Healthcare Reform by Dr. Elaina George

An honest conversation on healthcare reform, insurance companies & the doctor/patient relationship

Elaina F. George, MD

www.peachtreeentcenter.com

Now that President Obama has put heath care reform on the agenda, I am really afraid that the needs of patients and their physicians will continue to be ignored. I believe that good medical care is a right and not a privilege. However, the drive for true reform has been hijacked by the insurance and pharmaceutical industry.

I have seen a disturbing trend in medicine since I started practicing medicine in 1998. It seems to be getting worse. I am an ear, nose and throat surgeon in solo private practice in Atlanta, GA. I have a unique perspective on the health care system. I truly believe that the voices of average physicians need to be heard.

Imagine going to an ER after sustaining an injury to your face, sitting for hours finally being seen by an ER physician. You are given a CT scan, but not physically examined or treated. Instead you are told to see an ENT specialist and then paying for the privilege. Or what if you have a nose bleed and go to the ER 3 times over 2 days. The first time you are not even seen by an ER doctor. The second time you get a nasal decongestant but no IV fluid. The 3rd time you get your nose packed and told to follow up with an ENT doctor in 48 hours to have the packing removed. You call the ENT doctor on call and you are given an appointment in one month for the packing removal. These are two examples of patients who have presented to my office over the past 2 weeks.

I joined a large single specialty group practice when I left residency. In order to practice medicine and not just be a 'mill' I opened my own practice. I stopped taking HMOs because of the restrictions they placed on my ability to take care of my patients. When our system is compared to a system that has duel medical system like the Caribbean island of Antigua, the cost of medicine is controlled because the patient has a choice. Essentially, those who want to can use the public health system, but those who want to see a private physician are free to do so. The interesting difference is that people with private insurance tend to pay the physician directly and then get reimbursed directly from the insurance company. This has the effect of keeping costs down. The physician gets paid their fee at the time of service and the patient gets a portion back from the insurance company. There is no pressure for doctors to raise their fees because they are getting what they charge at the time of service. The costs associated with paperwork and re-billing denials are removed. The patient gets a discount of 40-80% as a check back from the insurance company and there are no hidden charges or cost shifting.

When the insurance company is the middle man there is a drastic decrease in what the physician is paid. For example, in a former HMO contract I was getting 18 cents on the dollar. I have since negotiated better contracts and now average about 55 cents on the dollar. However, In order to make up the short fall, the pressure has been to either see more patients or raise my prices. If you contrast this with a specialty that does not take insurance it is easy to see what has happened to the cost of care for the patient without insurance. For example, in plastic surgery - the price for a rhinoplasty or a face lift has essentially remained unchanged over the years because they are strictly fee for service.

In short, the cost of medicine has risen because of the insurance companies - the premiums paid have not gone to doctors, but instead has gone to the insurance company in CEO bonuses and investments in software and/or gatekeeper physicians and nurses who get bonuses for rationing healthcare by denying necessary procedures and tests. I can give plenty of examples of necessary medical care denied to my patients by a nurse making clinical decisions. The insurance companies have developed an elaborate system designed to pay as little and as late as possible (over 1 year after service in some cases). There is little oversight or regulation of this industry, and physicians have little recourse. For example, even if I get pre-authorization to perform a procedure. The insurance company can deny payment after the surgery is done and I cannot bill the patient because of the denial even if it is arbitrary. This has the effect of poisoning the doctor patient relationship.

There has been a disconnection of the doctor patient relationship for many reasons. Some of the most important are:

1. The rise of insurance companies as the middle man has increased the cost of medicine by rationing health care and limiting access (through rising premiums). This will get worse under a universal healthcare system. Insurance companies will wield even more power over access to health care. They stand to gain the most by having more people paying premiums. Health care will likely be rationed unless there are provisions in place to assure that: a) what is "medically necessary" is determined by the physician; and b) once pre-authorized by the insurance company, the medical treatment can not be arbitrarily denied.

2. The reimbursement to physicians has dropped every year since I left residency. That has led physicians to increase patient volume and add extenders such as physician assistants and medical assistants. This has been one of the biggest blows to the quality of health care and the doctor patient relationship because it has severely limited the time the doctor has to spend with his or her patient.

3. Disease has become a big business. Instead of promoting wellness and prevention, the cost has been driven up by managing chronic diseases. We are prescribing more medication, but our patients are sicker.

4. Direct marketing by big Pharma to patients has driven demand for expensive but not necessarily more effective or safe prescription medication.

The above mentioned problems must be addressed to insure that good healthcare is not permanently disabled.