of tax-free medical savings accounts which would empower you, the patient, to find good care at a good price. Demand policies that incentivize providers to discuss their results and disclose their pricing. Remind them that “health care” starts with individuals and that all Americans must be incentivized to stay healthy. Tell them that jackpot justice has no place in the compensation of patients who have been injured while receiving medical care, irrespective of the cause of injury. Stand for freedom, dignity, and respect for the individual citizen, and oppose any reforms that might imperil your right to determine what happens to your own body.
Cameron S. Schaeffer, MD
Cosigned by scores of physicians in Kentucky (Top)
Cash for Gomers
There are very few doctors who have not read Samuel Shem’s classic book “The House of God,” a very entertaining book about life in a Boston teaching hospital during the “Golden Years” of American medicine. Central characters are “Gomers,” the frail, elderly patients who are a source of torture for the training doctors who care for them and a source of revenue for the attending physicians who admit them to the hospital. The book highlights different styles of practice, ranging from the doctor who orders every test on every patient in an effort to leave no stone unturned to make a diagnosis, and the doctor who sees in patients a certain humanity, who has faith that perhaps the mechanism of life is smarter than he, and who realizes that love may be all that his patients need or even want when they are at their most vulnerable.
As a nation, we recently endured the “Cash for Clunkers” craze. Perfectly serviceable vehicles were crushed in the name of “stimulating” auto sales, thereby gutting the used car market and harming the working poor. One wonders why we haven’t started bulldozing houses to jumpstart the housing industry. This inability to see the value in things is disturbing. The inability to see the value in our healthcare system and in the people who receive the services of our nation’s physicians is likewise disturbing.
I’ve been reading and thinking about the Holocaust lately. How could it be that German physicians, the product of the academic flowers of Europe, remained silent in the face of such inhumanity and, in some cases, participated monstrously? Like all monstrous things, the Holocaust had modest beginnings. In prewar Germany, a patient’s care was the responsibility of the State, and the doctor’s primary responsibility was to the State, not to his patient. The Weimar Republic suffered a calamitous currency collapse in the wake of the Treaty of Versailles, setting the stage for a young, charismatic leader who could “fix” Germany and restore it to its lost glory. Political euphoria ensued. The State needed to be rebuilt, and all Germans were instructed to work together for the betterment of the State.
The fragile members of society contribute nothing of material value to the economy- the elderly, the mentally ill, crippled children, etc. In Germany, these were lives not worth living- a drag on the State and a roadblock to greatness. A slogan emerged: lebensunwertes Leben- “Life not worthy of life itself.” By the mid 1930’s, forced sterilizations and abortions were commonplace in Germany. Euthanasia became well-organized and widely practiced, sometimes without a physician even examining a patient. It is estimated that over 250,000 Germans were “offed” by the German State before the war because these individuals were a drain on the Reich. One wonders if anyone pointed out that the Hippocratic Oath says nothing about the needs of the State.
We are in the depths of an economic crisis, we are told, because of “greedy bankers” on Wall Street. Hitler blamed the Jews for the financial woes of Germany. When I read of protestors at the Connecticut homes of bankers, I think of brownshirts and Kristallnacht, and I am scared and ashamed. In truth, the failures of both economies were very much caused by disastrous governance, but Governments are only good at one thing- a lack of introspection on the Law of Unintended Consequences. Once the seed of inhumanity was sewn, that there is such a thing as a life not worth living, it was no stretch to start killing anyone perceived to be enemies of the State- Jews, homosexuals, gypsies, etc. The efficiencies learned came in handy in places like Auschwitz. In less vicious times, lives are distilled to monetary value, as they are in Britain today, or assigned an intrinsic value by the minds of men like Dr. Ezekiel Emanuel, President Obama’s “Special Adviser” on health care issues and the brother of his Chief of Staff, as reflected in his collectivist musings in the Lancet.
We are told today that we can solve the “crisis” in healthcare through the expansion of Government, never mind that the Government initiated the crisis when it disrupted the healthcare markets in the 1940’s. We are also told that we face environmental apocalypse unless the State curbs CO2 emissions. The words “spirit” and “breath” and “life” are linked etymologically and metaphorically, but the EPA tells us the very air we exhale is “pollution.” Perhaps the State will someday trains its sights on the valueless CO2 emitters among us in the name of protecting our healthcare system and our planet. Stay tuned for the “Cash for Gomers” program.
