Treatise on Health Care Reform: Part 2 of 3

I want to put forth here a philosophical discussion of healthcare funding in America. Before meaningful, long-lasting reform can be accomplished, Americans need to decide as a people whether the responsibility to pay for health care lies with the individual citizen, or should be shouldered by society as a whole.

There are definitely some things, in any society, that are simply better to be paid for collectively. For example, having each individual pay for and build the roads that he wants to travel upon simply would not work; there are obvious benefits to sharing the streets, and sharing the costs involved.

On the other hand, history has proven that when a society tries to have all things in common (as in the case of communism) dysfunction of all kinds tends to ensue. Although desirable in theory, the imagined equality under these types of systems rarely materializes in real life. A case in point is the former USSR and its communist system of government that eventually collapsed in on itself. Hitting closer to home, even covenant-bound Latter Day Saints couldn't pull this off effectively, on a relatively small scale when they attempted to live the united order.

We are a capitalist society (at least for the time being). Capitalism is, in part, governed by the principle of laissez-faire, which means, literally, "let it be," or "let it alone," (ironically enough, in French). With capitalism, it is generally accepted that, for the most part, people and markets should be free of government interference or control. Laissez-faire is by no means absolute, however; many industries are regulated by the government, to ensure quality or stability, or to prevent monopolization. Although there are some who think there should be absolutely no government regulation of commerce, etc, most reasonable people agree that some oversight is needed and helpful, particularly in certain sectors, like those that involve the basic safety, well-being, and yes, health, of the people. My dad, as a relevant example, worked for many years in a utilities sector, where the government has a certain involvement in ensuring that folks in rural areas have access to adequate, high quality telecommunications services on a more-or-less equal basis with those living in more urbanized regions.

These economic issues aside, there are other philosophical issues at stake with regards to health care funding. For example, while it is generally not considered unjust for grocery stores to deny people food because they can't pay for it, there is a sense that an injustice has occurred when a person in need of health care, particularly lifesaving health care, can't afford it and is, therefore, unable to obtain it. Of course, food is equally necessary for that person's existence, but is not necessarily considered something the person should be entitled to have when in dire need.

For a real-life but hypothetical example of this, consider a destitute person, about to starve, who walks into a grocery store and demands a meal; he likely would not get anything from the store's inventory without making payment (although a compassionate grocer might direct them to a food bank). On the other hand, the same person could walk in to any emergency room of any hospital in America at any time, and the law requires that the person be treated, regardless of ability to pay. Even I was irked the other day when I heard an uninsured patient's story about having been diagnosed with pre-cancer of the cervix, and then being told by her unapologetic gynecologist to raise enough money to pay for the surgery, and then come back. By the time she saved enough and returned, the cancer had advanced and spread, and was much more difficult and risky to treat.

Therein lies the dilemma for me. I am, in a way, of two minds. On one hand, I don't believe that providing every needed service is an appropriate undertaking for a democratic republic with a capitalistic economy. Nor, for that matter, do I trust our government enough to feel confident turning over health care to it. On the other hand, I don't quite feel right about denying health care to folks who can't afford to pay for it, particularly lifesaving care. If I had lived 150 or 200 years ago, I probably wouldn't have had a philosophical problem with it. But, in my heart of hearts, being who I am in the year 2009, I do.

This interesting shift in the collective thinking of Americans has been shaped over the years, without doubt, by the way health care has been paid for in America (see installment 1 in this series). In short, most of us have gotten used to somebody else paying the costs of our care; our employers pay for it while we work, and the government takes over when we retire. As a whole, we haven't needed to include health care costs in our personal budgets very much; once our basic needs for food, clothing, shelter, and the like have been met, we have been free to spend our surplus on things we wanted, like vacations, vehicles, cell phones, and other luxuries. We don't tend to "save up" for medical care, or include those costs in our planning. I see this every day in my practice when patients who "can't pay their bills" make me wait while they talk on their cell phones.

While there is definitely a certain percentage of Americans who simply could not afford insurance no matter what financial adjustments they made, I believe there is another group, probably a larger group, who choose not to purchase insurance. If asked, most in this group would, undoubtedly, say that they don't have it because they can't afford it. And, in their own minds, they honestly can't. A review of their budgets, however, would reveal that, with a shift in priorities, they could afford the premiums, although this would require that they sacrifice some things that they have come to view as essential "needs."

