Health Reform 'Won't Be Easy': Devil Is in Details, Dr. Simpson Says
This is the fourth in a weekly series of interviews with health-care professionals in the area who offer differing perspectives in the debate over health-care reform.
The health-care reform proposals now under consideration are unlikely to "meet the necessary measures for improvement in health care in the United States in regard to costs, quality or the delivery of care," says Dr. Patrick Simpson.
Or if they do work, says Simpson, an interventional cardiologist at Pinehurst Medical Clinic, it may not happen on the first try.
Simpson sees three major elements of health-care reform: achieving tort reform; rationing health-care services until we find the means of reducing certain diseases or eliminating their burden; and figuring out how to pay for it.
While everyone involved in the health-care reform debate would like for the general health of the nation to improve, there are many different definitions of what that means. The U.S system is currently "very expensive," says Simpson, who points out the differences between health-care access and coverage.
He expects to see some sort of result from the reform push from Washington, but says the "devil is in the details" and only time will tell if the current approaches will work.
Simpson spoke with staff writer John Krahnert. Here is an edited transcript of their interview.
Q: Could you tell our readers about your background?
A: I'm an interventional cardiologist at the Pinehurst Medical Clinic. I grew up in eastern North Carolina, did my training in Chapel Hill and then Vanderbilt and have worked here continuously since finishing training. That was about 10 years ago.
Q: What, in your opinion, is wrong with the current health-care system? Why is there a debate over reform right now?
A: I think it boils down to definitions of what is wrong and what is right.
We have a very expensive health-care system. The burden of costs are shifted throughout the population due to a number of factors, one of which is the payments that Medicare makes for services rendered, which frequently do not cover the costs of services. Hence many charges are shifted to private insurance, which subsequently drives up private insurance rates. When private insurance rates get driven up, the costs of the products for the companies that make this then go up, and it's shifted back to the consumer.
That's one of the many problems.
People talk about problems with health-care access and coverage, which may or may not be true, but I will point out that access and coverage are not the same things. Just because one has health-care coverage, whether it be in the form of insurance, a public option or the ability to pay out of pocket, does not mean one has access to health care.
Somebody who lives in Montana may be two hours away from a hospital. They may have coverage, but they only have limited access. By the same token, in areas that have limited numbers of physicians or services, you have access issues.
The lack of a standard definition regarding what we're trying to achieve makes the whole debate difficult. Everybody involved in this debate would like for every patient to do well and the "general health of the nation" to improve. One of the troubles is everybody has a different definition of what that means.
Q: What are the key elements of true health-care reform?
A: Again, on the issues regarding the definition of what "reform" means, I think there are three elements.
Number one, until we find the means of reducing certain diseases or eliminating the burden of certain diseases, you have to have some type of rationing regarding health-care services. We already have rations in health-care services. Some of the rations are overt, in which an insurer simply will not cover a service. Other rations are more covert, or what we term "back-door rations." In those cases, services are compensated at a rate below what they actually cost, hence the service is frequently not offered.
Until we come up with treatments and medication that actually eliminate diseases, you don't have enough money in the system to take care of all the patients.
The second part of health-care reform is tort reform. It is extremely difficult to estimate the burden of costs associated with efforts to catch every single heart attack that occurs in a given area. If a person sees 10,000 patient visits a year, and you're 99.9 percent accurate, you're still going to miss 10 potential heart attacks a year. Because any one of those 10 patients can subsequently file a suit, we have developed a system in which we do a large amount of testing to try to catch every single episode of a disease.
This is highly inefficient. It also leads to a large number of referrals in cases that would ordinarily not need a referral if the threat of legal repercussions were not there.
The third element of health-care "reform" relates to how one is going to pay for it. The idea that there is enough waste in the system that simply improving efficiencies will pay for the necessary additional coverage is incorrect. The health-care population grows by roughly 4 percent per year. So even if one could generate 4 percent cost savings every year, the system would merely be keeping even with the increasing number of patients.
If we keep our patients alive longer by performing better procedures, better medical care and better systems of care, those same patients return later for additional health-care needs and yet drive the costs of the system up further.
Q: Is the current reform legislation passed by the House and making its way through the Senate a good idea? Do you agree with it, are you against it?
A: I think the present administration made a commitment to health-care reform, and therefore we're going to see some type of product from this. Many groups are working to help influence this, and these include the politicians, the health-care industry, physicians and patients. Therefore, we're going to see some type of bill.
