Wednesday, December 30, 2009

Treatise on Health Care Reform: Part 4 of 4 (My Health Care Bill)

To both houses of congress, an open invitation: use this one instead. Please, read it first (if you do indeed know how to read). It won't take long, you can probably get it done before some lobbyist wants to take you to lunch today.

WHEREAS these United States of America were founded upon principles of liberty and freedom, and WHEREAS free market principles and capitalism have propelled this nation to its position as the only remaining superpower, and

WHEREAS this position of worldwide dominance is now threatened by excessive and ill-conceived government regulations in many sectors, including health care, which inhibit or restrict the actions of free markets in our nation, let it be

RESOLVED that the current "third party payer system" be abolished through the following actions:

1) Beginning today, it is unlawful for a provider of health care services to bill a "third party" for health care services. Payment should be collected from the person or person who received the services.
1a. Recipients of health care services are encouraged to carry health insurance. Benefits claims and reimbursement will be the sole responsibility of the recipient, not the health care provider.

2) Beginning today, it is unlawful for a provider of health care services to contract with a "third party" regarding the price of health care services.
2a. Recipients of health care services may contract with providers individually, or may do so as groups (such as groups of employees, communities, or neighborhoods). Insurers or other "third party payers" may not negotiate prices or conditions on behalf of health care recipients.
2b. Recipients of health care services may contract and negotiate individually or as groups with insurers regarding reimbursement amounts, premiums, and other terms of insurance.

3) Beginning today, the law requiring health care providers to provide emergency medical services to people, regardless of ability to pay (EMTALA law), is repealed. Individuals who choose to be uninsured do so at their own peril.
3a. Providers of health care services are encouraged to provide charity care to individuals who cannot afford it, but this decision is left to the discretion of the service provider.
3b. Local and state governments are encouraged to provide and administer funds for needed health care for the truly indigent, or for those in the income "gap" between Medicaid eligibility and insurable income. This will, in no way, be a responsibility within the jurisdiction of the federal government.

WHEREAS the current dual system of "individual" and "group" health insurance, each with separate rules, is patently inherently unfair, let it further be

RESOLVED that the laws governing these two separate types of insurance coverage be repealed, effective immediately, to be replaced with the following common sense initiatives:

1) There are no special protections for the underwriting of certain "groups." Premiums are individual.

2) With regard to "pre-existing" or current health conditions, underwriting for the purpose of premium assignment may be based upon health conditions which have been duly proven to be directly resultant from the choices or actions of individuals. Conversely, no pre-existing or current health condition may be considered in the underwriting process that has not been duly proven to result from the choices or actions of individuals. For example, a current or prior smoker may be assigned higher premiums since this choice is well proven to lead to worse health, but having Huntington disease (or having this genetic condition in the family) may not be considered in the underwriting process. Similarly, BMI may be considered, but age alone may not.
2a. Which conditions may be considered and which may not in the underwriting process will be determined by a panel of medical experts who are independent from and not to be governed or influenced by any branch of government. Their decisions will be subject to peer review, debate, and appeal, and will be reconsidered on a regular basis.

WHEREAS entitlement programs including Medicaid and, to a lesser extent, Medicare, are costing the American people more than they can afford, and

WHEREAS these programs do not do enough to encourage individual accountability for health and the use of health care resources, let it be

RESOLVED that the costs for these programs be reigned in through the following measures:

1) Medicaid recipients will be issued a series of vouchers at the beginning of each year. These vouchers will serve as currency for "copays" which will be required whenever health care services are sought.
1a. Visits to a primary care provider will "cost" 1 voucher, visits to specialists will cost 2 vouchers, visits to the emergency room will cost 4 vouchers. Recipients who have vouchers remaining at the end of each year will be allowed to redeem them (for cash, cell phone minutes, or Nascar tickets; that will be left up to the States to decide).
1b. Recipients who either run out of vouchers, or show up somewhere seeking care without one, may still be cared for, but will not be eligible for a refund.

2) Medicare recipients will not be eligible for benefits until age 70. Minimum age for eligibility will be adjusted based on changes in life expectancy, every 5 years.

There you have it. It's short enough that you can print a copy for everybody. Let's try something like this, then let these changes percolate through the system for about five years, and then institute further changes or regulations only as needed, allowing free market principles, capitalism, and free enterprise work their unique magic on "the system."

Since I began this series, it has become apparent that the liberals currently in power intend to pass some kind, any kind, of health care overhaul legislation. It has become glaringly obvious that they don't care so much about the actual content, or even whether it will "fix" the ailing, bloated industry. What these people want, and seemed intent to get, is control over a major American industry. Let's hope that, when all is said and done, common sense and some well-proven principles of American industry will win out over this insanity.

Thursday, December 24, 2009

Treatise on Health Care Reform: Part 3 of 3

My final thoughts on the health care debate are focused on one specific type of "cost." Most of the things you buy when you purchase health care items are not things at all, but are services. MRI scans, doctor visits, surgeries, and the like are things that you have done for you, not things that you take home. There are certain goods, however, that fall under the category "health care costs." These things fall under two basic categories, the first being equipment (known in the medical world as "durable medical equipment" or DME) such as wheelchairs, walkers, elbow braces, CPAP machines, etc. The second category is medication.

