“Mr. Public” returned to the hospital the other day. I met him 3 months earlier when he presented with a heart attack. I placed 3 coronary stents in 2 different arteries to restore blood flow to his severely damaged heart. He did not have health insurance and earned too much money to qualify for Medicaid. He returned in severe congestive heart failure because he couldnt afford to see a doctor or pay for his medications. The hospital will likely absorb the $50,000 initial hospital bill and the cost of the second hospital stay and I probably wont get paid. “Mr. Public” will miss additional work and risks bankruptcy.
This scenario is repeated continuously in my practice, in our hospital, and across our country daily. It seems to have worsened lately due to the down economy and job losses. Clearly something needs to be done. Whether or not you agree with the outcome, you have to give the President and Congress credit for finally taking action. Some version of reform is inevitable. Here is my best guess as to what it may include.
First, patients such as Mr. Public will obtain some form of health care. The most logical reform would include expanding the ranks of Medicaid and raising the income eligibility threshold so the “working poor”, who make up the majority of the uninsured, can qualify. Unfortunately government needs to be the safety net here. As much as I believe in free markets, and I do, the dark side of capitalism is that the poor, the underprivileged, and now the growing ranks of uninsured working Americans, are excluded. Society cant afford this when it comes to health care, both literally and figuratively. State governments, already cash strapped and running deficits, wont be able to afford this either. The Federal Government will need to subsidize a larger share of Medicaid than it does now, while allowing local and state governments to administer the program. The needs of a system in Florida are different than those in North Dakota. Healthcare systems need to be flexible enough to adapt to regional challenges. Second, we need to stem rising healthcare costs and further reductions in Medicare reimbursements are planned. Doctors are already struggling financially and such cuts will be catastrophic. Physicians will have to adapt. Likely the private practice model with solo or small groups will all but disappear, and more and more physicians will partner with, and likely be employed by, hospital systems. It is a natural partnership. We will need to work as a team and be competitors no more. Hospital administrators will need to balance budgets to keep the doors open while doctors should be more accountable for the healthcare dollars we spend. Most of us would rather leave the business side of medicine to others and just take care of patients anyway.
Increasingly, patients will be forced into hospital-based systems. Already, amendments to save home health care and hospice, services meant to keep patients out of hospitals, have been voted down. Government regulation of hospitals will continue to increase. Physician assistants, nurse practitioners and even pharmacists will provide more direct patient care in crowded hospitals and waiting rooms.
Finally, malpractice reform is a must. Defensive medicine, with its unnecessary testing, should cease. As physicians move to hospital based systems we will be covered in large insurance risk pools which have, historically, helped keep premiums down. Many of us will receive “coverage” under sovereign immunity as we basically become employees of the states which administer Medicaid. Physicians have been unable to successfully take on the trial lawyers. As employees of large healthcare systems or government run agencies we will at least have a shot.
Healthcare reform is difficult but necessary and will require sacrifice from everyone. We are Americans. No challenge is too great and our patients need our help.
