Prather Pediatric and Allergy Center - Ask Doctor Brent

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Title: The Health Care Criss - A Hard Look at Election Time

Category: Access To Children's Health Care





In this month's "Focus on the Family" in Physician's Magazine, four Christian physicians were asked for their opinions on the health care crisis and suggestions for improvement. The first was Robert Orr, M.D., a clinical ethics professor at Loma Linda University Medical School. The tenet of his discussion was that the medicaid system as it stands now is not working. He gave an example of how, in Utah, a family of three making $8,300 would qualify for Medicaid, but in Alabama would not because of the difference in state to state qualifications. Because of this many couples separate so that the mother and children can continue to receive necessary medical care. Also, from one state to another the range of benefits and pay to the physicians and medical caregivers differs dramatically. In Louisiana, primary care physicians, such as pediatricians and family doctors are paid fairly well for medical care. In Texas, however, they are paid less than half of what we get in Louisiana. Consequently, as you can imagine, very few physicians in Texas will accept medicaid. Excess Medicaid paperwork is criticized but this is becoming simpler now with computers, and, in my opinion, can be easily handled.

Another problem Dr. Orr cites is that many patients on medicaid still feel the stigma of being on public assistance. They may be treated differently than private patients. I can second that in having talked to many thousands of my own medicaid patients who are not welcomed in many offices around the state. In today's society, fewer physicians are offering free or discounted care for the poor as they did in past generations. The feeling is that it is a societal problem and not any individual physicians responsibility. Because of this attitude many small city and county clinics and hospitals have had to close.

Dr. Orr sums up by saying that medicaid is not working and it needs to be reformed or replaced. I agree with him and suggest that we follow the plan of the American Academy of Pediatrics which is spelled out in the Matsui Bill, House Resolution 3393. This will provide equal access to care for all children. You would not be able to tell one from another so that no one would be treated in a prejudiced way because they happen to be poor or disadvantaged. Dr. Orr also suggests that a good Christian response to the health care needs of poor people would be to follow the example of Jesus. First, he says we should have a burden for the needs of the poor and reach out to them. Second we must be like salt of the earth in creating alternatives to the current system which is failing. Finally, he suggests that we be the light unto the world by all working together to be advocates for poor people in matters of health care. I agree with most of what Dr. Orr suggests and also agree with his tenet that the medicaid system is not working effectively as it is now structured.




The second physician in the round table discussion in Physician's Magazine, September '92 issue, was Jane M. Orient, M.D., past-president of the American Physicians and Surgeons and present editor and director of the American Physicians and Surgeons News. She focused on the problem of fraud in medicine. She said bank robbers don't need to go down town anymore. They can just get involved in medical fraud. Unfortunately, this funny analogy is too often true. Recently, a large FBI sting uncovered medical fraud by hundreds of pharmacists and physicians who were over prescribing expensive medicines to medicare patients and then reselling them at discounted rates. This of course is one dramatic example of a huge problem involving a significant part of the 800 billion dollar annual bill paid for medical goods and services. Approximately 40% of that 800 billion dollars is paid by the government and Dr. Orient suggests that much of that is overpaid because of fraud.

In the past, when a doctor, hospital or pharmacist had to look a patient in the eye every time there was bill, there was a sense of honesty and trust which limited any overcharges. Now with medicaid cards or insurance cards with or without co-pay, the high charges are essentially ignored because somebody else is having to pay it. Dr. Orient suggests that the best way to stop this fraud would be to require patients to actually pay and it would be reimbursed or at least to have a definite co-pay for every medical charge. I agree with her, in general, and feel that medical costs could be cut by a third overnight by simply tying a co-pay to every single use of medical privileges. In other words, every medicaid or insurance patient would have to pay something out of their pocket for every medical visit, every emergency room visit, every pharmacy visit and every medicine prescribed at the pharmacy. This would probably cut down a lot of work for many in the medical establishment but the upside is that we would use that extra time and money to provide for the 30% of people in society who are not getting adequate medical care.




