Residential Space A creative outlet during residency, turned ongoing virtual soap box

National Healthcare System – The Way To Go  3

Posted on May 4th, 2006. About Health Care, Money, News and Politics.

I attended a conference this morning during which one of my colleagues, a graduating third year internal medicine resident, gave an excellent presentation on the pros and cons of a national healthcare system. Prior to graduating from medical school, I was quite hesitant about this idea. After a year of practicing medicine as a physician, I am in favor of it, because I honestly believe it would provide better care to more people at a lower overall cost.

Let’s be honest – healthcare inflation is drastically out of control in this country. It’s only getting worse – it will not get better. I think that is worth re-stating for emphasis – IT WILL NOT GET BETTER. Healthcare is >12% of our GDP and is rising. More than 40 million Americans are uninsured, and this does not include those on Medicaid and Medicare – also funded by tax dollars. In short, I do not think our current system is sustainable.

I was against this notion for a long time because I possessed several fears: A) Huge waiting lists would arise and it would take months to have a simple procedure done. B) Research and development would be stifled because drug company profits would fall and thus there would be less incentive to fund research. C) Physicians would be paid little for the amount of training they have undergone. D) The quality of care would be compromised.

I will address these points individually, as I believe many people share these concerns:

  • Waiting Lists – I, as an individual with excellent private health insurance, had to wait over two months for an esophagogastroduodenoscopy (EGD). I have had patients this year who have had CT scans in the ER demonstrating masses in their colons, and if they are not admitted to the hospital, then the soonest they can be worked in for a colonoscopy is three months. The truth is, we have horribly long waits today, and if anything a national system will be more uniformly funded in such way that some of these waits can be reduced.
  • Research and Development Dropoff – A national plan would likely involve bargaining with drug companies to label certain drugs in specified classes as “formularies,” that is, first-choice selections that can be obtained at lower cost. I am all for R&D, but much of the funding, even in private companies, comes from the federal government already. The National Institutes of Health (NIH) gives huge grants to the pharmaceutical industry for scientific investigations. In addition, 85% of new drugs are what we call “me toos,” drugs that are not new or innovative, but just different forms of what already exists and offers no added benefit to what is currently available. If anything, I believe that this new system would encourage true R&D – why develop yet another statin when three others, the three that are supported with clinical trials, have been shown to be more effective? They would be motivated to then focus their efforts on creative new approaches to, say, amyotrophic lateral sclerosis (ALS), a disease where no good treatments currently exist.
  • Physician Compensation – There are many models that exist for a national system, including one that supports single-party payer reimbursement. Under similar systems physicians are well-compensated without the hassle of having to jump through twenty different hoops with hundreds of insurance companies (and each company selects their own hoops) to try to get a procedure covered that may end up being denied – and if denied, the financial burden falls on the patient, or if the patient will not pay, the healthcare provider. On the other hand, under our current system, we see many patients without insurance who will never be able to pay the bill. The hospital, or the physician’s office, eats the cost. We are required to treat “emergencies” whether the patient has funding or not – and while this may seem okay to some, why should the hospital, a business, have to eat the cost? Under a national system, the hospital and physician are reimbursed for every patient, patient’s don’t have to worry about hospital bills, and the system comes into better balance.
  • Quality of Care Compromise – It is now difficult for me to imagine the quality of healthcare being compromised. For some of my patients, when they realize that their funding is about to run out, or if they worry that they can’t pay their bill, they leave the hospital prematurely before their treatment has been completed. Because physicians spend so much time on paperwork, there is less time to provide patient care – eliminate the papers, and suddenly we have more time to spend with each patient, or we have time to see more patients to reduce the waiting periods for appointments.

Perhaps the biggest reason I am in favor of this system is because it would bring preventive healthcare to the forefront of medicine and reduce the cost of catastrophic medical complications. For example, in Quebec a $2 copay was added for each prescription picked up at the pharmacy and a small copay (don’t know the amount, but it was similarly small – less than $5 per visit) was added to each visit. The number of ER visits shot up dramatically and the number of dollars spent on inpatient hospital admissions skyrocketed. Now, a system is in place with no copays for anything, and their healthcare spending overall is back down significantly. I have seen several studies outlining this and it really does appear to be effective.

There are multiple propositions on how to fund such a system. For starters, the taxes we pay for Medicare would go to the new system. It has also been estimated that the amount of tax required would be anywhere from 8 to 17%. It sounds expensive, and it is, but consider that employers providing health coverage (even with copays) pay anywhere from 7 to 25% of each employee’s annual salary to provide this benefit. Employers could still bear this cost, or else be able to increase salaries such that the federal tax could be removed from the employee’s paycheck.

Consider this – uncontrolled diabetes over years often leads to kidney failure, blindness, non-healing skin wounds that lead to amputations, and premature nursing home placement. If I have a patient with early diabetes and without insurance, she can either A) go to her physician for her checkups every two to three months and obtain her oral medication or her insulin free of charge, or B) she can act noncompliantly with her recommended care because she has no money and no insurance – and then, 15 years later, we have a woman in florid kidney failure, on dialysis three days a week (hugely expensive), going blind, in a nursing home at the age of 60, and draining the system of thousands of dollars a month. It sounds dramatic, but I cannot count the number of cases I have seen almost exactly like this one. I know people often think of a nationalized system as a “liberal” idea, but I insist that it is a fiscally conservative notion, and one that must be considered before being cast aside. Over a ten year period, it is estimated by healthcare economists that a nationalized single-party pay system would save over a trillion dollars – yes, that actually says trillion. A thousand billion. That’s $100 billion dollars a year.

If you have read this far, I applaud your attention span. If you would like to learn more about a national single-party pay healthcare system, one website many of us like is that of the Physicians For a National Health Plan. I am also including a link to the Physicians’ Proposal for such a plan that was published in the Journal of the American Medical Association in 2003. There are many excellent resources listed in the bibliography for more information. I welcome comments on this issue, as always, and hope to hear what you have to say.

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