Author + information
- Spencer B. King III, MD, MACC, Editor-in-Chief, JACC: Cardiovascular Interventions∗ ()
- ↵∗Address correspondence to:
Dr. Spencer B. King III, Saint Joseph’s Heart and Vascular Institute, 5665 Peachtree Dunwoody Road NE, Atlanta, Georgia 30342.
We, in the United States, have either the best health care system in the world or not, depending on whether one has access and can afford it. The simple promise from the politicians, from single payer to “free private market,” coming this election year gives predictable broad brush answers. The goal of universal health care has been a policy that has long been supported by the American College of Cardiology. The Affordable Care Act, flawed as it is, was the first step in achieving this objective. It was a compromise that requires major refinement. The political pronouncements that sound like opposite poles ring from “repeal every word of it” to “keep it and improve on it” to “replace it with something more comprehensive.” How different are these positions? Are any politicians proposing that health care coverage should not be available to all? I recently asked a former presidential candidate who has previously proposed plans for health care whether he was in favor of universal health care. His response, which was anticipated, was that he was in favor of universal health care access. Obviously access is not denied to anyone who can pay for it and who is willing to pay for it. However, there will always be people who will not take personal responsibility for obtaining health insurance. Most Americans are covered by employer-based health insurance plans that come with a benefits package and the employee accepts it as a “benefit.” What if health insurance was entirely voluntary and every individual was responsible for purchasing it on their own? What would be the participation in health insurance plans? Would it be 50%? I don’t know, but it is possible that the majority of people who feel that they are healthy would spend their money on other things and let health insurance slide. It would then be the responsibility of hospitals and doctors to shoulder the load when complications of illnesses required emergency visits. That is not so different from the situation a large number of our citizens are in today. Of course, we do have a socialized system of health care financing for all of us over 65. I remember very well the uproar in medicine in the mid-1960s caused by the Medicare Bill. It is difficult to find a politician today who is even slightly in favor of the elimination of Medicare. For the poorest people, the Medicaid program administered by the various states provides coverage. Now with the Affordable Care Act, some states have elected to accept the federal funding to expand the Medicaid program to cover a larger portion of their economically disadvantaged population. Still, 10% of the U.S. population remains uninsured, and their “emergency” care remains a burden for hospitals that have to absorb the unreimbursed costs. Many of these hospitals caring for a large number of uninsured patients, especially in small towns serving rural populations, are forced to close. This has been most marked in states that have failed to expand their Medicaid services even though the funds to do so are provided by the federal government. It is ironic that taxpayers in states that have refused the federal support for expansion of Medicaid are having their taxes utilized in other states to expand Medicaid coverage for their citizens. In an election year, it may be impossible to really address our health care financing, but the problem will not go away. Both those who support provision of universal health care and those who feel that health care should only be accessible would be happy if everyone had health care coverage. Patients would be happy. Physicians would be happy. And, hospitals that are struggling to survive would be happy too.
The critical question of how to pay for health care remains unaddressed. The move to put doctors and hospitals in the same boat has failed to cut costs or improve care. Few cardiologists are currently not employed by large organizations. These organizations were expected by some to ensure efficiency, appropriate utilization, and to reduce costs while improving quality. But what are the incentives? Large organizations have the same fee-for-service incentive to increase revenue by providing more billable events. This incentive has, of course, been operative for self-employed doctors but has always been balanced by the patients’ perception of the quality of the service. Time spent with the patient and perception of interest in the patient have been replaced with the efficiency of high-throughput and electronic medical records. Doctors and hospitals obviously should be allies, but their incentives are not the same and should not be. As I change my orientation from primarily that of a provider to that of a consumer of health care services, I pay more attention to the uninterpretable complexity of my billing statements and my insurance coverage. If we as physicians with state-of-the-art insurance coverage have problems understanding our own charges, allowed reimbursement, co-payments, etc., how can we expect our patients to have confidence in this “system”? For people without coverage (I don’t call them “patients” because they seldom seek health care except for emergencies), the avoidance of health care is no solution. Hospitals operating on a thin margin and incentivized to push doctors to increase utilization of services will not control costs or make patients happy. Doctors, most of whom are now employed by organizations, are increasingly squeezed to make the numbers. As long as the rules of the game remain the same, physicians and the organizations for which they work will emphasize providing as many services as possible in order to generate the fees that are necessary. Many organizations are now looking at radical changes in payment policies. The move from fee-for-service reimbursement to “value-based care” is widely discussed, and recently the Centers for Medicare and Medicaid Services has begun mandatory bundle payment for orthopedic patients. As this expands, the rules of the game will change to emphasize avoidance of services rather than the provision of unnecessary services. I believe that the move toward universal health care is unstoppable in a modern democracy, and so the question should be, “What is the best way to get there?” In the current political climate, polarization around health care financing has led to near paralysis. Everyone sees the problem, but who will fix it? I often hear doctors telling patients, “Yes, I know it is a mess but I don’t have any control.” In moving toward a rational system for health care for all, doctors must regain some control.
- American College of Cardiology Foundation