Resonse from Dr. Alieta Eck

Now you got me going. The answer is right under our noses– if we go back about 46 years–before the onset of Medicare and Medicaid.  It is not too late.  Here is the dream you are looking for, Greg.

The answer is for physicians to take on the care for the poor– for absolutely no pay. No billing, no CPT codes, no ICD-9 codes. Nothing.  No physician should earn his living caring for the poor. He should earn his living in his private practice where he can expect payment for services rendered.

And like the way it was before government decided that it could provide health care in an efficient, compassionate, low-cost manner, this free care needs to be done in non-government free clinics (NGFCs)– staffed 95% by volunteer physicians, nurses and support staff and funded by genuine charitable contributions– no government grants, no money extracted from overburdened taxpayers.

Patients self identify themselves as poor, sick and in need of a physician. Then they access the free clinic that is in their neighborhood, staffed by pleasant people who have chosen to be there and are genuinely interested in their well-being and future prosperity.  There will be no government bureaucrats filling out forms to see if they qualify for “benefits.” Each clinic will develop its own criteria to decide who is needy and needs the free care.

These patients need to know that the free clinic is not their medical home, but rather a bump in the road on their way to financial independence. Once they are on their feet, they can go to the same doctors who cared for them in the free clinic, but now in their practices.  Pay cash– but a fair cash price, not one that is trying to make up for the low fees paid by Medicare, Medicaid and HMO’s. A free market price, just like Jiffy-Lube for their cars.

The physicians and taxpayers need protection. If doctors are going to be providing free care in an NGFC, their medical malpractice for work done there will be covered by the federal government via the Federal Tort Claims Act (FTCA). But that is not enough. They need protection from the lawsuit hungry culture that has all but destoyed the medical profession. They need the state to step in and just cover them for malpractice– for their entire private practices. This will cost the taxpayers nothing unless there is a lawsuit– and these will be greatly reduced to episodes where real damage has occurred due to real negligence on the part of the physician. These cases are extraordinarily rare.

If the patients coming from the free clinics need specialty care or hospitalization, they need to access the system of “charity care” that the hospitals already have in place for poor people who have not gotten onto Medicaid.

The free clinics will be inter-connected via a sophisticated computer system. Thus surgeons who are willing to donate two operations per month will be able to sign on and find a patient who needs him, entered by the primary care doc who identified his problem via studies that were done by labs and radiologists who have donated their services. Obstetricians will identify two pregnant ladies per month, do their prenatal care in the NGFC, deliver them in the hospital and take care of them post-op. The absence of medical malpractice payments will free them up to do this good work.

The details will come easily once the structure is in place. All the pieces are actually there– but just need some realignment. Physicians are already covered by the state when they work in the medical school facilities.

Where will these free clinics come from? Where will they be? Who will start them and staff them? The answer again goes back 46 years– when all the hospitals were named after saints and popes and patriarchs. For the natural place where charity begins is in the faith communities. And there will be no shortage of volunteers, as the baby-boomers are retiring at a rate of 10,000 per day.

On Saturday, June 11th, at 10:30 AM, there will be a meeting of pastors held at the new facility of the Zarephath Health Center, 495 Weston Canal Rd, Somerset, NJ 08890. The ZHC will move from a 900 square foot to a 5,000 square foot facility, ready for the many volunteering physicians who will be looking for a place to see the poor.  The purpose of the meeting is to teach pastors how they can start a free clinic associated with their church.

The speakers will include:

  • The pastor of the church who has watched his congregation grow from 150-2,000 in the past 7 years– as people, rich and poor, are attracted to a church that cares for the poor.
  • The social worker who is also the builder who used many volunteers and thankful former patients to put together a clinic with 5 exam rooms, a dental room and 3 intake rooms where kind volunteers will just sit and hear the stories of the patients that come.
  • The physicians who have manned the ZHC for the past 8 years– who have learned much about the poor and what they really need.
  • The former FTCA administrator who now works for Echoclinics.org, a philanthropic group whose stated goal is to facilitate the starting of 10,000 free clinics by 2030.
  • The community activists who have convinced 6-7 legislators in NJ to write the New Jersey Volunteer Physician Protection Act to make this concept a reality.

It will be a time of interaction and real problem solving. Let me know if you want to be there, and I’ll have an extra sandwich for you!

Alieta Eck, MD

co-founder- Zarephath Health Center

NJAAPS.org — watch my discussion of this idea with Judge Andrew Napolitano, and my testimony to a Senate health sub-committee.

