June 3, 2017
Republicans are trying to cut health care spending. But hacking away at Medicaid, weakening coverage requirements and replacing Obamacare’s subsidies with a convoluted tax credit will not deal with the real crisis in American health care.
The Affordable Care Act was misnamed; it should have been called the Access to Unaffordable Care Act. In 2015 health care spending reached $3.2 trillion — $10,000 for every man, woman and child in America. While our health care system is the most expensive in the world by far, on many measures of performance it ranked last out of 11 developed countries, according to a 2014 Commonwealth Fund Report.
But deregulation will not fix it. To the extent that we can call it a market at all, health care is not self-correcting. Instead, it is a colossal network of unaccountable profit centers, the pricing of which has been controlled by medical specialists since the mid-20th century. Neither Republicans nor Democrats have been willing to address this.
Most Americans mistakenly believe that they must see specialists for almost every medical problem. What people don’t know is that specialists essentially determine the services that are covered by insurance, and the prices that may be charged for them.
Physician specialty groups have created “societies” to provide education, establish clinical guidelines and handle public relations. These range from the Society of Surgical Oncology to the group that represents me and my ear, nose and throat colleagues, the American Academy of Otolaryngology-Head and Neck Surgery. They are also lobbyists, charged with maximizing the incomes of member doctors by influencing pricing decisions made by the Centers for Medicare and Medicaid Services. Those prices become the benchmarks for private health insurance companies, too.
There are so many specialty organizations because each develops authority over a niche market and vigorously guards its turf. Imagine building a house by allowing each workman to do his own thing. The plumber would put a sink in every room. The electrician would install chandeliers on every ceiling. The carpenter would panel every room in luxurious wood. That’s how health care works.
Though they would vigorously deny it, entrepreneurial doctors often treat each patient as an opportunity to make money. Research shows that physicians quickly adapt their treatment choices if the fees they get paid change. But the current payment incentives do more than drive up costs — they can kill people.
Sedated endoscopy, for example, which is used by gastroenterologists to treat conditions like acid reflux and to perform colonoscopies, carries significant risks of adverse effects, including mortality. Joan Rivers’s death from the procedure was not a one-in-a-million complication. Reported death rates vary considerably, but one rigorous study suggests that the death rate is 1 in 9,000. Since approximately 18 million sedated endoscopies are done each year in the United States, “routine endoscopies” may cause 2,000 deaths a year.
And yet, for acid reflux, there is a safer, cheaper and equally accurate procedure available called transnasal endoscopy; unfortunately, doctors rarely employ it, presumably because it doesn’t pay as well.
The focus of my practice is acid reflux that affects the nose, throat and lungs, so-called respiratory reflux. By the time patients arrive at my office, most have already seen otolaryngologists, pulmonologists, gastroenterologists and allergists. They have undergone unnecessary CT scans, MRI’s, blood work, allergy tests, asthma treatments, endoscopies, and nasal and sinus surgeries. Each specialist performs the procedures that generate income for them, and then passes the patient along.
But when it comes to managing acid reflux, specialists offer no advantage over primary care physicians. Indeed, sometimes all a patient needs are basic changes in diet, lifestyle and sleep.
Neither the Affordable Care Act nor the Republicans’ American Health Care Act addresses the way specialists are corrupting our health care system. What we really need is what I’d call a Health Care Accountability Act.
This law would return primary care to the primary care physician. Every patient should have one trusted doctor who is responsible for his or her overall health. Resources must be allocated to expand those doctors’ education and training. And then we have to pay them more.
There are approximately 860,000 practicing physicians in the United States today, and too few — about a third — deliver primary care. In general, they make less than half as much money as specialists. I advocate a 10 percent to 20 percent reduction in specialist reimbursement, with that money being allocated to primary care doctors.
Those doctors should have to approve specialist referrals — they would be the general contractor in the building metaphor. There is strong evidence that long-term oversight by primary care doctors increases the quality of care and decreases costs.
The bill would mandate the disclosure of procedures’ costs up front. The way it usually works now is that right before a medical procedure, patients are asked to sign multiple documents, including a guarantee that they will pay whatever is not covered by insurance. But they will have no way of knowing what the procedure actually costs. Their insurance may cover 90 percent, but are they liable for 10 percent of $10,000 or $100,000?
We also need more oversight of those costs. Instead of letting specialists’ lobbyists set costs, payment algorithms should be determined by doctors with no financial stake in the field, or even by non-physicians like economists. An Independent Payment Advisory Board was created by Obamacare; it should be expanded and adequately funded.
Finally, the bill would create an online database, reporting all physician conflicts of interest, as well as information on how many procedures each doctor performs, with related morbidity and mortality data.
If the president and Congress are serious about getting health care costs under control, this is a starting point. If there ever was an area where bipartisanship might triumph, it would be reining in a corrupt health care system that grows like a cancer on our country.