A System for Health Care by Dr. Paul Nussbaum
June 26, 2009
The United States is engaged again in a debate on health care and the best system to provide and receive health care. Other nations across the planet have similar debates and there are different approaches to care in different countries. I add my opinions as a provider and consumer of health care to have some more fun muddying the waters.
First, it is my opinion that health care, like housing, clothing, and transportation is not a right, but a privilege. I will continue to scour the US Constitution for the right on health care, but to date I have not found it. With housing, clothing, and transportation citizens choose to purchase products based on ability to afford. There is no single car, house, or pair of pants that folks use; we are diverse based on our ability to afford. Health care really is no different.
As a provider the most frustrating thing is that I need to get permission from a complete stranger to examine and treat a patient, I am told how much I can charge, and I am further told how much I will get paid. I wonder if anyone reading this will consider what it would be like to have to call someone to sell a pair shoes, sell a car, or to purchase a house. I wonder what it would be like for you to be told you are only permitted to sell this shoe or that house and that your commission on that sale will only be a certain percent!
It seems to me that most consumers are pretty smart and understand what they can and cannot afford. If I place my name and title on an office building the consumer may choose to solicit and pay for my services. My fees will not be unreasonable because the consumer will go to the next doctor who charges less and I will be out of business. I will be able to work directly with the consumer who will exchange a fee for my professional service.
As a consumer, I have recently purchased a Health Savings Account (HSA) as I am self-employed. I find the ability to manage my own health account valuable and freeing. I enjoy asking the nurse or doctor how much a procedure costs and then choosing a less expensive procedure or I simply do not have the procedure. With an HSA I am able to approach utilization and purchase of health care services the way I approach other products and services in the market. I am in control.
One final opinion is that the United States is far too medicalized, too invasive, too bureaucratic, and too expensive. We have some great professionals and tremendous resources, but we neglect the simple things that can really curb disease and chronic conditions. We do not focus on exercise, nutrition, stress reduction, cognitive stimulation, and communication. We do not do enough to curb bad habits and we view all of these things as external to the “real health care system” when these are the precise behaviors that cause the medical conditions that are so expensive.
Some suggestions for health care delivery might include the following:
1. Put the consumer in charge of his or her health care and treat it no different than other products in the market
2. Create a standard basic safety net for major medical crises that will probably need to be both employer and government subsidized and that means taxpayers.
3. Get rid of all middle layers of the health care bureaucracy. There should not be anyone employed for precertification, preauthorization, or claims management. The doctor and the consumer will manage this as the consumer does with other products purchased everyday.
4. Each doctor will set his or her pricing and the consumer will decide if the prices are reasonable.
5. Stop dictating to doctors what procedures can and cannot be performed. They are licensed in medicine to already know what to do and do not need a bureaucrat to tell them this information.
6. Create products that are preventative and wellness based across the lifespan that the consumer can purchase. These products or programs should be part of the primary health care system.
Dr.Paul Nussbaum
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Comments
I really thank to one who
June 28, 2009 by Anonymous, 18 weeks 6 days ago
Comment id: 37596
I really thank to one who wrote this article. I have always been reading and writing texts like this in blogs. Also, I, as a daily writer, present my respects to everyone. I just watched videos like this in youtube. I research in all areas.
I think people must first research before writing.
Shopping for health care is
June 26, 2009 by Anonymous, 19 weeks 1 day ago
Comment id: 37551
Shopping for health care is not like shopping for anything else because consumers are ignorant of the factors that pertain to quality. If my physician tells me that I have an enlarged prostate and need surgery (and not the many other options); how do I choose the surgeon. Will I use price?, a physician rating service?, my insurance company's list of urological surgeons?. I will ask my physician for his recommendation and if he tells me that so and so is the best cutter who uses the most nerve sparing techniques and preserves continence and sexual function for most of his patients. He may not be at the hospital my insurance company prefers, or if I am to pay for it myself as you propose, the least expensive. god willing, I will pay for the best result if possible. The point is that much of what medicine provides is not price sensitive.
Perhaps I could shop for the cheapest place to perform a bi-annual physical ( I'm 72). But for more serious issues I am going to seek the provider/method/medicine that provides the best result.
Dan
Dr. Nussbaum makes points out
June 26, 2009 by Anonymous, 19 weeks 1 day ago
Comment id: 37563
Dr. Nussbaum makes points out that it is useful to refer to the Constitution of the United States as a background to considering how to devise an appropriate healthcare system.
In this regard, it can be useful to review and consider the Preamble to the Constitution, which reads:
"We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defense, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America."
And by way of comment:
To "secure the Blessings of Liberty" is certainly a central and noble goal mentioned in the Preamble to the Constitution, but it is important to note that it is not the only goal mentioned, and given that the other general goals in the Preamble are stated first, this could imply that these other goals may in some ways be prerequisites or foundations for the goal of securing the Blessings of Liberty, and therefore would be important priorities to take into consideration in formulating any policy.