Response from Dr. Marcy Zwelling

The Immorality of Irresponsibility

This nation was founded on the principles of “natural law” and many believe fashioned after the writings of Thomas Aquinas.  Thomas Aquinas, theologian and philosopher, realized and wrote about the capacity of human reason to grasp what is right: our morality.  He wrote that truth was understood through reason and human reason was the basis for all law.  He even recognized and wrote about the law of economics, the idea of a fair price.  If the suppliers’ costs are not covered, the business cannot succeed, reasonable and rationale.

Natural law stands as the foundation of our constitution and is the basis of our founders’ passion for every American’s right to self-determination. Man should be able to formulate his /her own destiny within the confines of a reasonable legal system.  The law defines our inherent obligations to each other and the public at large but does not compel us to practice self-sacrifice.

I believe that most Americans believe themselves moral. Most of us want to do the right thing.  We vote that way and define our relationships that way regardless of our politics.

Reason or natural law would have it that “the right thing,” basic human nature does not allow for irresponsibility.  How is it reasonable that any human would not want to take care of his/her own personal needs as best he/she can?  Protect himself and his family? How is it possible that it is immoral for me to not want to accept my neighbor’s personal responsibility?  It is not.

If personal responsibility is the moral paradigm that is the underpinning of American freedom, it cannot be moral that any person be allowed to dispose of that obligation. Morality and reason demand that I work for myself first. My morality demands that I not allow my neighbor’s indifference to his/her own needs mandate my personal contribution.

American morality has no place for personal irresponsibility.  If we are going to turn our economy around and provide the framework for American world leadership we must come to terms with our personal morality. Anything less will bankrupt our pockets and our sense of reason. Personal responsibility is our American duty.

The AMA No Longer Matters

One of the discussion lists I participate in had a lively exchange about the AMA’s new Executive Vice President, Dr. James Madara. Some people thought he was a good choice, others thought he is too much a creature of academic medicine and too much of an Obama liberal. I really have no idea, I said, but over the past few years the AMA has betrayed America’s patients and I have no use for the organization. Then I added another post:

Folks,

I really have no business commenting on the AMA, so I won’t (any further.)  I love — quite literally — every poster on this list. You are all great physicians, dedicated citizens, and decent people in every way that counts. I do not want to discourage any of you in doing what you see as the right and moral thing.

I want to throw in a different thought that really has little bearing on what the AMA does. I hope you will indulge me, because I think it may provide context.

I no longer think this health care system — or this economy, or this government — is capable of being reformed. It is too late. I have asked every economist I know about how we get out of the mess we have created, including schools that don’t teach, growing numbers of people dependent on government handouts, a regulatory system that destroys entrepreneurship, and the impossible debt we have accumulated.

Not one has offered anything approaching an answer. Not just a practical answer, but even any theoretical, dreamland answer. There is no way out. That means the entire house of cards will collapse. Maybe not for another 20 years, maybe just 10. By collapse I mean something close to an early Mel Gibson movie in which survival is the primary motive.

A very large portion of our population has no practical skills. They may have advanced degrees in comparative literature or they may be great systems consultants and six sigma experts. But they don’t have a clue how to feed themselves, make clothes, build shelters, or fix a broken bone. After the collapse, the people who will prosper are those who can actually do something of value.

Feel free to dismiss all this as irrelevant to anything currently on the table. And perhaps I have become a kook in my old age. Certainly there have been nonsensical doomsday predictors forever, and maybe I have joined the crowd. But I have looked for any ray of sunshine and have not been able to find it. Sorry.

So my interest in health care now is to find a way that one patient and one doctor can find each other and work out a mutually beneficial relationship. Anything else is just noise.

Greg Scandlen

Very much to my surprise most of the people on the list agreed with me. I will publish a couple of the more extended comments in a moment. I would love to hear what you think.

 

 

The Destruction of American Medicine

By Greg Scandlen

The New York Times has published a sobering article by Gardiner Harris  which describes how quickly we have allowed the best health care system in the world to slip through our fingers.

The story keys off Dr. Ronald Sroka, a family practice physician in Crofton, MD. It says,

Handsome, silver-haired and likable, Dr. Sroka is indeed a modern-day Marcus Welby, his idol. He holds ailing patients’ hands, pats their thickening bellies, and has a talent for diagnosing and explaining complex health problems. Many of his patients adore him.

But he is being pushed into extinction by academics like David J. Rothman, president of the Institute on Medicine as a Profession at Columbia University who is quoted:

Those of us who think about medical errors and cost have no nostalgia — in fact, we have outright disdain — for the single practitioner like Marcus Welby.

Mr. Rothman’s disdain and his allies in the insurance industry and government bureaucracies are winning the war. The article explains:

The share of solo practices among members of the American Academy of Family Physicians fell to 18 percent by 2008 from 44 percent in 1986. And census figures show that in 2007, just 28 percent of doctors described themselves as self-employed, compared with 58 percent in 1970.