Cameron S. Schaeffer, MD (Top)
My Skills Are My Own
My mother will tell you I was born to be a doctor. I was drawn to science at a young age, particularly biology, and she nurtured this passion. Over the years, every animal that can conceivably be kept as pet in a suburban home shared my bedroom. She permitted me to keep dead animals in her kitchen freezer which I dissected with an X-Acto knife in her basement. I was my hometown’s Outstanding High School Senior in Biology when I graduated from high school (Lexington, KY), and I received an academic citation in Cell Biology at Dartmouth despite being an English major. For sixteen years I pursued my dream of becoming a doctor, half of those years at the bedside or in the operating room, sometimes working 130 hours per week. My heroes are my father who taught me to work, and the surgeons who taught me their craft. I stand upon their shoulders.
I gave up my youth on this journey. While my college classmates were earning big salaries and had all the advantages of compounding interest from an early age, I deferred earning a good living. They built businesses and their capital resides in the tangible and intangible assets of those businesses; my capital is in my mind and in my hands. I earned my capital assets, and the price was very dear. In many ways, every other doctor’s story is my story.
We now have a President who meddles in the affairs of private companies while claiming that he has no desire to meddle in the private economy. He claims the capital assets of these companies in the name of the taxpayers and to pay off his political base. He fires a CEO and presumes to run a huge company when he has never worked a day in his life in a private venture. It is therefore no stretch for him to believe he can claim the capital assets of physicians, i.e. their hands and their minds.
Other than the bonds of family, there is no relationship more sacred than the doctor-patient relationship. What greater expression of trust can there be than to let another human being open your flesh to be healed. What is more precious to a person than his or her body?
Doctors made a grave error when they allowed third parties to meddle in this relationship, and all but a few professional medical organizations have bought into this construct. It was all done for money. Every doctor knows that if he or she had to negotiate payment directly from his patients that his income would suffer. The America Medical Association’s cash cow is its coding system used by insurance companies and the Government to label the citizens of this country with various diagnoses, some highly personal in nature, every time they see a doctor. Your ailments, things you may not even want to share with your spouse, are linked to your name and to your social security number in computer databases all over this country.
Our rights as citizens are enshrined in the founding documents of this country. Foremost among these is the inalienable right to live freely in the pursuit of happiness. Our rights are given to us by our Creator, a term which the Founders left up to us to define individually. These rights are based in Natural Law which, at its core, holds that a person has a basic right to live as a free and independent being with his or her own body and soul. One cannot put a price tag on or give a local habitation to these rights.
By definition, medical care cannot be a right; it is a service performed by professionals for patients. It cannot be found in the Declaration of Independence or in the Constitution. Unlike true rights, you can put a price on health care because it consists of the cost of labor (physicians, nurses, and hospital workers), supplies, rents, capital investments, equipment, hospital infrastructure, etc. When our President speaks of a “right” to medical care, he is telling people that they are entitled to things that have a monetary value which they may or may not be able to afford. More specifically, he is telling them that they have a claim upon my skills as a physician just as if he were telling them that they have a claim to whatever is on the shelf at Walmart.
My skills are my own. I earned my assets through hard work and self denial in the same fashion that the entrepreneur built his business. They do not belong to the President or to his bureaucracy. They cannot be nationalized. They cannot be coerced. They cannot be purchased except upon terms that I deem agreeable.
We are at a crossroads as a nation when it comes to healthcare. We can either choose to restore the doctor-patient relationship, a relationship based on free association, mutual respect, personal choices, and confidentiality, or we can choose another path, one based on coercion, mandated rationing, and databases. Doctors have a choice too. We can choose to treat patients on our terms, understanding that there will some patients who will not be able to pay fully for our services and that we will provide them. We can refuse to continue to submit to interference by third parties, i.e. insurance companies and the Government, in the relationships we have with our patients, and we can reject any claims these parties make upon our skills. We can warn our patients that in every country on this earth that has chosen the path of socialized medicine that rationing has ensued, even for services they can afford, sometimes resulting in higher morbidity and mortality. We can demand that the organizations that represent us recognize that we are free and independent agents and that our right to pursue happiness in our work and the health of our patients is not negotiable.