What is a "more perfect Union"? Is it only agreements among states, or does it imply the entire social compact, including all of the social and economic interrelationships between all of the people. What form of health care system supports a "more perfect Union"?
What form of health care system allows us to "establish Justice"? What are the criteria we use for defining justice? Justice for whom? For what purpose? Inasmuch as there are conflicting interests among various groups relating to various issues, what are the just resolutions of these conflicts?
What insures "domestic Tranquility"? Is it merely a police force, legal system and correctional system? Or does tranquility and social cooperation involve a much broader set of processes? Does health have anything to do with tranquility and social cooperation?
Does "providing for the common defense" only involve defense against threats of physical attack? Is defense against disease at least suggested by the concept "common defense"? And doesn't the word "common" imply everyone in society, not just those who can pay for it privately?
What does it mean to "promote the general Welfare"? Welfare of whom? What are the criteria for what constitutes "welfare"?
The preamble uses the word "common" in "common defense" and "general" in "general Welfare". These have two sets of implications -- who benefits, and who provides. Common defense and general welfare suggest that everyone in society benefits. They also imply that there are appropriate circumstances for society (through government) to provide services for the common and general good, both by allocating funds raised through public taxation and by enacting laws and regulations. We have public transportation, public education, public roads, public libraries. And we have public health measures as well. None of these are specified in the articles of the Constitution. But are they not implied in the Preamble? Sure, one could say that there is no "right" to public schools or public libraries specified in the Constitution. But legislatures are constitutionally empowered to enact laws which create laws, rules and services to which every citizen has a "right" by virtue of the laws enacted. And one could argue that any one of these laws are "unconstitutional", but one could also argue that a) they are implied by the Preamble, and thus not inherently "unconstitutional", and furthermore that they are constitutional insofar as the Constitution devolves to the legislature the right to make laws.
Living in a society in which justice, domestic tranquility and general welfare are pursued requires all of us to do things that we may not prefer, and that we may consider to be contrary to our personal liberty and pursuit of happiness. Children may not like to go the dentist, airplane pilots may not like having to go through a preflight checklist, drivers may not like wearing seatbelts or observing speed limits. Similarly, doctors may not like certain precertification procedures. Without arguing for or against any specific healthcare administrative procedures, the general point is that the basis for evaluating those procedures is their outcomes, not their inconvenience. If preflight checklists and auto seat belts save lives, aren't they justified? Similarly, if things like precertification for certain costly and risky medical procedures does demonstrably help to prevent unnecessary cost and suffering, couldn't they also be justified under certain circumstances?
Finally, consider President Abraham Lincoln (who, we recall, presided over the great challenge of preserving the union of American states and established a most basic element of justice by emancipating the slaves). In his Gettysburg Address, Lincoln referred to "government of the people, by the people and for the people". Doesn't that include all of the people?
Matt (an MD)
Please pardon the typo in my
June 26, 2009 by Anonymous, 19 weeks 1 day ago
Comment id: 37564
Please pardon the typo in my earlier post responding to Dr. Nussbaum's post.
In the first line, the word "makes" should have been deleted in my proofreading.
Matt
not anonymous
June 29, 2009 by Anonymous, 18 weeks 5 days ago
Comment id: 37607
Marvin Thalenberg MD- 32 years in solo practice, 10 years as a County Health Commissioner, 24 years as an Associate Professor.
medical practice
June 29, 2009 by Anonymous, 18 weeks 5 days ago
Comment id: 37609
I started my solo IM practice in 1955.The elderly were charity cases, but fees were small, and tests rare and cheap. 10 years later medicare came in and elderly patients became a profit source for practitioners, many of whom abused the system . The elderly could afford surgery, and because it was universal single payer, everyone paid into the system his whole working life- still does.
The problem arose when medicine became commodicized. about 25 years ago. Paul Starr in his "Social Transformation of American Medicine' summarized it- medial practce went from a cottage model betwen patient and doctor- to an industrial model- insurance companies as owners, doctors as workers and patients as product. soto keep investors happy and profits rising, primary care doctors increasingly became hamsters on a wheel, seeing 5 patients in an hour.
It makes no sense to have for profit insurers.There is no realistic competition. Senator Grassley's state has one insurer for 75 % of its population. They insurers spend 15-20% on administration as compared to medicare's 3%, and spend huge amounts of money to deny claims.With 360 HMO's the system is hopelessly complex.
The most effective and cost effective HMO's are nonprofits like Kaiser-Permanente, Geisinger,Mayo. The best hospital system , with best IT, is the VA.Andwith 36 million onMeicare, and 1 in 5 children on medicaid, we canthust start over with grand declarations of principle. We have an aging population with increasingly expensive diagnosis and treatment. No one can pay for MI'sandstents and cabgs and HER testing and avastin- it mustbe done with general insurance, andit has to bepid for with higher taxes. soit hasto be more efficient, with comparative effectiveness systems.