Commentary
by Richard H. Bernstein, M.D.,
Charlotte Family Health Center

A Tilted Playing Field

As a practicing physician for over 30 years, I believe the recent anti-healthcare reform editorial in The Charlotte News requires a response. As a family doctor, I interact with most insurance companies that operate in Vermont. Of them all, there is one that never denies a patient because of a pre-existing condition, never requires time-consuming pre-authorizations for tests such as CAT scans or MRIs, and never refuses to allow a patient to see the physician of his choice – or mine. This company never would kick patients out because they were too sick nor exclude from coverage patients with unfavorable family history of severe illness. This company is Medicare. Likewise, the Veterans Administration, operating in the mode of the British healthcare system in which the government owns the facilities and employs the physicians, provides high-quality, very cost-effective care to its clients. In fact, looking at the situation strictly from the patient’s viewpoint, Medicare, Medicaid and the VA system are extremely important and well-regarded. On the other hand, the private health insurance system, in effect since the 1930s, has led to the costly and imperfect system we have today.
There is a need for health reform in this country. Currently, the U.S. spends more per capita on health care than any developed country. As one example, in 2006 we spent $6,714 per person, or 15.3% of GDP, while Canada spent $3,678 or 10% percent of GDP. Yet, according to 2009 estimates, the U.S. ranks 44th in infant mortality (Canada is 35th, U.K. is 30th) and 45th in life span (U.K. is 37th).
A 2007 article in the American Journal of Medicine notes that 67% of all personal bankruptcies were medically related, and of these, 92% had medical expenses over $5,000. Most were middle-class, well-educated individuals owning their own homes who were caught by high deductibles and co-pays and huge out-of-pocket medication expenses.
A survey in 1991 by the Organization of Economic Cooperation and Development showed that 29% of Americans wanted to completely rebuild the healthcare system, compared to 17% of Britons and 5% of Canadians. In 2007, the number of Americans jumped to 34%, while 15% of Britons and 12% of Canadians advocated complete reform.
The U.S. is the only developed country without a national health plan, while citizens in those countries with national plans remain more satisfied than Americans, spend less and have better outcomes. Clearly there is a need for change, though how medical care is funded may be more important than who is doing the funding.
Under the current fee-for-service model, the more services a doctor prescribes, the more the system profits. If a doctor recommends an expensive test or treatment, most people would submit, assuming the physician is acting in the patient’s interest. But what if the physician owns the testing facility or is employed by the entity that does? This appears to be the case in McAllen, Texas, where per capita medical expenses exceed $15,000, twice the Medicare average. Interestingly, notes Harvard surgeon and medical writer Atul Gawande, the Mayo Clinic and Cleveland Clinic spend less than the national average and have better outcomes. According to Gawande’s New Yorker article, over-prescribing of tests, operations and hospital stays in McAllen, each carrying its own risk for harm, leads to far higher costs and poorer outcomes.
An honorable physician makes recommendations based on scientific knowledge. However, when financial self-interest is involved, science dies. Medical studies today are largely underwritten by pharmaceutical companies. A physician may think he’s acting in the patient’s interest, but the information that guides him may not be the best information. There are a lot of organizations that profit from the decisions your doctor makes: pharmaceutical companies, insurance companies, medical equipment suppliers, hospital x-ray departments and cardiac catheterization labs, to name a few. While most people remain very satisfied with their own physicians, the system itself rewards and encourages over-utilization of expensive tests and procedures and treatments of questionable value.
And then there’s the waste. In our office, a staff person spends a great deal of her time sending requests for pre-authorization of tests and exemptions to drug exclusions to various insurers. Each insurance company has its own forms and policies. Those who advocate for a single-payer healthcare system point to the high cost (nearly 30%) of bureaucratic waste in the current private insurance system.
Like the banking industry, the medical industry has created a tilted playing field, and it’s not tilted in the direction of the average consumer. The system demands reform and will not reform itself. From the way the system is financed, to the costs to consumers, to the way money is spent by providers, I think the time and opportunity for change has come. I personally believe that the so-called public option under debate provides the best opportunity over time to change the current system to one where the patients’ interests are primary. This is, after all, the reason many of us entered the medical profession in the beginning.

– Richard H. Bernstein, M.D.
Charlotte Family Health Center