Yesterday, I was reading the Greenville Hospital System (GHS) medical staff newsletter.  One of the articles was excitedly explaining how GHS had struck an EXCLUSIVE contract with Blue Choice Medicaid.  This means that the 14,000 members of Blue Choice Medicaid in the Upstate area will only be able to receive their medical care from GHS physicians.  The article was presented as very exciting, positive news, but I saw it as an illustration of what is happening to health care in the United States as it moves away from individual centered health care to corporation based health care.

The deal between Blue Choice Medicaid and GHS, despite all of the claims about improving quality is really about money.  It has been done for the purpose of both GHS and Blue Choice making more money. Of course, contractual deals between businesses have been done as long as business has been around.  This makes sense, if you are talking about Walmart buying  a large volume of shirts from a manufacturer so that they can sell them cheaper to entice the consumer to come into Walmart and buy the shirts.  I think it is a different matter both morally and functionally to do this in healthcare.   In order for the deal between GHS and Blue Choice to work, a population of patients has to be bought and then their behavior as well as the behavior of their doctors controlled in order to produce “savings.”  This would maybe be okay if the patients were free to move in and out of the Blue Choice Medicaid plan, but whether you are talking about Blue Choice Medicaid plan or any other insurance plan, the patients do not have the freedom to move and out of their insurance plan.  As a consumer, I have the choice to buy a shirt at Walmart or Belks or wherever.  However, as a patient I am locked into the insurance plan that my employer chooses or in the case of Medicaid, the plan the state chooses for me.  I have no control over the deals that have been struck by these insurance plans.  If I am insured by Blue Choice Medicaid and my doctor is not part of the GHS network, I will be forced to either change doctors to one of the GHS doctors or go without insurance coverage, which few can afford.

This process has been going on for quite some time and it has been accelerated by the Affordable Care Act (Obamacare).  Once insurance began paying a majority of the health care costs, patients and doctors were no longer viewed as individuals, but now lives to be purchased and members/providers whose behavior was negotiated and controlled.  Obamacare brought Accountable Care Organizations into existance and this is driving much of what is happening now.  Under Obamacare, much of the money will be distributed to hospitals, who will then determine how the money will be spent for the healthcare of the populations under their control.  This is why hospitals have been very aggressive at buying physician practices and coalescing numerous hospitals into their networks.  The more healthcare a GHS can provide, the more of the money they can keep for themselves.

On the surface, GHS trying to provide a wide range of services themselves is not a problem.  However, it becomes a problem, when they establish themselves as a monopoly that drives out of business any doctors unwilling to be owned by a system and thus controlled by the system.  It becomes a problem when patient’s choices are limited because their doctor is not part of the system or their doctor is limited on who he/she can refer to based on whether they are part of the system.  It is a problem if the patient’s choices are challenged because the choice does not fit the patient behavior guidelines of the system.  It is problematic, when vastly different individuals with unique needs, preferences and biologies are all treated as one monolithic patient population.

As a doctor, I will never be owned by the system.  As a patient, I fear the kind of health care system being created is not in MY best interest.

In 1992, in order to encapsulate the central issue in the Presidential election that year, James Carville popularized the statement:  “It’s the economy, stupid.”  I am reminded of this during some of my patient encounters.  I think of a couple  I delivered a few months ago.    This couple had transferred to me, from a local obstetrical group, part way through her pregnancy.  A major reason for transferring, was that they wanted a nonmedicated  vaginal delivery and believed they would be more likely to achieve that under my care than that of the obstetrical group.  Unfortunately, her delivery process turned out nothing like they had planned.  There was an induction, an epidural, vacuum and ultimately a cesarean section of a healthy baby boy.  At the conclusion of this birth, I felt terrible.  This couple had come to me for a specific style of delivery, but I believed I had failed to meet their expectations.  The day after the delivery I went to visit this mom and talked with her about her birth experience.  To my surprise, she was extremely happy with her birth experience.  Obviously, she was thrilled with her new baby,  she was also very happy with the whole experience and happy they had changed doctors, even though the details of the birth had not turned out the way they had planned. 

I have been reflecting on the reason for the positive satisfaction, despite the specific unpleasant details and I believe it can be encapsulated in the statement, “it’s the attitude.”  What was the attitude that this couple found appealing?

1.      This couple was treated like family.  Since I am the only delivering doctor in this practice,  I get to know them very well and they get to know me.  We not only talk about their pregnancy, but also about both their and my personal lives. They know that, except in a very rare situation, I will be the one shepherding them through their labor and delivering their baby.   I will not be turning them over to another doctor, who might have different ideas, because my shift is now over.  They have my personal cellphone number and can reach me when I am needed.  At the end of all this, the couple has no question as to whether or not my priority is their well being.

2.    Throughout the pregnancy all interventions are discussed and a seeking of approval is obtained.  This is even more important during the labor process.  Nurses did not suddenly start doing things because the doctor ordered it.  Rather, the reasons for any intervention are thoroughly reviewed prior to the intervention happening.  The attitude part of this is that they are treated as equals in this process.  While I may have more education and experience, their input is just as important as mine.  This is a collegial process with sincere give and take.   This means they remain in control of what happens, rather than being taken over by a big unresponsive medical system.