It’s enough to make you weep, but there is perhaps a sliver of good news. A friend sent the following e-mail to one of my discussion lists:

Last week, Senator Whitehouse came to northern Rhode Island to speak to his home community. He had largely an elderly and retired audience of about 300. His comments were focused on them as he spoke of how he would fight to retain Social Security and Medicare. The audience clapped politely. Whitehouse continued to discuss healthcare. He eventually came to speak about physicians, lighting upon the topic as to how our actual charge per service differs depending upon what insurance each person has. “Go ahead,” he said, “call a doctor and ask what they charge for a certain visit or procedure. They’ll ask what insurance you have.”

I rose and said “$50.” I introduced myself to the audience and said that I charge $50 for an office visit, that I don’t take insurance, and that as a result of the massive cost savings by not having a coding specialist, collections specialist, or billing overhead, and by not having to rent an office big enough to house all those people, I can charge a reasonable fee while each patient retains the confidence of knowing that no third party will have any of their private medical information, of knowing that there are really only two people in the room when we talk, and of trusting that I’m going to provide the treatment that they really need rather than the treatment some third party tells me I should be providing.

I expected that this largely Medicare-covered audience would shake their heads and whisper “dinosaur” under their breath. Instead, I received applause and a few dozen new patients the next day. Each said roughly the same: “I’d rather pay for the care I want than have insurance cover me for care I don’t want.”

If indeed most new physicians choose to look toward the type of practices described in the Times article, that will allow all the physicians who want to run their own lives to do so without worrying about whether they’ll have enough patients. There will always be patients willing to pay a reasonable fee out of pocket for the kind of care that can be delivered by doctors like Dr. Sroka.

While the bulk of American medicine may accept becoming little bureaucrats, doing the bidding of their masters in Washington, a sliver will simply offer their services to patients on a cash or concierge basis. These few may grow until medicine becomes once again the noble profession it once was.

Krugman’s Blinders

By Greg Scandlen

There has been a lot written about Paul Krugman’s recent op-eds  and blog posts about how thinking of people as “consumers” rather than “patients” violates their “sacred” relationship with doctors.  My colleague Ben Domenech had one of the best rebuttals in Consumer Power Report #269.

It is more than a little disconcerting to hear people like Paul Krugman suddenly invoke the sacred doctor/patient relationship when they have been working so hard to have bureaucrats control both physicians and patients. But I want to make a different point, one that has been lacking in most of the commentary.

The whole point of Consumer Driven Health Care is to get people involved in their health care decisions long before they become patients.  For decades the “health policy community” has been fretting over this very thing – how to improve “health literacy,” how to get people to make healthy lifestyle choices, how to get people to ask questions about their treatment alternatives, how to teach people when it is appropriate to rush to the Emergency Department and when it is not, how to teach people the differences between the various medical specialties, etc., etc., etc.

We have health education classes in high school. We have newsletters with “Tips for Healthful Living.”  We have media reports about the latest breakthroughs in prevention and treatment.

None of it worked very well – until the advent of Consumer Driven Health Care. Suddenly people are responsible for making decisions about how to spend their own money for their own health, and they demand more information about their options. They sit together in the kitchen to decide how much money to set aside in a saving account and how big a deductible they can handle.  They have discussions about how often the kids go to the doctor and whether they will need glasses or dental work in the coming year. They look for lower cost generic drugs to replace the name brands they have been using. They use home remedies first, before making an appointment with the doctor. They participate in wellness programs.

They are not yet “patients.” They are active “consumers.”

If the Krugman’s of the world would take off their political blinders, they would see something wonderful is happening in the market.  But that would shatter their illusion of an all-powerful bureaucracy fixing everybody’s problems.

I Get a Kick Out of Uwe

By Greg Scandlen

Princeton professor Uwe Reinhardt is a really funny guy. Really. If you have ever caught one of his talks, he will leave you in stitches. Not the medical kind of stitches, but the other kind usually associated once-smoky nightclubs and a lone comic on the stage.

But he tops all of his previous comedic efforts in a single letter to USAToday. He begins by trying to rebut a recent op-ed:

One of the more mindless clichés trotted out in the health care debate is that “one size doesn’t fit all.” In seeking to rebut USA TODAY’s fine editorial on “RyanCare,” a proposal by Rep. Paul Ryan, Ed Haislmaier trots it out once again. He does this in a country whose entrepreneurs discovered a century ago that there are huge economies of scale in the idea that one size does indeed fit all to meet common human needs.