At certain points in my own life, I, by the way, have fallen into this group. I chose that approach during college, for example. At times, when my wife and I were first married, we went without insurance. We didn't try too hard to prevent pregnancy, knowing that if she became pregnant, she would qualify for Medicaid, and that the government would pick up the tab. Why did we do it this way? Well, we were all healthy, and not likely to incur major medical expenses. (All insurance is, after all, a gamble, and when one is young and healthy, the odds are a lot longer.) Plus, looking back, I think I knew in the back of my mind that if something catastrophic happened, there was an adequate safety net there. I didn't have to live in fear that I wouldn't be treated; I knew that, when push came to shove, I would be, regardless of my ability to pay. If I wanted to have health insurance, I would have needed to work more hours, and cut back on the credits I was taking in school. This would, of course, have resulted in a significant delay in my career track, probably by 2-3 years, at least.

Although I never spent much energy investigating the implications of "going bare," in the back of my mind I also knew that medical bills really couldn't ruin me financially, because I didn't own anything of value. I had a good sense that, in the end, if some unanticipated thing happened to me or my family, we would qualify for government aid because we had no significant assets that could be taken away to pay the bills. Was that the wrong approach for a responsible citizen to take? Perhaps. (Ask not what your country can do for you...) Was it a good decision, purely in terms of finances? Sure! In a health care system funded mostly by insurance dollars, is it going to work if very many people choose that approach? Not on your life!

So, at this crossroads in the history of American health care, one major decision we should be making is whether we believe, deep down, that health care funding is an individual or a public responsibility. It is a difficult question, and, unlike the issue discussed in the first article I wrote on this subject, I don't think this issue necessarily has to be answered in "either/or" fashion. Perhaps this one can have it both ways; I'll elaborate my own ideas on this further in the fourth installment.

Update; Plastic Surgery in Beverly Hills, Baby!

Last week Lori accidentally tore out her tarsorrhaphy while getting dressed; her shirt caught on the stitch and pulled it right out. Needless to say, that didn't feel very good, and sort of made mincemeat of her eyelids. Here's what it looked like after it came out.Her ophthalmologist said at that point, since she really hadn't regained any significant function, it was time to have something more definitive done; we couldn't do any more temporary tarsorrhaphies. Lori had been worried about this eventuality, but she had been talking with one of her friends one day, whose dad had a permanent facial nerve palsy resulting from a brain tumor. His eye had been giving him fits just like Lori, and he had tried all kinds of things including an implantable gold weight, none of which had really solved the problem for him. Eventually, though, he had seen a doctor in California who had implanted a metal spring in the eyelid, and restored his ability to blink. This intrigued Lori, and she had done some research into the procedure, discovering that the physician, Dr. Levine, was still practicing in Beverly Hills, California, and had performed thousands of these procedures over the past forty years or so. At one point, he had even called her personally to explain the procedure and answer her questions; she had been pretty impressed with that. As she looked into it more, she also discovered that Dr. Levine is the world's foremost expert in eyelid springs. If you have to have it done, he is the guy you want to do it, apparently. He has done thousands of spring procedures, has been doing it for more than forty years, and has, literally, written the book on the subject (well, there isn't any book, but almost any medical literature you can find on it over the past forty years has his name on it).

So, when this happened, we quickly began making plans to go down there, knowing that the longer her eye remained opened, the more uncomfortable she would get. Here she is with him having her preoperative evaluation.He is a nice, short little Jewish man in his seventies who, although he has been living in California for decades, still has a trace of New Jersey accent that betrays his eastern upbringing. After I got to know him, I asked him if he had ever though about retiring, to which he shrugged and dismissively replied, "I enjoy what I do."