Cameron S. Schaeffer, MD (Top)
Whom Do You Want Operating on Your Belly
(or Reattaching Your Head?)
One of my favorite cartoons depicts a prepubescent King sitting on this throne saying to his aged adviser: “On with his head!” Fixing the health care system may be as difficult as recapitation, but it certainly begins with a King who has insight.
I am a surgeon in the middle of my career. For the last few weeks, I have circulated an essay that proposes a way out of the health care mess, based on quaint notions like freedom, privacy, patient dignity, individual rights and responsibilities, and free markets. I hear a lot of agreement, but I also hear a sense of helplessness and the sad realization that everything we have worked for will be taken from us and our patients are going to suffer for it. We are all patients eventually.
Most people have no idea what it takes to become a doctor and what it takes to practice medicine. The sacrifices are enormous, personally, financially, and physically. It is well known that physicians have higher substance abuse, divorce and suicide rates than most other professionals. One year, a well-known surgery training program was reported to have a 100% divorce rate. When I trained, 120 hour work weeks were the norm, and staying up all night every other night was not uncommon. With my advanced degree, I earned about $10,000 per year for every forty hours of work per week. Many seasoned physicians still work 80 hours per week, so first divide their salaries in half to make comparisons to other workers.
Many of my college classmates immediately embarked on careers that rewarded them with high salaries. Many physicians can’t begin to save for their retirement until their forties or even fifties due to student loans. At 5% compounding interest, a $1000 saved at age 25 becomes $7358 at age 65, while $1000 saved at age 45 only becomes $2713. That mathematical reality explains why many bright students are eschewing medicine and why many medical students are eschewing primary care to pursue specialty care for the sole purpose of paying off debt.
Most of us are in small group practices; I practice alone. Some of us never turn our beepers off so that we are always available for our patients. Our families suffer for it. It is a grind, and there is burnout, but there are rewards that no one but us understands. To peer into a patient’s body and to be entrusted with something so precious as another person’s life, or their belly, or their ability to create life is a sensation that cannot be related in words. Few people ever get to hear the words “thank you” expressed from the depth of another’s soul.
Our President has publically stated that surgeons are paid $30,000 to do amputations and that pediatricians (sic) remove tonsils because that’s more lucrative than treating sore throats. The outrageous accusations of fraud and battery aside, it doesn’t occur to him that doing what we think is in our patient’s best interest might also be in the taxpayers’ best interest. Every week, I see Medicaid patients, and in some cases I am paid less than it costs me to see them. I have saved children’s lives, and I have been paid by Medicaid less than it costs to buy a television. Medicaid pays for diapers for deformed, incontinent patients, and I do operations on such children so that they can wear underwear for the first time in their lives. I am reimbursed by the Medicaid program only a tiny fraction of what that operation will save the Medicaid program in diapers for the next seventy years. I do operations that save the taxpayers the cost of dialysis and kidney transplantation, yet I am paid only a fraction of those savings. I saw a mother today who thanked me for working with her child to fix a problem without resorting to surgery. I regularly see families who have been told they need surgery, and I show them that they do not. I see children for free, and my door is open to all. My story is the story of all my colleagues. I offer these examples not to complain or for self-aggrandizement, but to offer a perspective to those, like our President, who impugn our motives or accuse us of ripping off the taxpayers.
Low and inadequate reimbursements are destroying our health care system. I know a cardiac surgeon who gets paid more to do cosmetic vein surgery than a triple bypass. I know a plastic surgeon who gets paid more to puff up lips than doing a breast reconstruction. I know a radiologist who is looking at getting into commercial real estate. The Government’s reimbursement system has so corrupted the real value of care that it forces doctors to lay aside their skills to survive, and the patients of this nation are suffering for it.
