When in Doubt, Cut It Out.

One of my friends, a surgeon and a colleague, has a favorite axiom that he has frequently used in deciding upon the proper care of an acutely ill person who presents with increasing right lower abdominal pain; “When in doubt, cut it out.” Sometimes that which the surgeon excises requires the addition of something to replace the missing tissue or its intended function. In the illustration used above, the appendix is one exception. However, if for example a thyroid gland is removed, thyroid hormone must be prescribed to replace the missing vital metabolic substance it produced. In the case of a sick healthcare system, cutting out the offending agent is in definitely order, but we must also have a proven method of replacing that which is no longer available in the care of our citizens. Furthermore, that entity which is used to replace that diseased system that has been extirpated must have a proven track record of success. Having now diagnosed the problem, the etiology of our ailing healthcare delivery system, as being the multilayered, bureaucratic, managed care that has been provided by HMOs, all we need to do now is to “cut it out.” We must immediately remove it and replace it with a more workable system; the tried and true method of all successful American business called free enterprise.

As explained in a previous article, the HMOs with their over paid CEOs, the multiple layers of bureaucratic intrusions, the needless rules and regulations, the reams of paper work, the hours of surveillance upon the practices of physicians and their patient’s charts, plus the thousands of HMO employees needing paychecks are collectively what has caused the cost of medical care to reach unbearable levels. We were able to function quite well before those managed care organizations were put in place, separating one’s doctor from oneself, and we will be able to function just as well after they are gone. The reader may recall that the HMOs were supposed to be the cure for the increasing cost of medicine; they have resulted in just the opposite. The government planners who put those managed care organizations into place failed to realize that another bureaucracy, the federal Medicare System was the real cause for that initial, insidious rise in the cost of care between 1965 and 1980. Thus having misdiagnosed the problem, it was only natural to expect that the wrong remedy would have been implemented. Having prescribed the wrong therapy, the metaphorical patient (the delivery of healthcare) not only remained sick, the patient became critically ill, had to be sent to the intensive care unit and is now on life support. Had practicing physicians been consulted early on, the misdiagnosis would have never occurred and the deadly therapeutic mixture (the HMO fiasco) would never have been prescribed.

As an aside, one of my very wise mentors once told me that the patient would always provide me with the correct diagnosis if I simply asked the right questions. The reason that the Federal government and managed care organizations have never correctly diagnosed the problem or offered an efficacious cure is because they have failed to ask the right people (practicing physicians) the right questions. This has also been true of hospital administrators and boards of directors (on which I have served); they seldom ask the ones who really know the answers when it comes to the efficient, expedicious delivery of health care.

By excising the failing HMO organizations we can better utilize the billions of healthcare dollars being consumed by those uncaring, bottom line, business people and focus those monies, not on improving the profit margins of the insurance industry, but instead in refining the delivery of health care at a price that people can afford. The following is the scenario that will work. First the employers of our working millions take the money they now confer to the HMOs (roughly $13,000 per family) and instead give it to their employees. Federal legislation needs to be put in place so that those payroll dollars are not taxed if they are documented as having been used for the purpose of health care. The employee must verify that he/she has put half of that increase in pay into a health savings account (HSA) and that they have purchased catastrophic health insurance (CHI) with the remaining half; I.e. $5000 deductible. The employer still gets the tax deduction and the employee need not worry about paying more taxes for an increase in his or her income.

The catastrophic health insurance will cover any extraordinary hospital expense that could normally bankrupt a non-covered person. With the money in the HSA, the employee can shop for the best deal with the best doctor that will meet his self determined medical need. That is the basis of consumer driven free enterprise. Currently, neither a physician, a laboratory, a radiological facility nor a hospital receives the exact dollar amount they bill for the service they render. For example, if you are covered by Medicare and have supplemental health insurance, by simply examining your most recent bill, you will notice that the practitioner or facility charged a certain amount, while Medicare allowed only a certain percentage of that billed amount and that the supplemental insurance picked up only a portion of that which Medicare did not pay. In the case of people under the age of 65, the HMO pays much less than the bill indicates. The total of what is paid to the doctor, the hospital or ancillary facility typically amounts to less than 50% of the original charge, and in some cases it is even less. In fact, I recently read a bill that was submitted to Medicare by a sleep study specialist. The bill was $500 for interpreting the numerous bits of data that was collected while the patient was asleep over an eight hour period. Medicare paid the physician $122.87 and the patient’s co-insurance paid another $24.57. Thus the physician’s total reimbursement was $147.44 or 30% of that which he had originally billed. Therefore, by establishing new fee schedules based upon what they actually now receive under the managed care system, physicians, ancillary facilities and hospitals can immediately lower the cost to the patient but still not take a cut in their current income. The difference will be that which was formerly siphoned off by the HMO.

By using the HSA wisely, and not seeking medical care for minor problems or going to expensive, crowed emergency rooms or ambulatory health care facilities, young, relatively healthy employees will be able to accumulate quite a large sum of funds in their HSA, which also accrues interest, that will no doubt cover any extraordinary expenses in their later years that will more than off set the $5,000 deductible portion of their catastrophic health insurance. Furthermore, as this consumer (patient) driven free enterprise system is implemented and the cost of medical care falls, even those persons not covered will be better able to afford care when they really need it. After seeing that the elimination of the HMOs has improved the delivery of healthcare for the under 65 population, a similar adjustment in the Medicare delivery system can also be employed. Prior to 1965 doctors managed quite well caring for the elderly. In fact today’s over 65 senior citizens are in general, better off financially than most working younger folks who are raising families and saving for their children’s education.

Free enterprise also stimulates entrepreneurs and that will further improve the health of our nation’s health care system; this would be what we physicians call adding adjunctive therapy following surgery to remove a cancer. I can envision groups of physicians who treat similar illnesses affording their patients a one-stop shopping, specialty mall. These facilities can be built in conjunction with contractors with a similar entrepreneurial spirit. Diabetics are often treated by their primary care physician (internist or family practice physician) in cooperation with a team of other physician sub-specialists: an endocrinologist if the diabetes is particularly severe, an ophthalmologist (for eye care), a nephrologist (if renal failure ensues or dialysis is needed), a podiatrist (for foot care) and a cardiologist (heart disease being common in diabetics). Given the rising cost of travel, the diabetic would welcome having to devote an entire day in that facility to see his or her various physicians. There would no doubt also be a need for radiology and laboratory facilities as well as a coffee shop in that mall. Free enterprise stimulates the economy; socialized medicine as proposed by Senator O’Bama and other liberal minded politicians stifles it. This proposed free enterprise, which is so dearly needed, will not happen unless every citizen who finds the current cost of medical care intolerable demands that their respective, elected representatives to congress (House and Senate) change the system. If they refuse, we can offer them the same exit (and extirpation) that we are offering the HMOs, and then we will elect representatives who do have our best interest at heart. Be assured that the HMOs will be lobbying very earnestly to protect the golden egg that the proverbial goose (called managed care) has deposited in their bank accounts.

Several other remedies are needed to supplement this principal cure (a surgical excision) for our ailing health care system, the additional adjunctive therapies will be addressed in articles over the next two weeks; namely tort reform to reduce malpractice fees and unwarranted suits, the reduction of pharmaceutical costs and the essential need for every American to become more serious about his or her own general health.