3.    All options were attempted.  During the labor, she was encouraged to move around and change positions.  Other methods of achieving a vaginal delivery were pursued.  There was no timer running, so she did not feel pressured by the doctor’s fatigue, schedule or arbitrary time line. By the time the decision to do a cesarean section was made, the couple knew there was no other option and were in full agreement with doing the section.

Every case is different and rarely there is a true emergency or situation, where the doctor has  to take a more paternalistic approach.  Nevertheless, that should be very uncommon.  

Too often, the doctor has the attitude that they are the educated professional and the patient’s views and concerns are irrelevant.  Too many times, doctors will make up rationalizations to justify what they want to do to the patient, rather than admitting it is a doctor preference or the way they do things.   

My view is that physicians need to be transparent with their patients.  Agree or disagree with the patient’s viewpoint, a physician needs to be collegial in their approach.  If the doctor disagrees with the patient’s viewpoint, than try to persuade them in a respectful manner.   A doctor should never approach the patient with a condescending attitude.  A doctor should not make things up, to get a patient to agree to a given treatment.  Physicians should treat patients the way they themselves would want to be treated.  It is the attitude!

After a great deal of thought I have decided to drop my health insurance.

As everyone without health insurance knows, this a very scary position in which to find oneself.  Being in the healthcare field myself, I am well aware that a single day of hospitalization can generate tens of thousands of dollars in bills.  I also know that as a 53 year old self-employed man with hypertension and a history of oral cancer,  once I drop my health insurance, I will never be able to get it again.  I also know that the older I get, the greater the probability of developing an expensive medical condition.

Given this reality, why would I drop my insurance?  The answer is that while I can still technically afford my health insurance,  I can no longer justify the extremely high cost of maintaining health insurance.  My premiums have steadily gone up, so that I am now paying $1,400 per month for a plan that comes with a $6,000 annual deductible.  This means that, I am now paying $18,000 this year, to prevent the health care system from bankrupting me.  No matter the item we purchase, there is a point at which we decide the price exceeds the value of the item and for me health insurance has now reached that point.  This is a single item in my budget and I cannot justify paying that amount of money for an insurance policy.  It is no wonder that so many families are unable to afford health insurance when the cost for it is this high.

I do not blame the insurance companies for this out of control cost of health insurance.  I know that insurance companies are not living in poverty and there is much about the way they do business that totally frustrates me, but neither do I think they are the major cause of unaffordable health insurance.  I believe  the major cause of high health insurance premiums is out of control health care costs and the premiums are rising to cover the ever increasing cost of health care.

Unfortunately, the politicians whole focus is on ways to pay for our health care, rather than answering the question of why is health care so expensive?

Some blame the costs on an aging population, advances in medical technology and too many in the population being uninsured.  While these things may be contributors to cost, I believe they are not the major reason for these runaway costs.  I believe the real culprits are other items.

The reality is we have created a health care system in this country that almost no one can afford.  It started back when employer and government provided health insurance was initiated.  This began the decoupling of health care from market forces and the price of health care started climbing.  This produced a vicious cycle of higher prices trying to be compensated by more subsidies and higher premiums and less control by patients and doctors.  Unfortunately, we have now gotten to the point that patients are no longer the doctor’s customers, but have become mere widgets to be manipulated by the system.  This view of patients will become fully manifest when Obamacare is fully implemented.  When market forces are removed, they are replaced by rules and enforcers of the rules.

A major contributor to sky rocketing health care costs is the escalating mounds of regulation.   The justification for these regulations range from preventing “improper payment”  to creating a perfect health care environment.  I could argue with these justifications, but right or wrong, the need to fulfill these regulations costs our health care system millions upon millions of dollars each year.  As an illustration of the impact of regulations on our health care system, go by a hospital parking lot Monday through Friday and see how many cars are in it.  Now go by the same parking lot on Saturday.  The amount of reduction in cars is an approximation of the cost of regulation to our health care system.   While one could make an argument for a small amount of regulation; we have long surpassed the ridiculous and we are now at a level where the whole system is in danger of collapsing under the weight of the regulatory burden.

Lawyers are a tremendous expense for our health care system.  There is, of course, the direct cost of malpractice judgments.  One can debate the merits of a tort system, but when a plaintiff is paid a judgment, the money for that payment ultimately comes from health insurance premiums.  The even bigger impact of doctors and hospitals being sued over bad outcomes is the cost of doctors ordering lots and lots of expensive tests and spending lots of time documenting, for the purpose of protecting themselves from law suits.  I am sure, some will argue that it is good that the fear of lawyers makes doctors so cautious, but I have to ask, at what cost?