We are now engaged in a great health care debate, and we are being vilified as uncaring and greedy. We have a President who smokes cigarettes and who therefore may find out one day what an otolaryngologist does. We have Congressmen intent on passing reforms from which they intend to exempt themselves. We have insurance companies that play games with patient’s lives and the reimbursements that physicians rightly deserve. We have drug companies, dug in like ticks, lobbying on a scale that is nauseating. We have a population that gets fatter and fatter and sicker and sicker which demands immediate and perfect care paid for by somebody else, increasingly foreign nationals to whom we are financially indebted. We have attorneys standing at the ready, willing to sue doctors for any bad outcome, whether or not we have committed any malpractice.
We are professionals, not puppets. We do not belong to anyone, in particular to a Government that allegedly functions under a Constitution that makes no mention of a right to health care and whose 13th Amendment proscribes “involuntary servitude.” The assets of the businessman reside in his building and its contents; ours reside in our heads and in our hands. We earned them; they belong to us. We want to use those assets to heal our patients, on mutually agreeable terms. Our patients want that as well.
The problems of our health care system can be solved through good leadership, sound economic principles, a sober view of human nature, an eye to our Constitution and our nation’s founding principles, and a profound respect for patient freedom, privacy, and dignity. We have none of that coming from Washington. The VA hospital system is dysfunctional. The Indian Health Service is a joke. Medicare and Medicaid are bankrupt. The nation is bankrupt. We have amassed a debt that cannot be paid even by the next generation or by massive inflation. Our senior citizens paid into the Medicare system, and they intuitively know that it is they who will bear the brunt of proposed reforms that can only ration care to control costs.
You get what you pay for. If our society is unwilling to make proper reforms to pay physicians appropriately, it will get what it pays for. But, you say, physicians drive nice cars and live in nice houses. That’s true; some do. But many are up to their eyeballs in debt or have no savings, and they are looking for a way out. Our society should think long and hard about whether or not it wants to stop paying physicians well. The best and the brightest students will always gravitate to careers and endeavors that pay well, so the real question becomes: “Whom do you want opening your belly?”
Cameron S. Schaeffer, MD (Top)
The Social Glue of Healthcare
A friend of mine from Europe told me that everybody likes socialized medicine until they get sick. Security is comforting, but that doesn’t mean you’ll be comfortable when the security you think you have becomes necessary. Humans find their greatest security in the things that bind them, one to another, like glue.
I like my insurance guy, but, having never filed a claim, I have no idea if he is worth a damn. Just as you learn the true character of your insurance man when you have a claim, a patient learns the true character of his surgeon when he has a complication. The patients to whom I am closest are not those who came and went, but the ones who unexpectedly stuck around. I have never been sued as a practicing physician, and I have long suspected that many suits arise from the perception of indifference to suffering and the perception of emotional abandonment. No less important is for a patient to be secure in his knowledge that his surgeon will be available in the event of suffering. As I am writing this, I received a call from a young surgeon seeking advice about a case. Perhaps I helped him and his patient, and perhaps I did not. Ultimately, what was important is that I was there for him in much the same way we physicians are there for our patients. That is the unseen glue of the healthcare system that we have so miserably failed to explain. It is a human, social bond that cannot be legislated or imposed by bureaucratic fiat and which, once lost, is irreplaceable.
I am a surgeon, and I fix a lot of things. I’ve been tearing apart and fixing things since I was a little kid. I had every kind of pet you can imagine as a child, and my mother knew I was going to be a surgeon before I had all my teeth. There is no profession more different from mine than neurology, but the most meaningful words spoken to me in medical school were spoken by a neurologist. After seeing a patient together, he pulled me aside and said to me with an alarming seriousness: “I can’t help that man. I can’t do anything for most of my patients. But what I can do is be there for him.” I call that pure human, social glue.
I do a lot of minor surgery. Not uncommonly, I meet patients in clinic, do an operation, see them one more time, and never see them again. Most of these patients probably don’t know a lot about me, perhaps less that they know about their auto mechanic. They rely on the “system” that makes sure there are no quacks out there cutting on people. Of course, a few bad apples slip through the cracks, but they are quickly exposed and drummed out. What should make the news is the astonishing number of good apples. There are a lot of things that go on behind the scenes that people take for granted, particularly the credentialing of physicians to meet and maintain standards. This vetting process is currently performed voluntarily by other physicians, during medical school, training, board certification and maintenance of certification, hospital credentialing and review, and peer review. Our patients are oblivious to this professionalism. This glue that binds us is taken for granted.