But, then his comic gifts kick in. He just can’t help himself:

KFC, McDonald’s, Burger King, Holiday Inn, Marriott Hotels and many more now global companies all base their business models on the idea that one size fits all. And Wal-Mart might soon teach us that the idea also applies to medical clinics, and someone might show it for hospitals as well.

Wal-Mart as an example of how “one-size fits all?” I know a lot of my liberal brethren would rather be caught dead than be seen inside a Wal-Mart, and there may not be any in the rarified environs of Princeton, New Jersey, but c’mon – are there no photographs in Princeton? Every Wal-Mart I’ve ever seen includes acre upon acre of variety.

And, in case someone doesn’t find anything to his liking in the Wal-Mart, there are thousands of other stores from Dollar General to Saks Fifth Avenue to choose from.

Now, my friend Uwe may prefer the old Soviet-style GUM Department stores for his retail needs, but is that really the model he wants to apply to health care? I can’t wait to hear the reaction once all the Princeton professorate is required to shop only at Wal-Mart.

Fortunately, right below Uwe’s letter is one from a Frank Zoz of Waterloo, Iowa, that is not nearly as funny, but might actually work –

I am absolutely convinced that health care costs will never be brought into control until people are spending their own money, or at least think they are. “RyanCare” changes to Medicare seem to be a step in that direction.

I think the ultimate solution is Health Savings Accounts (HSA) for everyone, with which they pay for insurance premiums and health care. The question is how these accounts are funded.

I am a John Deere retiree and on Medicare. John Deere provides insurance for its retirees. It provides money into an account (similiar to an HSA) from which we can pay for insurance and medical bills. My wife and I happen to have a Medicare Advantage plan and are very happy with it. The HSA covers our premiums and any significant additional costs. We have leftover funds that can be used for emergencies. If the government must be in health care, the best thing it could do is help fund HSAs for everyone.

Increasing Frustration

By Marcy Zwelling Aamot, MD

Americans’ frustrations are increasing. While we were promised that the cost of healthcare would soon stop its upward trajectory, we have yet to see any evidence of anything of the sort.  My individual premium is going up every year while my co-pays also go up.  Every business person with whom I speak complains about their healthcare costs and that includes the deans of our university where their health care costs are consuming so many dollars, they are starting to cut classes and decrease opportunities offered students.

The debate continues in Washington, DC and the promises are coming a mile a minute right along with the threat that we are all going to have to “take it in the shorts” one way or the other.  I wonder if individual Americans wouldn’t be better off managing our own healthcare demands rather than leaving things in the hands of the government or the insurance companies that have not earned our trust or our respect.  The latest budget debate and near closing down of the government assures me that things would be better in the hands of the average American.  We seem to appreciate the value of a dollar and understand value much better than our elected officials.

The solution is really quite simple.

1) We need transparency in health care.  How can we even start to manage our dollars without knowing the cost of care?  Every medical facility and establishment should be require to post their retail cash prices.  This costs nothing and at least starts to bring some honesty to the discussion.  We can start that today by asking our city councils to demand that every medical facility business license require the posting of  retail prices. You may be surprised to find that a mammogram costs less than $100.00 and yearly lab can be purchased for less than $50.00 cash.  Those who use their insurance and pay their deductible know that the cost is goes up when the payment for services is circuitous through insurers or the government.

2) Congress should require every insurer and itself (including Medicare) to sell a catastrophic only health care insurance plan that is actuarially based and open to all patients including those with pre-existing conditions.  The premium for this policy would be affordable and available to all.  Community rating does NOT apply. Patients must be charged the actuarial value of the policy but it should be available to all.  Surely, that person with hypertension will pay some additional cost but smart insurers will find a way to attract those patients by offering them a reduced rate for proof of adequate medical treatment.  This also puts patients in charge of their own healthcare.  As it is, there are many “pay for performance” opportunities for doctors but they have all failed because they have not offered incentives to the right person.  It is always the patient who should reap the benefit of his or her investment in their health.

A free market is the only way to bring competition back into the medical care marketplace and healthy competition drives innovation and excellence.  The current fixed pricing system offered by Medicare and health insurers has taken away opportunities afforded by human nature, our competitive spirit and drive.  The cost drivers are all the middle-men and regulations imposed on what should be a transparent and open marketplace.

In the end we want a healthcare delivery system where the patients can be empowered to be responsible for their own health and life investments.  Doctors need to direct our care to our patient’s specific individual needs and we must be answerable to that person in our exam room, not the government or an insurance company.  History has taught us that with freedom of self-determination, America will always find its way to excellence.  Why can’t we assume the same in the healthcare market place.