I had a couple of interviews with conservative talk hosts here in Pittsburgh Monday night on the Pittsburgh Cable News Channel with Kevin Miller and Tuesday morning on KDKA radio with Mike Pintek as representative for Doctors for America on health care reform. I thought I'd share, and perhaps get a little constructive input.
I have to say that I thought both hosts were fair to me, though the television host seemed to try to bait me into peripheral discussions [He is a moon landing skeptic, for instance!] while the radio host was more focused on getting detailed information out of me, which I appreciated.
The issues that seem to be the most concerning to conservatives, or at least get them the most stirred up, are those concerning the cost of the program and the impact on
the budget and, of course, taxes, the ceding of control of health care decisions, or rationing decisions, in their minds, to the dreaded government bureaucrats, and euthanasia. Believe it or not.
My response to the cost argument is the one you all know, that our current non-system costs way too much, far more than any other place on the planet, including the countries like
France and Germany who cover everyone, don't ration in any significant way, and have no longer waiting times than our own.
Skepticism abounds about drawing any lessons on health care reform from other nations, as the utter failure, in the conservative mind, of Canada and Britain, necessarily precludes us from learning anything at all from them. I did manage to point out that while both Canada and England have had problems with their systems due primarily to inadequate spending, they did manage to insure everyone. I also pointed out that in Britain, since the liberal Labor Party took over from the Conservative Thatcher/Major governments, things have improved significantly on the waiting times front.
They expressed concerns about the cost of the Public Option being thrown about of a trillion dollars or more. In the context of health care spending currently of 2.4 trillion, one trillion over ten years, or 0.1 trillion per year does not seem like much. On the other hand, we are in danger of putting a layer of something that should be good over top a heap of a messed up non-system. I specifically agreed that Obama's message that, if we were starting from scratch, single payer makes the most sense was true. “Government Bureaucrats!” Mr. Pintek played a clip of Barney Frank saying that if the public option were done well and performed well, it could very well lead to single payer. Mr. Pintek suggested that they were trying to be sneaky with this, but I suggested that if they were, this was not a very sneaky way to do it. But even if this was how it would turn out, where's the harm? If the public option proves to be so wildly popular that private insurers get crowded out and the public in the end decides that perhaps this is the best way to provide health care, isn't that a great thing? “Government Bureaucrats!”
So, rationing is next, and is always the real subtext of all of this. Both hosts were aware that insurance companies sometimes deny care, but neither seemed to consider that we
ration by income. I told both the story of a patient of mine who was a middle aged man, without insurance for quite a while. He'd had a cough for close to a year followed by an intermittently bloody cough for a couple months and then developed such difficulty breathing that he finally came to the emergency room and then into my ICU with respiratory failure. He had, by this time, metastatic lung cancer. I pointed out that while you can go to the emergency room for emergency care, the familiar canard of “they can just go to the emergency room,” rings hollow in nearly every basic health care situation. I paraphrased from a wonderful letter from the New York Times, and pointed out that ER's don't do cancer care nor manage asthma nor prenatal car nor diabetes and don't do any of the things we think of when we talk about every day health care needs.
But what about government bureaucrats rationing health care? They both seemed disbelieving that this did not seem to concern me terribly. I argued that we could be well served by a commission made up of physicians who used comparative effectiveness research and analyzed the benefits and costs of treatment to help guide us , rather than medical directors at private health insurers making these determinations.
I regret that we did not get to end of life issues on the PCNC show, but we did on KDKA. I was asked what I thought of the House Bill and what it would mean to us with respect to Advance Directives and forcing the elderly to forego treatment. I think that it will finally make decent payment available for physicians to do Advance Care Planning, which is the term for having discussions on what a patient's wishes are when they are at the end of their lives. This is a very good thing, something that physicians involved in EOL care have been advocating for for years because it is the right thing to do. I have EOL discussions with patients and families literally every day I spend in the ICU. Letting your family know what you want at the end of life is a great gift to them. I tell this to patients and families all the time and it is so true: these are agonizing decisions to make when you have not had these important discussions. If people think about this even for a minute, they will know it is true. I also pointed out that advance directives can go either way, and if you want every last treatment until they are nailing your coffin shut, you can specify that in your AD as well.