I suspect that in countries with socialized medicine the vetting of physicians is not done by other physicians, but by professional bureaucrats who check boxes and shuffle papers. (If it is done by physicians, how much are they paid and have the reformers factored in those costs?) A bureaucrat can verify that a physician has done such and such number of a particular type of operation and should be credentialed to continue do such cases, but he will never understand the sudden, deadly clarity that comes from standing over a wound and wondering what it is that should be done, or the tossing, sleepless nights wondering if what was done should have been done. These questions are not answered in lectures or textbooks or “guidelines.” The truth may come in quiet reflection at the OR table, or in the form of a phone call to someone with more gray hairs bought dearly through his own tossing, sleepless nights. Will those phone calls be answered in the future, or will shifts end and beepers be turned off? Who will consider the subtleties, stand for that young surgeon, and say before his peers: “He agonized over that patient, and we should give him the benefit of the doubt?” That is the glue of the healthcare system.
For the first time in my professional career, after treating thousands of patients, I received a letter from an irate patient. She accused me of rushing straight to surgery with her child to look for his missing testicle instead of doing an ultrasound first. It matters little that if an ultrasound had identified an undescended testicle that her child would need an operation or that if an ultrasound had failed to find a testicle that her child would need an operation. What matters is that I apparently failed to make her understand that her child needed an operation and to gain her trust. We have lost our standing as physicians because we have lost our patients’ trust, which is why they don’t trust us now when we speak. We can debate the cause of that loss of trust, but I think it springs from the perception of greed. I believe the third party payment scheme was a Faustian deal, a solvent on the glue, and the source of our collective insolvency.
Cameron S. Schaeffer, MD (Top)
Public Option Healthcare Is Bad Medicine
As a physician, I have been saddened and appalled by the silence and abdication of my leadership in the debate on “Public Option,” the Orwellian term for the latest healthcare reform. This passivity must stop, and we doctors must begin to speak out to protect our profession, our healthcare system, and the sanctity of the doctor patient relationship.
The primary reason we have runaway inflation in the healthcare industry is the absence of market forces. Those went out the window when the government froze wages in the 1940’s, inducing companies to provide health care benefits to attract employees. The spending accelerated with the creation of Medicare and Medicaid in the 1960’s.
All markets require a few basic things. First, quality and price must be transparent. Second, buyers and sellers must be free to contract with one another. In a competitive market, supply and demand control prices. Only 12% of the “healthcare dollar” actually comes directly from patients’ wallets, and for many it is absolutely free. When something is free or perceived to be free, there is no brake on the consumption (demand). Health care services which are paid 100% by the patient, like Lasik eye surgery and cosmetic surgery, have stable or falling prices because those markets are intact. The only way to control costs in the presence of subsidized demand is by limiting supply. That’s called rationing.
Most of the remaining 88% of the healthcare dollar is paid by government insurance (taxes and borrowing from our children) and private insurance paid by employers. Employers look at total labor costs when setting salaries. By purchasing health insurance premiums for workers and deducting those costs, businesses pay workers lower salaries and pay the government lower taxes. Total business costs are passed on to customers. In other words, the government’s tax policies depress wages, lower tax receipts, cause inflation, and hide the 88%.
The government fixes prices for medical services, irrespective of costs to providers, and the government is proposing more cuts. Because current government reimbursement for healthcare services is below market value, some rationing already exists. Most private physicians don’t see Medicaid patients or accept new Medicare patients, and they survive because private insurance subsidizes public insurance. What good is government “insurance” if doctors can’t stay in business accepting that insurance? If private insurance shrinks, the insolvency of Medicare and Medicaid will be magnified.
Insurance rates have been increased by hundreds of state mandates. When a state mandates coverage for certain services, insurance companies either raise their rates or leave the state- higher costs and less competition. If a patient knows he will never go to a chiropractor, there is no reason outside of lobbying and campaign contributions by chiropractors for that patient to have to pay for mandated chiropractic care. If state legislatures allowed health insurance companies to offer policies cafeteria-style, costs would come down.