Mandated coverage of all kinds of things is expensive.  The politicians, in their yearning to buy votes by looking compassionate, have passed more and more laws requiring insurance plans to cover various and sundry things.  There are many of these items, but some of the latest items have been mental health care, children to age 26, preventive health care, contraception and soon coming preexisting conditions.  This mandating of coverage may sound wonderful to those getting the benefits, but these mandates come with a huge price tag.  One of the major things is it eliminates an insurance company’s ability to offer an affordable policy because they have been mandated to cover so many things.  This creates a larger pool of people with no insurance at all because all that is available are plans that cover everything and are therefore too expensive for them to purchase.   All of these “wonderful” mandates will do one no good when one cannot afford to buy the insurance in the first place.

There are other factors impacting the cost of health care, but these are some of the major ones.  Whatever the reason for the costs, the reality is that health care in the United States is extremely expensive and health care is something everyone of us is going to have to purchase sooner or later.  What am I going to do?  I am going to be participating in a cost sharing cooperative (Samaritan Ministries).  There are a number of these out there, but their monthly premiums are $350/mo instead of $1,500/mo.  They provide no coverage for day to day medical needs (neither did my high deductible plan)  and take more time on my end, but in my mind not only are these plans markedly cheaper, but they are how health insurance should work.  We will see how it goes.

A patient recently asked about the crocheted stirrup covers we use in our office.  I told her the story behind the original ones, which she enjoyed, so I thought I would share the story here.

About fifteen years ago, Geraldine came to me as a new patient.  She was 78 years old and was having some abdominal symptoms.  She had already seen a few doctors over a period of time, but no one had been able to diagnose the cause of her symptoms.  I did a work-up on her and unfortunately had to tell her that her symptoms were coming from ovarian cancer, which at this point was pretty advanced.  Because of her poor prognosis, even with treatment, she opted to not be treated for the cancer.  In a matter of months she was too weak to get out, so I began to make house calls on her.  Every couple weeks I stopped by her apartment to check on her, but mostly we just talked.

During one of these visits she told me she was so appreciative of my having diagnosed her problem, even if it was not fixable, and for my coming to see her in her home.  She wanted to show her appreciation by doing something for me.  What did I want her to do?  She was quite weak, so I was not sure what to tell her.  However, I had noticed that whenever I came to see her, she was crocheting something.  I had recently read about a doctor trying to make those horrid office stirrups more comfortable by putting crocheted covers on them.  I told her about the idea and asked her if she could make a pair for me.  Geraldine was ecstatic and within a week she had made me a whole bag of crocheted stirrup covers.  A month or so after this, Geraldine passed away.

Our stirrup covers have now been replaced several times over, but to this day, whenever I use them, I am reminded of Geraldine and the simple task that brought a sense of purpose to the twilight of her life.

This past summer I had two very bright and eager student rotate through my office.  One was a health administration student in the School of Business at Winthrop University.  The other was a 3rd year medical student, who obtained an MBA prior to entering medical school.  I asked both of these students the question:  Why do businesses exist?  They both gave me the answers that they have been educated to believe are the correct answers, but neither of these students, educated in university schools of business could give me the correct and very simple answer.

As a physician, I am often told by patients that they do not want medicine to cover the symptoms, but an answer as to the cause of the symptoms.  Until one knows the cause of the symptoms, it is impossible to prescribe the proper treatment.  We are currently living in a day where widespread unemployment, economic stagnation, out of control debt and mutually exclusive political philosophies are the symptoms of a serious and life threatening disease.   If we want a solution to all of the symptoms, we need to know the underlying disease process.

Economic activity occurs as people exchange money for goods and services.  The money that people use to purchase goods and services come from one of two places.  They either earn it through their employment or it is given to them through charity or government programs.  In the first case businesses employ people and pay them for their work.  In the second case, money is given to charities and government by businesses and employed individuals in order to be distributed to those who are not employed adequately to meet their needs.  In both cases, the bottom line is that money originates with businesses.  Those business may be multibillion dollar conglomerates or a child’s lemonade stand.

If we have a sick economy, it is because there is an inadequate amount of business to generate the money required for all of the needs.  This brings us back to the original question, “why do businesses exist” for if we do not know why they exist we will be unable to create the environment in which they can prosper.

Businesses do not exist to employ people.  They do not exist to provide health insurance or other benefits to their employees.   They do not even exist to pay taxes, so the government can fund its programs.  Businesses do not even exist to produce goods and services.  Large or small, businesses exist so the owner of the business can MAKE MONEY.  Employment, benefits, taxes, charity, production of goods and services all happen on the way to a business making a profit.

When the regulatory environment becomes too onerous or fear of litigation too great or labor too expensive or tax burden too high or demand for the output too low for the owners of the businesses to make an acceptable profit, the business will disappear.  When this begins to occur on a large scale the entire economy suffer and that is what is happening in our economy today.

For a variety of reasons, it has become socially unacceptable to pursue profit in our country.  Even our business students do not want to admit it.  At one time, our country was the best place in the world for a business to prosper, but that is no longer the case.  Until we once again create an environment where making a profit is laudable and doable we will continue to have a failing economy and we will ALL be poorer for it.

That is my diagnosis and treatment for the problems plaguing our economy.

Keith Stafford, MD