The US governmental healthcare system, Medicare, was established to serve the elderly, whereas all other individuals have to obtain health insurance through their employer or purchase it privately. Employers usually contract with private insurance companies and pay part of the premiums with the employee paying the other part. Other people, such as the self-employed, purchase their health insurance directly from an insurance company. Insurance has become increasingly more expensive and some (particularly the young and healthy) choose not to purchase any. Additionally, there are a growing number (over 40 million) of indigent families, low-income families and illegal aliens who are uninsured.
Medicare and insurance companies have reduced reimbursement levels while premiums continue to rise. Coverage has decreased and certain procedures, tests, medications and evaluations are no longer reimbursed. Paperwork to be completed by patients has become more complex, time consuming and voluminous. One can seldom call a provider and actually speak with a human being. Computers have a limited number of input options and responses. Meanwhile, costs continue to escalate and the USA is spending close to US$2.5 trillion every year on healthcare. Every individual spends over $7200 yearly on healthcare. These costs have driven numerous families, faced with critical illnesses, to bankruptcy. These costs are depleting Medicare reserves and bankrupting the economy. Something must be done soon.
Promises
During the last elections, US politicians from both parties vowed to fix this problem. Now, both parties have proposals for reforming the system. The Democrats, having a majority in the Congress, have had their proposal approved by a very slim margin (∼1% of the total number of votes) in the House of Representatives. They had promised to:
• Help the uninsured by providing free or low-cost insurance depending on income level;
• Help the insured by regulating insurance companies, forcing them to insure high-risk individuals and not allowing them to turn down anyone because of pre-existing illnesses;
• Make the system more efficient by reducing costs;
• Help seniors by increasing prescription drug coverage;
• Help employers by not imposing overly onerous insurance requirements for their employees;
• Crack down on frivolous malpractice suits;
• Address the medical liability problem;
• Not raise taxes.
Congress is finding it impossible to abide by all of these conflicting promises.
Product
The House of Representatives’ proposed healthcare legislation is a 1990 page document weighing 19.6 lb and standing 8.25 inches tall. It is longer than the King James Bible. This is certainly not appropriate reading for an airplane flight. Legislators will have to read this at their office desks (or electronically). I am a fairly fast reader; I can read an interesting 300-page book in a couple of days. I have to wonder how a busy legislator with a full calendar 24 h a day, 7 days a week will manage to read this dry document written in legalese. I doubt that those who voted actually read the entire bill. The Senate has now submitted its version that will soon be discussed and brought forth for a vote. It is a 2020 page document that is almost as voluminous as the Physician’s Desk Reference. Has any physician ever read the entire Physician’s Desk Reference?
As I write this editorial in early December 2009, I know that by March 2010 the USA will have a new mandate changing our healthcare system. This mandate will intend to change the system for the better. I, for one, am very skeptical that this will be the end result.
Current system
Americans have had excellent healthcare. We have access to the best diagnostic procedures and the best therapies. We have a choice in that we can choose a form of health insurance that allows us to select our doctors or we can pay a bit less and join a health maintenance organization that will assign doctors for us. If you need an MRI, you will get an MRI, and it will usually be scheduled within a couple of weeks. If you need elective surgery, such as a hernia repair, and you want it done soon, it can usually be scheduled within a month. Were it not for the steady increase in healthcare costs, we could say that we have the perfect system.
Issues leading to escalating costs
There are just a couple of problem areas that have led to this debacle. In no particular order, they are medical malpractice, health insurance and others.
Malpractice suits have steadily increased over the years and so have the awards granted by the judge or jury. Many are frivolous but hard to dispute or prove before a jury that is biased in favor of the patient. Those that are justified result in awards that are unreasonably high. The legal process (e.g., paperwork, negotiations, expert witnesses, depositions and court appearances) is time consuming and costly. So much so that insurance companies have become eager to settle out of court if it will cost them less time, money and effort (even in the case of a frivolous suit). Lawyers who bring such suits know that they can get the insurance company to settle and thus have become increasingly willing to sue. After all, they will pocket 30% or more of the award (plus expenses).
Malpractice insurance companies are in business to make money. So, what do they do? They raise premiums. I have a friend who is a thoracic and cardiovascular surgeon practicing in a large metropolitan area. He tells me that the first 3 months of every year, his entire gross income goes towards payment of his malpractice insurance premiums. In some states, malpractice insurance for obstetricians has become so costly that many have opted to practice gynecology and not perform any deliveries. Even when the delivery is uncomplicated, there is no statute of limitations and they can be sued if the child fails at school years later (claiming cerebral anoxia during childbirth).
Physicians are very much aware of malpractice liability. Being sued for malpractice is not an ‘if’, it is a ‘when’. It is almost guaranteed that a physician will be sued and probably more than once. So what do they do? They practice defensive medicine. Defensive medicine is expensive. Today, if you go to an emergency room with head trauma, you will get a MRI (or at least a CT scan). It does not matter that you were not unconscious, that your pupils are round, equal and reactive to light and accommodation, that you know your full name and the date and time of the week, that you are well oriented and that you will not even require sutures. If you have a bump on your head, you will get an MRI (sometimes even before a physician examines you). If you cough and have lost some weight you will get a chest CT scan. If your joints ache they will be x-rayed. If you have indigestion, you will get an exercise electrocardiogram (stress test) and maybe a multigated acquisition scan and cardiac ultrasound, just in case. On the therapeutic side, cancer patients are no longer advised in terms of what chemotherapy the physician believes is best for them. This responsibility is transferred to the patient. They are told that there are several treatments that could be used and that they have to make a choice. It is the equivalent of choosing an entrée from a menu written in a language you do not understand. In summary, defensive medicine has changed the way that we care for patients. These changes are definitely not in the best interests of the patient and have served as one more multiplier for the rapidly escalating healthcare costs.
Congress does not adequately address these root causes of our healthcare debacle in the bills currently under consideration. Thus, the USA’s healthcare reform will not work because it amounts to applying band-aids to a gaping wound that requires major surgery. In my next editorial I will suggest ways to address these problems.
Financial & competing interests disclosure
Antonio J Grillo-López is a member of the Board of Directors of ONYX Pharmaceuticals and of the Board of Trustees of the Hope Funds for Cancer Research. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.