The proponents of “Public Option” say it will introduce “competition” to the medical marketplace. We already have over a thousand health insurance companies in this country! That incongruity aside, how can you have free competition when the government is both the player and the referee? Should we even the playing field by allowing insurance companies to print money? Creating any government option scheme is simply putting the camel’s nose into the tent, and with the shekels come the shackles. First comes the coverage, and then comes the control. The end result will be Single Payer, government-rationed healthcare with its attendant waiting lists and indifferent providers.
The doctor patient relationship is a free association based on trust and mutual respect. At its core, government run healthcare is a coercive intrusion into a private relationship, a violation of the patient’s right to privacy, and a violation of the Hippocratic Oath. Under a government-controlled health care system, doctors will be told how to practice their art as if it is a science, based on “evidence” when such evidence frequently does not and will not ever exist. Furthermore, the most sensitive information imaginable will be housed in vast electronic databases for various purposes, and databases are never secure.
We need more market discipline and more privacy in the health care industry. We must eliminate market distortions in the tax law, decrease the regulatory burden on providers, and empower patients, not bureaucracies. We should increase the supply of competent doctors through immigration. We must repeal state mandates and allow patients to purchase the services and coverage they want from whomever they want. Doctors need to deal directly with patients, and patients need to deal directly with their insurance companies, as they do for other forms of insurance. All this would give patients higher wages, lower premiums, more options, more privacy, and a sense of costs, and it would put pressure on doctors, hospitals, and insurance companies to lower their fees and give better service. It would end the unconscionable practice of charging uninsured patients higher, non-negotiated fees. Most importantly, we must all seek to eliminate, not expand, third party interference in the doctor patient relationship.
Cameron S. Schaeffer, MD (Top)
Take Two Aspirin and
Call My Union Man in the Morning
When I was a Chief Resident in Urology at the VA Hospital in Salt Lake City, I called the OR at 2pm and told them I had a case that needed to be done. Is it an emergency? No, but I need to get this case done soon, and I don’t have any other time on my schedule this week. How long will it take? Three hours. We can’t do it. Why not? The janitors go home at 4 pm. So. Well, there won’t be anyone to clean the floors. I’ll clean the floors. Sorry.
I suspect “sorry” is a word you hear often in countries with socialized medicine. If you are in renal failure and above a certain age in Britain, you hear the word “sorry.” If you have breast cancer and need expensive cancer therapy, you hear the word “sorry.”
Shift work is here to stay in American medicine. Reimbursements are such that internists can’t afford to leave their offices to take care of their patients, so we have “hospitalists.” Emergency room call for general surgeons is so onerous that we now have “surgicalists.” An entire generation of physicians has trained under the eighty hour workweek restriction, and there is talk of limiting practicing physician hours “to protect the patients.” I am not demeaning shift work by physicians. For some doctors it is a terrific practice arrangement, and I know some excellent hospitalists. However, most inpatients will tell you that they would prefer to be cared for by the physician they see as an outpatient, the physician who best knows their health.
There’s an old saying: “Professionals work until the job is done, and blue collar workers work until the shift is done.” Shift working by physicians has blurred this distinction. When I think of blue collar workers, I think about unions, and I don’t think it is any stretch to envision the unionization of shift-working physicians, especially if they work for the Government. Among other things, unions negotiate limits on what can be expected of their membership by employers. Work hours are a sensitive issue. What will happen when your union surgeon is elbow-deep in your belly when his shift ends? Will he finish the operation, or will the surgeon on the next shift finish the job? Unimaginable, perhaps, but stories of resident surgeons walking out of operations because they have reached their eighty hour limit are commonplace.
The study of Government is the study of the law of unintended consequences. Pick any Government program, and I’ll show you the unanticipated costs and the unforeseen consequences. You can start with “Cash for Clunkers” and work backwards. The Government taxes the businessman to “create a job,” but we will never know how many jobs that businessman would have created had he been the one to deploy his capital. If your physician works for the Government, don’t be surprised when he says: “Take two aspirin and call my union man in the morning.”
Cameron S. Schaeffer, MD (Top)
Where Will All the Rich Canadians Go
for Medical Care?