Because these items are "goods" rather than "services" it is easier to focus on them and compare them to similar items in other sectors; it is much easier to place intuitive value on an actual thing than on a service.

Take pills, for example. Never has a society paid so much for so little. To understand this, consider the cost of most generic medications these days, which can be purchased for $4 for a month's supply at WalMart. This price includes the wholesale cost, plus markup, plus a standard "filling fee" that goes to the pharmacy. Many people don't realize it, but the actual production cost of that same medication is probably less than $1. The manufacturer, and the pharmacy, are probably each taking a 100% or so markup, still a killing.

Now, consider the cost of your average, new, branded drug. Most of these now cost in the neighborhood of $100-120 for a month's supply. Some are less, some are much more. The actual production costs of these drugs isn't any higher, usually, than drugs that are available generically. The pharmacy typically makes the same on the sale whether the drug is generic or not. So, all that money in the margin is going straight to the manufacturer.

How can this possibly be justified? Drug reps will tell you that the answer is simple: R&D. It costs so much to bring these drugs to market that they need to charge that much to recoup. There is always the risk that, once the manufacturer has expended all those research dollars on a drug, it doesn't make it through the FDA approval process, so they need to charge that much to recoup the costs of the "duds" they test but can't bring to market because they flunk out somewhere in the testing and approval process.

Well, I see somewhat of how much money these corporations throw away on stupid, frivolous things, and so I don't fully buy that explanation. Plus, the system as it is does not encourage companies to develop drugs that I need, it encourages them to develop drugs that will make the most money. What kind of drug will make money? Let's see, a "golden goose" drug will be intended to treat (not cure) a lifelong, chronic illness. No wonder my sample closet is chock full of hypertension and diabetic drugs! No wonder we haven't had a significant new antibiotic in 15 years: those are too good at curing the conditions they treat!

As I have outlined previously, I believe strongly that allowing free market principles to take hold in health care would go a long way toward "fixing" the system. I'm not sure this axiom fully applies to pharmaceuticals; all the competition in the world isn't going to encourage companies to develop drugs that we need. These people went to college, and it doesn't take a rocket scientist to figure out which types of drugs, for which types of conditions, will sell.

So, if the government is so intent on socializing something, why not the pharmaceutical industry? It irks me that probably 90% of the biochemical research done to develop a drug is done in the academic realm, mostly funded by the NIH and other government organizations, from my tax dollars. A pharmaceutical company then takes that knowledge base, built on the backs of the taxpayers, tweaks a chemical a little bit, patents it, and laughs all the way to the bank. They, literally, get us coming and going.

Why not make it illegal to patent a chemical intended for human consumption (a drug)? Pharmaceutical companies could still battle it out to produce better drugs than each other, they just couldn't own exclusivity.

True, this would stop private-sector R&D in its tracks and remove most of their incentive to develop new drugs. That's okay, in my view, since the new drugs they're researching aren't necessarily the ones we need anyway. As a physician, I don't need one more hypertension drug, I need the ones that I already have to be affordable. I need to not spend half my day figuring out how my patients are going to afford the treatment they need.

Let a governmental organization decide where research dollars are directed, based on public health needs. Let them assume the costs associated with FDA approval, and then pass those costs on to the consumers. Drugs would start out generic! Insurance premiums would plummet.

While I am, by nature, loathe to voluntarily trust the government to run stuff if it doesn't need to, I really do wonder if this would be one area more suited to that. What private entity can decide where to best direct drug research? If there is one that can do it fairly and rationally, let them do it. I would not completely socialize pharmaceuticals; I would hope that pharmaceutical companies would still produce, market, and distribute drugs; they would simply do so in a much smaller market, in terms of dollars. Americans don't need, or want, to see drug commercials during the Super Bowl.

Keep watching for the fourth (and final) installment in this series; this will be my own "healthcare bill," the one I would put into law if I were King, guaranteed to be considerably less than 2,400 pages long.

Thursday, December 10, 2009

Update: Lori Can Smile! And Taste! (A Little)

It has been over 3 months since Lori's facial paralysis began, and just this week she began to get the first tiny bit of movement back in her face. Watch in the video how she can turn the right corner of her mouth up in a trace of a smile. It may seem like a small thing, but it's progress!

The video also shows her blinking with her new "palpebral spring." She has been SO much more comfortable since the procedure. Almost all of the swelling and redness are gone (it has been about 5 weeks since the surgery). If you watch closely, you can see that the right eye blinks just slightly slower (and opens slightly slower) than the left. It isn't so obvious that you notice it during casual conversation with her; you have to look to see it. She is thrilled with the results, and thinks that it was definitely worth it! We remain amazed at the simple brilliance of this procedure, and how much benefit a person can have from the restoration of the simple act of blinking the eyes!

She also noticed during breakfast today that she could taste her key lime yogurt and banana! This is also a new thing, and a sign that the nerve is regenerating. She is ecstatic about this, and doesn't even complain that she now gets the metallic "Lunesta taste" with her sleeping pill again.
Here are some photos of her tonight. She is looking beautiful as ever.
Lori continues to handle this medical adventure with grace and style. I admire her for the courage and fortitude with which she has faced this so far. Maybe we are starting to see the end of it for her, though, and that is exciting!