The idea of the eyelid spring is simple, really; because Lori's ability to shut the eye is impaired, but her ability to open it is not, she needs an artificial, downward or "closing force" to balance out the unopposed "opening force" left over from her damaged nerve. By implanting a bent and coiled piece of metal within the eyelid, attaching one end to the bone above and the other end to the top eyelid itself, the needed closing force is supplied. Here's a picture of the spring as it appears before fitting; it will be shortened considerably on each end and then, when its implanted, each end is coiled and placed within a dacron pouch so that there aren't any sharp edges. If done right, the opening force still works, so that she can overpower the force of the spring and open the eye, but when she "turns off" the opening force in the act of blinking, the spring takes over and gives her a nice, quick blink that looks pretty much like the other eye and closely resembles normal function of the eyelid. Implanting a gold weight within the eyelid is another option which accomplishes nearly the same thing, the major differences being that the gold weight is more noticeable, and tends not to work when the person is lying down, since the "closing force" in that case is really just the downward force of gravity pulling on the weight. If you're lying flat or even tilting your head back slightly (as many people tend to do while sleeping), the weight actually tends to open the eye even more, so a lot of people who have weights tend to have to tape their eyes at night. Since gravity is slower to move than the "snap" of a normal blink, the weighted lid tends to lag behind the other one and, if it is too slow, it won't shut all the way during the blink.

Anyway, as it turns out, Dr. Levine's office is located in Beverly Hills, so we ended up staying at a hotel right at the end of Rodeo Drive called The Tower Beverly Hills all week while Lori underwent her evaluation and spring fitting, had the surgery, and her postoperative care. Before her first appointment we had a few hours, so we walked around the town for a little while. If you look closely, you can see a beautiful movie star that happened to be standing under the sign.He was kind enough to agree to let me come in during the surgery, so I took a couple of pictures in the operating room. Here is Dr. Levine on the right, with his assistant, Norma, on the left.They actually woke her up at a couple points and had her sit up and open/close her eyes to make sure the eyes were more or less symmetric during blinking. Like all good plastic surgeons, he took some photos (for the tabloids, I guess).To look at her today, you couldn't tell because her eye is swollen completely shut, but I saw it during the surgery and it was looking really good.Dr. Levine also tightened up her lower lid, and lifted up her right cheek, which were both sagging a bit. This makes it easier for the lids to meet during a blink so that she will get a nice, smooth film of tears covering the cornea and protecting it from the harm that comes when it dries out. You don't realize it, but you blink your eyes about every 4 seconds while you're awake. If you don't think losing your ability to blink is a big deal, try keeping your eyes open without blinking and see how long you last. For the past 2 months, Lori has basically been involved in one big, long staring contest with her right eye; it is easy to see why that was making life difficult for her. We are excited for the swelling to go down so we can see how it all turned out.In the postoperative photo, Lori looks like she is grimacing a little on that side; during the surgery another surgeon named Dr. Joel Aranowitz used some really long sutures to lift up the sagging part of her right upper lip; the "lift" is a little exaggerated right now because of the swelling, but should make her face look and function more normally once the swelling subsides. We are, of course, hoping that this will be temporary, just for a few months. We remain optimistic that she will regain most, if not all, of the function in her face. But, everything we have heard has indicated it will be several months, or even up to a year. This will be, if nothing else, a very nice, temporizing measure. They can take the spring out again, later, and we certainly hope that is what will happen.

Lori's friends had this really pretty flower arrangement sent to her in our hotel.We have wonderful, supportive, loving friends and family who have supported and loved her during this difficult time. We don't have words to express the gratitude we feel for them.

Treatise on Health Care Reform: Part 1 of 3

I can't help it. I need to sound off on "health care reform" since the whole argument is driving me crazy. It seems like you can't watch the news, pick up a newspaper, listen to the radio, or read anything on the Internet without hearing about how we need to reform the healthcare system.

Well, I have a few thoughts on the subject, so here's one physician's current view on the debate. Actually, it is more than a few thoughts; this will probably rival the stimulus package bill in length, so I plan to present it in four parts: 1) Controlling Costs & the Concept of Employer-Funded Health Insurance, 2) Rights vs. Expenses, 3) Pharmaceuticals and Equipment. The fourth (much shorter) installment will succinctly outline what direction I think reform should take for the best good of all concerned; I plan to call this last one my "Proposal For Health Care Reform 2009." Lest you think I am suffering from 'delusions of grandeur,' let me say up front that I don't think for one minute that my opinion counts one whit in this debate. Still, it makes me feel better to put it out there, so here goes:

Controlling Costs & the Concept of Employer-Funded Health Insurance
One one hand, some politicians today think we should let the government finance the system entirely, turning it into something akin to the public school system, available to all at no direct cost. Increased governmental control will reign in costs (somehow). On the other hand, some think that the insurance industry just needs to be deregulated and allowed to sell plans across state lines. Fostering increased competition between those who pay for health care will reign in costs (somehow). And, of course there is every conceivable variety of opinion in between.

