Saving Medicine: The Three Cs

The answer seems to elude our public officials but is really not complicated.  It involves the three C’s:  Cash, Catastrophic Insurance, and Charity.  — Lee Hieb, MD

Dr. Hieb explains the problems about government run programs and offers up some rather simple solutions.  We can purchase anything we want with cash, and at MediBid we are providing just that. Physicians list their services, and patients can select one of their choice and make arrangements — no insurance company telling you what you can and can’t have done.

Catastrophic insurance, also called Critical Illness insurance, is the only true kind of insurance.  It is there for you at times of major injury or long-term illness.  Auto insurance does not oil changes and new tires, but is there for high-cost damages.

Charity is how the poor were taken care of before government programs were put in place.  Churches and other community organizations took care of the poor in their neighborhoods.  Based on kind hearts and Christian virtue, there was no need to force people to help.  Medicaid is a poor substitute for charity, says Alieta Eck MD, who started a charity clinic to care for the needy of her hometown.  Her clinic functions fully on donations of goods and money, and NONE from the government.

Saving Medicine: The Three Cs

by Lee Hieb, MD

American medicine today is truly in crisis, but not for the reasons most often reported.  Those who generally believe in government solutions cite a need to improve quality, provide access to care for everyone, and to decrease cost. Government, with its inevitable over-regulation, does not solve these problems, but makes them worse. Since 1965, and the implementation of Medicare and Medicaid, the federal government has written over 150,000 pages of regulation which increases cost of practicing medicine, squanders the energies of highly trained professionals whose time is now spent in compliance, and often directly and negatively impacts quality care.  And this negative result is not limited to the minority of Americans the government set out to help, but impacts all Americans inside and outside the Medicare umbrella. Government “health care” exemplifies Ronald Reagan’s aphorism that “When government is the problem, more government is not the answer.”

By way of illustration, consider the case of Doppler Ultrasound.  This is a twenty-some-year- old test done to diagnose blood clots in the legs.  Until last year this procedure cost $235 and took less than an hour to perform and deliver the result to the doctor.  Enter an unelected government bureaucrat, or to use a newly coined term, “Medicrat”, who decided that the same technicians who have been performing this study for years need additional certification…a certification that takes two years–essentially insuring that hospitals must hire a new generally less experienced graduate.   Of course, since market forces did not demand more techs, there are not that many new grads being produced, so many hospitals cannot hire one, and smaller hospitals may not easily afford a second ultrasound tech.  As a result of this one requirement,  small hospitals all across America have become unable to do this simple test in their own radiology department.  Today, to get care for their patients, providers must spend time calling around to find a hospital which can do the test.  Then, the patient must be bundled into an ambulance without any doctor or nurse in attendance.  God help them if they are terribly I’ll, which some of these patients are.  They are driven to the other hospital where they may lay around in a radiology suireboot hours, and finally rebundled into the ambulance and returned to their  hospital of origin.  With luck, the results can be called to the doctor within eight hours and the patient survives the ordeal.

As for quality care…forget it.  If it hasn’t happened yet, it is only a matter of time before someone dies as a result of this gross delay in care,  and the ambulance-ride-to-hell-and-back.   In fact, some hospitals are so worried about  this gross breach in quality that they are practicing civil disobedience prefiguring ignorance of the regulation, risking their own certification to stay open as hospitals rather than risk the lives of their patients.

Cost?  This one regulation has multiplied the cost by 15 to 20 times by adding the cost of an ambulance ride (in my rural area this amounts to $3000 to $4000) to a $235 test.

But what about access?  Clearly it has decreased access for Medicare  patients, but what about the insured?  Suppose Bill Gates were traveling through the wilds of Iowa and ended up in my hospital with a swollen leg.  He offers to donate a million dollars to our hospital if we will just do the test and not ship him elsewhere.  Sorry, Bill.  We can’t do cash pay patients.  We can’t do insured patients.  We can’t even do the uninsured that the government  purports to care so much about.  According to the Health and Human Services representative we contacted, that would be “discriminatory” against Medicare patients.

So much for government medicine.  The bloated Medicare bureaucracy has wreaked  havoc upon a once honorable profession and has brought medical care in America to the brink of disaster.  Doctors are retiring at the first economic opportunity. We have a critical shortage of specialists.  There  are, for example, only 12000 Oncologists in the entire country in spite of a growing and aging population in need, and we are producing only 300 general surgeons a year.  Young  med school  graduates are trained to be shift workers, transferring patient care to hospitalists and other lower level “extenders”.  Hospitals cannot stay afloat in locales most in need.  And, for the first time in my 30 plus years in medicine we are short of critical supplies–things such as Valium and tetanus toxoid, certain catheters, Propafol for anesthesia, and common antibiotics such as Levaquin, to name a few.

The answer seems to elude our public officials but is really not complicated.  It involves the three C’s:  Cash, Catastrophic Insurance, and Charity.