In theory, many of the bills have good points. But like anything else that comes from Congress, the devil is in the details, and what in theory sounds like a good idea, in practice may or may not be so.
In the House bill, I think it is irresponsible for the politicians to state that there will be defined levels of premiums with unlimited benefits. Health-care economics are like every other set of economics in the world. If you have a defined payments into the system, you'll have a defined amount of benefits.
If we put X billion of dollars to pay for health-care services, we will get X billion worth of services and no more.
In the 1980s, the HMO organizations made efforts to reduce the cost of health care by having "improved efficiencies." These organizations are run by the private sector and tend to be more efficient than government-run organizations. They cannot save the health-care system any money. The extra administration imposed by the HMOs ate up all of the savings.
Any efficiencies that come from the government plans may very well be consumed by the regulatory burden of the government itself.
Q: What do you think of the public option? Is it going to bankrupt private insurance? Is it a bad idea?
A: I think the public option is an effort by the present administration to ensure coverage for all Americans. I think this is a reasonable desire, although it may be impractical, and it may have been blown out of proportion.
People quote a figure of 45 million Americans without coverage. But in the same study that gave us the 45 million number, they pointed out, there were only about an additional 15 million Americans that will receive coverage under a "public option." The other 30 million have chosen not to have coverage and likely will do so under a public option.
As far as whether a public option will bankrupt insurance companies, I don't know enough economics about that. I think it will come down to a simple cost solution.
As an owner of a business that supplies insurance to employees, if the public option is less expensive than the private options, we will insure our employees with the public option. If the public option is more expensive than the private options, then one wonders why we have a public option at all.
Q: So is it fair to characterize you as being for or against the current legislation, or is it not that simple?
A: I don't think it's that simple. I think most health-care providers, administrators, industry and hospital personnel would like to "improve health care," [but] I don't think any of us can necessarily agree on what "improve health care" means.
At the present time, we have a system that's driven by metrics, in which organizations will determine certain guidelines for delivering quality of care. However, meeting guidelines does not necessarily mean that your patients will do better.
Our guidelines and our present medical studies are very good at telling us how to take care of 10,000 people with a disease. The art of medicine is taking the information you learn in treating the 10,000 and treating the patient in front of you. That may or may not meet the current guidelines.
So it becomes a very difficult situation to "improve the quality of health care," because it's difficult to agree on what quality is to begin with.
Q: Does the current legislation meet the guidelines for true reform that you laid out there?
A: I don't think that the current plans that we have are going to meet the necessary measures for improvement in health care in the United States in regard to costs, quality or the delivery of care. At least, they're not going to meet this in their first attempt.
As Mr. [Charles] Frock [CEO of FirstHealth of the Carolinas, interviewed in next week's final installment in this series] pointed out in his commentary a couple of months ago, one of the good things is that Congress has always shown the willingness to try to improve issues that they don't get right the first time. And I expect this will be a very similar issue. This will take three or four attempts before we really see plans that address most of our issues.
Of course, the cynic would also point out that it may take three or four attempts before Congress completely ruins health care as well.
Q: What's not being talked about enough in this debate?
A: What's not being talked about enough is rationing health care. We have a country that's increasing in age and has an increasing need for health-care services. Even if you can improve the efficiency of the existing system, unless one is willing to add additional money, you can't cover all of the services.
One can debate which services should and should not be covered. However, even with our existing ability to do studies, there are many things that we will not have data to determine whether it's beneficial to improve the life expectancy of the patients. The federal government does not have enough funds to do the studies that are necessary to try to determine this, and private industry will only do the studies when it's in their best interest.
Q: If you were czar for a day, if you could choose what kind of health-care system you wanted to put in place, how would you approach that?
A: So if I could be czar for a day, and this applies to health care as it does to any other part of government, the health-care system I would choose is equivalent to a benevolent dictator -- decisions made by one person who truly has the best interest of the country at heart, and who is very well-educated in the delivery of health care to make decisions that benefit the patients without regard to any special interests that may be negatively impacted.
Q: Anything else you'd like to add?
A: The vast majority of people that go into health care, whether it be physicians, nurses, hospital support staff, administrators and even most of the people associated with industry, went into health care to help people get better.
No amount of government reform will take away from this desire. As long as we're still able to take care of patients in a manner that allows us to treat them the way that we would like to be treated ourselves, we will still maintain a high quality health-care system.
When our health-care system no longer allows us to take care of patients the way we would our mother and father, then we have a problem. Only time will tell if the current approaches are going to help us or hinder us.
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