What nobody seems to want to talk about in the whole debate, is why medical services cost so much in the first place. Why is it that the cost of evaluations, treatments, supplies and equipment are so quickly outstripping society's ability to pay for them?

During my short career as a physician, I've seen a remarkable transformation occur. We have always had people who lacked health insurance entirely and were burdened with heavy bills when they got sick, but when I started practice as a resident in 2001, most people with health insurance rarely thought about the costs of health care at all. They had low deductibles, low or no copayments, and their employers usually picked up the tab for the insurance premiums, entirely. There were few, if any, restrictions on which physicians they could choose or which treatments they could have.

Now, many employers have limited how much of the premium they will pay, passing the rest on to the employee in an effort to have some control over the cost of these benefits. Yearly deductibles are increasing, and copayments for drugs, a relatively new concept, have risen from around $3 to $60 or more monthly for many meds. Additionally, insurance companies are increasingly involved in the doctor-patient relationship; the question for many patients has changed from "which treament is best?" to "which treatment is covered?" And, more recently, I have noticed an increasing number of patients with average incomes who can't begin to afford their medications, even with their insurance paying its portion.

Why? This is what nobody seems to be asking right now. While they squabble back and forth about how we can possibly pay for the "skyrocketing costs of healthcare" things, nobody wonders how the heck we got here in the first place. Perhaps part of the solution lies in identifying and correcting the underlying cause of the cost increase.

Let's review a short course in American Healthcare History, from a funding perspective. Health insurance as we know it didn't exist until around 1930; prior to that people were on their own to pay, in cash or in kind, for medical services. Those who couldn't pay simply did without, unless they could find a charitable physician or hospital, or some other generous group to pay for medical services for them. Many of these "uninsured" patients died of potentially curable conditions, simply because they couldn't afford treatment; this was not considered unusual or cruel, or in any way unfair. It was, simply, a fact of life.

Early insurance "cooperatives" were set up by large employers as a way to provide low or no-cost medical services for their employees, usually for the treatment of on-the-job injuries or illnesses. These groups evolved over the years into large conglomerates we know today as Blue Cross, CIGNA, and the like. As other, smaller players entered this market, they began to stratify patients into various risk categories, using an underwriting process like that employed in the life insurance business; patients likely to cost the company more were charged higher premiums, or were denied insurance altogether.

The next major evolution in healthcare funding was the HMO; these organizations were different in that, rather than trying to control costs simply through risk stratification, they began to focus on the supply side of the cost equation. They negotiated with hospitals, physicians, and other suppliers of healthcare using this basic bargaining phrase: "we have a ready supply of insured patients for you, if you agree to the conditions of our contract." The original HMO concept was that cost management through time-tested business principles, combined with an emphasis on prevention, could produce lower premiums for patients and higher profits for insurers. To an extent, the HMO concept works as a business model, although much of the envisioned cost savings gets swallowed up by the vast 'middle management' required to administer such plans effectively. Initially, these groups only attempted to control how much they would pay for each service recommended by physicians, not which services could be offered; the doctor-patient relationship was considered independent and sacred.

More recently, though, as costs have continued to spiral upward and profits have become more and more difficult for insurers to realize, even this boundary has been crossed and, in many cases, obliterated. Many physicians in HMO arrangements feel like simple puppets of the organization; every decision they make with respect to their patients is influenced by the mandates of the insurance organization. The historical doctor-patient relationship as we know it has, for many, ceased to exist, supplanted by the doctor-patient-payer relationship.