Cash for outpatient and “small ticket” items keeps cost down through free market competition and through decreasing medical office overhead.  In my previous private practice I employed seven people, five of whom were necessary only to deal with third party billing .  If patients had paid cash at the front window, I could have functioned with two employees–a significant decrease in my overhead.

Secondly, a doctor cannot overcharge the patient who pays cash because the patient can find some other doctor with better cash prices.  In contrast, prices continue to rise in the Medicare monopoly which fixes the price for everyone.

Cash at the window gets rid of fraud.  A physician, no matter how unscrupulous, cannot defraud the guy at the front desk and charge him for services not rendered because the patient knows directly what was done to him.  Nor does the physician have to dictate a three page note to convince Medicare or an insurance company that he did what he claimed on the billing form.  Finally, doctors  would not have to fear criminal prosecution for choosing an “incorrect” code out of the mammoth Medicare required code book for office procedures.

Catastrophic  insurance is not new.  It is the way your car and house insurances work.  You don’t use them for every little repair on your house or car, and truly you hope never to have to use these insurance policies at all.  Catastrophic insurance is meant to protect you from truly catastrophic financial loss.  When your roof blows off you call your insurance agent.  When a shingle blows off you take out your wallet.

Unfortunately,  today in medicine, we buy health insurance expecting it to cover every little runny nose or well child exam.  Of course an actuary, the person who can tabulate the risk this year of your roof blowing off, cannot know how many times you will visit a doctor for preventative care.  So true “insurance” becomes “pre-paid health care”–a very different and unpredictable product which inevitably results in  a wild spiral of over utilization , followed by price increases, followed by more use “to get my money’s worth”.

We need health insurance to operate like our car and home insurance.  It should only cover the big expenses and we take care of the rest with cash.  With this type of insurance you wouldn’t need a “Patient Bill of Rights” since you, not your employer, are the customer and treated as such.  You wouldn’t need portability legislation because you, not your employer own the insurance policy.  And the cost of private insurance with a high deductible is generally half as expensive as  employee based low deductible insurance.

The third “C” is charity.  Americans are historically charitable.  But government medicine is not charitable.  It is predicated on theft, where you put a gun to your neighbor’s head and force him to pay for someone else’s medical care.  Charity is when you reach into your own pocket, and for centuries Americans did so.

Before Medicare, in the fifties and sixties, my father was a “Marcus Welby” type small town country doctor.  In those days, people  were not dying in the streets for lack of care.  Those who really needed assistance were helped by their friends, their families, their neighbors, community organizations, and churches.  Those who received such aid saw it as charity–not an “entitlement”–and  were grateful, not taking advantage of those who offered the help.  Local charity is vastly cheaper than government largesse which diffuses tax dollars into a ponderous bureaucracy before doling out the meager leavings.  And if cash were the basis of outpatient care, and catastrophic insurance the basis of inpatient care, all costs would lessen and it would be cheaper to care for those truly in need.

In truth, there really is a fourth “C”: Compassion.  Compassion is intrinsic to the art of “medicine” but plays no role in the government delivery of “health care”.  Physicians aren’t born with compassion, but develop it as they come to know and care about their patients as individuals.  Federal regulators who decide your care from 3000 miles away have no compassion because they have no personal relationship to patients.  Government health care by its very nature is impersonal.   Government in all deaprtments must make choices in what it funds.  When dealing with aircraft procurement defunding means the death of a production line.  But,  in government medicine, where people have no private choices, defunding a disease or procedure may mean the death of patients.  No Medicare or insurance reviewer wants to face the fact that denying care can lead to death.  To make such a job tolerable, those denied care must be depersonalized.   To the officials making health care decisions at a distance, patients are known by their medical record numbers and their diagnostic codes.  You become a “covered life” not Mary Jones.

It is no accident that the Jews were given numbers and robbed of all personal identity before being killed.  It is no accident that in 1938 the decision for euthanasia was taken out of the hands of the victims’ local physicians and placed into the hands of a distant committee.  The British National Health Service, which has condemned many people to premature death through denial or delay of care,  at one point began bar coding patients.

Ultimately, there is always more potential medical care people may want than they or any group can afford.  The issue is who makes the choice.  Rather than being told by some desk sitter in DC that my care is not deemed “medically necessary”, I prefer discussing my options from a personal, compassionate physician who knows me, cares about me personally, and who can discuss with me the pros and cons, the options, and relative costs of treatments.

Government pundits love to talk of prevention, but most real prevention comes not from your doctor, but from making better lifestyle choices. The traditional role, and I believe, the real reason for medical care is to treat disease.  And disease is not just illness from germs.  It is literally “dis-ease”, i.e., the allieviation of suffering.  Government, no matter how massive and computerized, will never provide a sympathetic ear, a caring touch or any compassion for suffering.  Returning to a system of cash payments catastrophic insurance and charity will return doctors and nurses to the patient bedside, allowing them to practice the “art” not just the Medicare prescribed algorithm of medicine.


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