The next person focused in the round table discussion in the September issue of Physician's Magazine was Steven Price, M.D., a family practice physician in South Hamilton, Massachusetts. Before coming to the United States, where he has now practiced for twelve years, he practiced seven years in Britain and six years in Canada. Dr. Price summarized the three major proposals for health care reform before giving his final recommendation. The first proposal is the single payer system in which the government would have the authority to collect funds through taxes and to organize and administrate the entire health plan. This would be similar to the plan in Britain or Canada. The second approach would be restructuring the private insurance market to allow more Americans to buy insurance. This is the Bush Plan and would allow small firms and individuals to buy insurance through medical vouchers or tax credits. The hope here is that by running the system privately the plan would be managed better and avoid runaway medical costs. The third plan which is part of the American Academy of Pediatrics recommendation is called the Pay or Play Approach. This is also the general plan proposed by Clinton. This system would rely on private health insurance but would require employers to provide some form of health insurance for all their workers or pay a payroll type tax. Those who are not working would be on a medicaid type system with costs connected to a sliding scale according to their income. Cost containment here would be a combination of both government regulation and market competition. Dr. Price feels that after his experience of working in England, Canada and the United States, that the best choice would be a program closer to Canada's. He feels that this would at least insure medical access for all people in society, which is a major problem today. He stresses that there are problems with the Canadian system as there are with any system and we could take the things that are working well from it and try to improve on them. He closes by saying that the wasteful duplication and complex administrative excess in America is a big cause for its high cost (now 14% of our gross national product). He also stresses a need for more emphasis on family care medicine. This might require rewards and incentives for medical facilities and care givers in less desirable locations where medical care is not being provided such as rural areas and remote areas of the country. I agree strongly with Dr. Price's recommendations, having talked to hundreds of Canadian patients and doctors.





The last doctor in the recent article in Physician's Magazine to address the health care crisis was William Crevier, M.D. of Chicago. He is in private practice as an internist and pediatrician in south Chicago and teaches a course called Health Care Delivery to the Poor in the United States at the University of Chicago. Dr. Crevier feels that one reason we are having trouble getting doctors to rural and inner city areas is because of a lack of role models for primary care in our medical institutions. Also there is a fear of inability to pay back loans which can be in excess of a hundred thousand dollars for many medical students by the time they graduate. The educational environment in which many medical students are taught does not provide an encouraging look at ways of caring for indigent patients. Their problems are frequently way out of control and the over-worked understaffed inner city hospital treats them in a rough manner which does not engender the young doctor wanting to choose indigent care as a long term goal. Dr. Crevier is a part of a national effort to provide preceptors for medical students who are interested in helping the poor in rural areas and inner cities. This preceptorship program is run through the Christian Medical and Dental Society Domestic Missions Commission (CMDS) and the (CCHS) the Christian Community Health Fellowship. There are presently about 50 medical schools participating and it is hoped that all medical schools in the United States will soon be involved. With this goal in mind, up to 300 students graduating annually in the United States could be involved with these missions and be heading out to the real needy areas in our country to provide medical care. To help these students, loan repayments are available through many states, through the federal government, through the National Health Service Corps and through private interested parties, particularly in inner cities. I personally think Dr. Crevier should be commended for his mentorship and example in this area. I would like to see all doctors, not just doctors in the country or the inner cities, but all doctors in every part of the United States give at least part of their time - perhaps 5 or 10 percent of their time - to the indigent as all doctors did in the past. I am confident that if we all did this there would be no patients uncared for and very few poorly cared for.

In summary, we do have a health care crisis and with the upcoming election just months away it is critical that we focus on it and force our legislators and presidential candidates to come up with a realistic workable plan and at least begin the long process of solving the health care crisis. I urge you as interested citizens and parents to push for such changes and specifically to encourage our legislators to strongly consider the Matsui Bill, House Resolution 3393 which would at least provide universal health care for all children in our society and be a good start toward universal health care for all people in our society.