Another important historical element is the introduction of Medicare in 1965. Patterned after Social Security, this fund basically takes money collected from working Americans in the form of a payroll tax to pay for health care costs for retired people. This fund was a godsend not only for many elderly people, but for the medical industry in general, which, along with the rest of the world, had undergone a technological explosion that had greatly expanded what medical science could offer patients. Now, able to offer lifesaving and life-prolonging treatments previously unavailable, and with a virtually unlimited federal fund from which to draw for payment, physicians and hospitals across the country became wealthy beyond their wildest imaginations. Life expectancy for the elderly increased accordingly, and this placed an additional demand on the fund. In time, Medicare learned and began to apply HMO principles like the rest of the insurance community, and introduced strict limits on covered services in an attempt to control spiraling costs. Today, Medicare is not appreciably different from any other insurer in most respects.

Around the same time Medicare was introduced, the government instated certain tax incentives for businesses supplying health coverage for their employees; special laws were introduced governing "group health insurance," which gave special protections to individuals covered by group plans. These special protections took away many of the risk stratification strategies insurance companies used to determine who they would and would not cover. For example, insurers were prohibited in many cases from denying coverage for preexisting conditions. These same protections were not afforded people who weren't covered under group policies, and the difficulty those with health problems have in obtaining "individual insurance" persists even today; this disparity is one thing that some politicians are targeting as part of the reform being considered this year.

With that historical context, consider the original question. Why does healthcare cost so much in America, particularly compared with what it used to? For sure, there is no single, all-inclusive answer to this question. I believe, though, that most of the reason has to do with the way insurance has removed costs out of the consumers' eyes. For too long, patients knew nothing of what their medical services were costing them. Not only were they not paying the bills, they weren't even paying the insurance premiums.

Without incentive or motivation for patients to shop around, the providers of medical services have for years had basically no free-market control over rising prices, and they have acted accordingly in the pricing of their services. Rather than set their prices based on competition and what the market would tolerate, providers simply set their prices "higher than the highest payer's allowed cost," leaving all cost control in the hands of payers alone, who don't actually consume the 'goods.' Of course, competition among payers for patients then drives costs up, instead of down, like competition among providers would do. Not experiencing the costs themselves, patients as a whole have gotten in the habit of demanding nothing but the best, latest, greatest, most convenient, and, of course, most expensive care; this behavior is a natural by-product of the system we created. Not surprisingly, this handcuffing of free market principles in the healthcare market has led to the price explosions we continue to see. We have, unwittingly, created a system that is a perfect recipe for price inflation.

Of course, the lucrative nature of this service sector as a whole has encouraged more and more research, innovation, and development of new technologies for diagnosis and treatment, each more expensive than the one before. Of course, once a new modality for treatment or diagnosis is available, it becomes part of the "standard of care," and insurers have to cover it; premiums, then, rise accordingly as the insurers' cost burden increases.

When you think about it, the surprising thing is not that this has happened. The surprise is that the problem has taken so long to reach critical mass, which I believe it has. I see it every day in my practice, where the 'standard of care' comes head to head with its associated costs, which more and more patients simply can't afford, even if they have insurance.

So, what to do, then? Well, I'll offer my opinion on that in part 4, straight up. But before we can meaningfully reform the health care system for the long term, I think we need to decide one thing as a country: should health care services be available to Americans as service market items, like catering, carpet shampooing, or window-washing? Or, should they be purchased by the public collectively, through taxation, and provided to the people as a "right," of citizenship like we have decided primary education should be? In my opinion, you can't have it both ways and also have a system that will work for the long term, and that is what Americans have come to expect.

Two important legacies have been created with Medicare and the employer-funded health insurance concept, which are important to recognize. The first of these legacies is government involvement in health care. As with any program supplied by federal funding, Medicare has federal strings attached; the introduction of Medicare and its sister program, Medicaid, introduced government regulation of medical services. Most insurers now piggyback their own regulations and reimbursement rules on to those of Medicare so that, in a very real sense, the government controls funding for the entire healthcare industry. In effect, the doctor-patient-payer relationship has now further evolved into the doctor-patient-payer-government relationship, even for those who aren't covered by "governement insurance." Too often, people and their various medical problems are treated as just another football in the great political game. The introduction of politics into the mix has further complicated the delivery of health care in America.

The second legacy is that patients across America have come to view access to health care services as a public "right," like access to education has become, rather than as an individual "expense," like food or housing. While not specifically granted either by the Constitution or by any existing act of a governing body, this alleged right has, nonetheless, become very real in the minds of many Americans. This dichotomy will be explored more fully in part 2; stay tuned.