We took a few emails/calls on KDKA. The first was not so much supportive, as antagonistic to the host and the conservative listeners. Thanks, but no thanks for that email. The
second was from a nurse who wanted an “American” solution and seemed to resent my referring to France and germany, but in the end, seemed to agree that we needed reform and I think was OK with a
public option as a way to get there. I think it was at this point, Mr. Pintek caught me flat footed when he followed up and asked how Germany makes decisions on what is covered and what is not. I recalled that the benefits packages provide by the insurers there were standardized, but what I wasn't aware of was that they have a commission that does do cost benefit analysis on treatments before they are approved as benefits. This commission has been accused of dragging its feet on new treatments, but this likely reflects a bias among many physicians to not adopt treatments until the evidence is solid. This has actually been studied in the US, and Massachusetts, with Harvard and Mass General and some of the finest health care in the world has this same regional bias and are slow to adopt new treatments. I'll try to remember this for next time!
The last call was from a physician's spouse who had heard me speak about Medicare and what I consider its adequate reimbursement. The host had said he thought the reimbursement was low and that some doctors would not accept it. I pointed out that, depending upon where in the country you practice, Medicare may be your best payer (Nevada, Southeastern PA) or at least, as in the Pittsburgh area where we are, not too far off from private insurance plans. I also pointed out the cost
of $82K per physician annually to deal with insurers and billing.
I had also pointed out that most doctors support some form of national health insurance, particularly PCPs and even a majority of general surgeons, but not some specialists like radiologists, anesthesiologists, and surgical specialists. I think she was a little peeved by that, because that's what she started her comment with. She said that many doctors won't take Medicare, and especially when they go to national meetings she hears this from people around the country. I have heard this before, even from fellow Doctors for America physicians telling me what they hear from colleagues. But if you look at what Medicare actually pays us, the regional variation is very small, with the exception of Alaska (the physicians of Alaska owe fromer Sen. Stephens for that). So whether Medicare fees look like a pittance to you or not has more to do with what your private insurers are paying you than what medicare is paying you. So, certainly physicians will look at a $150 fee from a private plan and a $100 fee from Medicare and conclude that Medicare may not be worthwhile. That is not unreasonable, but when you factor in the cost of dealing with private insurers, $82K per doc or about 14% of overhead, maybe Medicare is subsidizing the private plans! Anyway, I wish I'd had the presence of mind to ask what her husband's specialty was!
Things I didn't get to squeeze in but will try to next time:
"It is a mistake for any nation to merely copy another; but it is even a greater mistake, it is a proof of weakness in any nation, not to be anxious to learn from one another and willing and able to adapt that learning to the new national conditions and make it fruitful and productive therein." Teddy Roosevelt, “Man in the Arena” The Sorbonne, Paris, France, 1910
Public
opinion favors not only the public option, but national health insurance of some kind. And they are willing to pay more in taxes for it, even if this is phrased in such a misleading way in every polling I've ever seen.
England's NICE, by analyzing cost of care in the context of benefits to patients has led to price reductions from pharmaceutical companies in order to meet their cutoff. And NICE can be pressured if it is felt to be making unwise recommendations.
Having an independent commission running Medicare, rather than Congress, might be quite an improvement.
If we do manage to get to a German or French style system, which party would be more likely to demand cost cutting resulting in longer waiting times and rationing of care?
I was asked about Massachusetts and demurred because I really don't know enough to comment intelligently. I wish I had referred them to the PNHP site, as they have lots of information and intelligent critiques of what's going on there.
And things to add from your comments will go here:
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