Our current health insurance dilemma dates back to the 1940’s, when businesses responded to wage controls by providing tax-deductible health care benefits- a way to raise people’s real wages without raising nominal wages. There developed, then, a bizarre expectation that one’s boss is supposed to provide one’s health insurance. Other than the distortions created by Government tax policy, is there any compelling reason why one’s employer should provide one’s health insurance but not other types of insurance (ie. home, auto)? Food, clothing, shelter, and transportation are more basic needs to show up at work on time, healthy, and well-rested. These necessities are provided by the worker’s wage.
The problem with our health care system is that we have too much health insurance, not too little. The explosive growth in health care utilization primarily comes from the profound disconnect between the person paying for it and the person using it. Americans love freebies, and it’s no different when it comes to health care. The only check on the consumption of a commodity is its price. If gas were free, we’d all drive SUV’s. When your only out-of-pocket expense is a $10 copay, you internalize that a doctor visit is worth about $10 when the real cost is much higher. When it is free, it is only worth your time and the cost of the ride to and from the doctor’s office, which is sometimes free as well.
Why do we use health insurance to pay for doctor visits? The average follow-up doctor visit is considered to be worth about $60 by most insurance companies. The patient pays $10 and the insurance company pays $50. A decent meal out with your spouse costs about $60. Why do we not have “hunger insurance?” After dinner, you could pay $10 and then tell the restaurant owner to submit to your hunger insurance company documentation of what you ate so that he can spend the next three months trying to get the remaining $50, most of which will go to paying people to disburse and collect that $50. You and your spouse can eat at McDonalds for $10, but if you could get a $60 meal for $10, which would you choose? Do all the people involved in paying for that doctor visit really contribute anything materially to that patient’s care or anything else? Do you really need a third party involved in a $60 transaction? The inefficiencies are staggering.
Until people actually have to pay for their health care, over-utilization will persist. A doctor might start hearing questions like: “Do I really need this CT scan? or “Isn’t there a cheaper drug that will do the same thing?” What they hear is: “I’ll take the brand name drug because my drug copay is only $10.” It’s easy to say: “Do everything for mama” when it wont cost mama’s estate or her children a dime after she racks up a $250,000 hospital bill in the last month of her life because no one wanted to let her die at home. If mama’s estate or her family had to pay 10% of that hospital bill, “Do everything for mama” might become “Pull that plug right now.” If it cost a Medicaid recipient $5 to go to the emergency room with the sniffles, he might just try to tough it out, instead of going to the hospital where he will get blood work and a chest XRAY, courtesy of the taxpayers and ordered by a doctor who is pretty sure the guy just has a cold but who doesn’t want to get sued.
Of course, as the costs go up, so does the cost of the insurance to cover the costs. At that point, many young people who are perfectly healthy make the rational decision to forego health insurance given the unlikely event they will become sick, joining the ranks of the “uninsured.” Health insurance for young people remains fairly cheap. Clearly, there are young people who cannot afford inexpensive health insurance, but it would be an interesting experiment to require proof of health insurance before letting them buy a brand new car, a cell phone, liquor, cigarettes, junk food, lottery tickets, movie tickets, a meal at a fancy restaurant, pet food, a television, cable TV, satellite TV, internet service, stereos, a Game Boy, designer clothes, jewelry, a camera, or any of the rest of the stuff young people buy that they need far less than health insurance. The more people who pay into insurance pools, the cheaper it becomes for everyone. The simple fact is that many people choose not to buy health insurance because they prefer to spend their money on something else, thus driving up the cost of health insurance for those who choose to purchase it.
As painful as it is, the only solution is exactly what is happening to state workers and everyone else in the private sector- people are going to have to start paying for what they are consuming. The biggest crisis is yet to come, when the baby boomers start needing end-of-life care. Unless the elderly, who have had their entire lives to save for their health care needs, have to pay a higher portion of their health care costs (an unlikely scenario given their political clout), the only solution is to ration health care, raise taxes, or open the floodgates to immigrants to expand the tax base. My bet is on rationing. Medicare is already using reimbursement schedules to drive medical decision-making. The Government has already mandated 80 hour work weeks for medical trainees. When the Government imposes similar 80 hour work weeks on all practicing physicians, there simply will not be enough doctor-hours available to provide the care our society has been consuming. Doctors will then start rationing, as they do in countries where health care is “free.” But where will the rich Canadians then go for health care?
Cameron S. Schaeffer, MD (Top)
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