Single Payer Initiative   11/94

The National Health Care Reform was declared dead by Senator Mitchell, who gave up a Supreme Court appointment to implement it this year, just as Proposition 186, the California Single Payer Initiative, is in full swing. Preliminary polls over the past year have shown about two-thirds of California voters are against it and about one-fourth are for it. That's about as close to "dead on arrival" as a proposition gets according to Robert Nelson, one survey sponsor. There is some renewed interest both within and without the profession, with pros and cons in each group.

I have received over a hundred items from both sides espousing their views. The pros state that there will be so much money left over by the state government takeover of health care that coverage will be much improved and administrative costs is capped at 4%. The cons state that most administrative costs are hidden and there will be over a $40 billion short fall despite a $40 billion increase in taxes to cover the $100 billion health care budget. This would more than double the cost of California government which has current general fund revenues of $41 billion.

If health care were improved and full coverage were obtained, it may be worth the increased cost. But all the various proposals are only changing the environment in which we work with our patients. They only speak to decreasing costs, a payment system, increased regulations, and changing corporate structures. The only way the current level of care can be maintained in a new environment is for physicians to figure out a better way to take care of our patients. Otherwise it will be less tests, less x-rays, fewer consultations, fewer hospitalizations, less this and fewer that, with worse care, missing preventable or curable disease until it's too late.

Berwick, in a recent issue of JAMA, asserts if we as clinicians ever see fit collectively to declare the goals of health care reform to be "OUR" goals and set about to enthusiastically improve them, and work with the objectives of reform in mind, nothing could stop us. If we want to stop feeling battered and oppressed by reform, we can achieve the goals of health care reform ourselves. We can take the leadership and translate the broad goals of reform into a specific insiders agenda of improvement. That would be the best solution for our patients and us.

First, we must reduce unwanted and ineffective medical procedures at the end of life. In human terms, using unwanted procedures in terminal illness is a form of assault. In economic terms, it is a waste, estimated at about 10% of all health care costs.

Second, we must increase our patient's active participation in medical and surgical decisions, which will reduce more expensive medical intervention as the disease progresses, improve functional status, and decrease hospitalizations up to 50% over matched controls in many instances.

Third, we must reduce the use of inappropriate surgery, hospital admissions, and diagnostic tests which research consistently shows is common, despite the prevailing opinion to the contrary. Berwick challenges clinicians to accept the fact that unnecessary and inappropriate care is pervasive; that we best get involved before those who regulate, measure, or purchase health care understandably tend to treat this problem of inappropriateness from their own outside perspective--hence their current infatuation with protocols, guidelines, algorithms, and critical paths. Outsiders can judge care, but only the insider can improve care.

These three modifications would continue to give our patients the world's finest health care at a competitive price. But it would only be temporary unless the health care team headed by physicians obtain the cooperation of hospitals and insurance carriers.

Physicians should display or make available their fee schedule. When I went into practice in 1970 and posted my fee schedule, I was told it wasn't professional. I'm glad to see that organized medicine now agrees that our fees should be widely disseminated. A friend just received a bill from a Carmichael hospital for $33,000 for an eleven day stay. Being a business man, he noted that his doctors fee was only about $1000 or roughly 3% to manage his life and death situation. He stated that he had to pay a 10% management fee on the property he owned. Yes, physician fees are a bargain. We should publish them. We have nothing about which to be ashamed.

Hospitals should similarly publish their charges. In fact they should have pricing manuals readily available so the doctors could look up the charge of every order that is written. Research has shown that 13% of hospital costs are saved by doctors who write their orders on a computer where every charge is listed as it is typed. This is because when an order for a heavily promoted drug is written and the costs are displayed, another order is usually entered which is equally effective and costs far less. It should be a goal to computerize every hospital medical record. In the meantime, having the manual of charges available is the next best thing. Furthermore, the hospital itself is computerized and, therefore, is able and should be required to print out every 24 hours the charges for each order the physician entered the previous day. To change from a $1000 a day antibiotic to a $500 a day antibiotic on day two will still be a large savings over the course of a standard hospitalization. I would suggest that this be done voluntarily on a motion from the medical staff.

Insurance coverage should all be converted to indemnity plans so that there is always a deductible and co-insurance for the patient to pay which research has shown is a major cost containment factor. Our current predicament was brought about by our employer paying the premium and our unions always demanding the cadilac of plans with complete coverage without restraint. Hence, the need for managed care--putting a clerk, a nurse, and possibly another doctor between us and our patients. An articulate doctor can get the most sophisticated and expensive tests through the system. A non-assertive doctor may have difficulty in obtaining a CT scan of the brain in a stroke situation. Hence, the savings in cost is not equally distributed amongst our patients. Of all the suggestions made above, this is the only one which may require legislative or congressional action by making indemnity plans tax deductible and full coverage no longer deductible. This would immediately bring about further reduction in overall health care costs.

Why are doctors and patients for proposition 186, the government take over of the health care system? It is total exasperation with the current system. Many doctors say the current situation is so bad, that anything else looks good.

That reminds me of a patient that I was seeing in consultation some years ago who returned every year for a CXR, PFT and overall pulmonary evaluation. He had been dyspneic, gasping for each breath for many years. One year as I put up the chest x-ray and saw a new spot on the lung, I looked at it very carefully and said, "I'm sorry, Mr. Hightower, that spot looks serious." I was surprised to see the patient smile. I repeated, "It looks like a new growth is starting in your lungs." My patient said "Well, Doc, I know now that my suffering and suffocation will soon be over. Can you tell me when?" He had a disease, emphysema, which was so bad that lung cancer looked good.

Let's not throw away over three generations of evolved private health insurance and practice patterns for a current situation not of our or their making. Let's make our correction and progress forward rather than retreat to the system used by the old countries, from which our foreparents escaped. It's not working there and it won't be accepted here. To continue to improve a system of which the world is envious, we must first deal with proposition 186 by defeating it. Let's then get together to continue to improve the world's best health care system at a price we can all afford.