Docs offer varied cures for ailing health care system

August 24, 2009

Indianapolis physicians are mixed on the merits of a government-run, "public" health insurance plan. How reforms

                  might affect their pay is another major concern.

Dr. Ernest Asamoah, endocrinologist, Community Health Network, Indianapolis

He supports the creation of a government-run “public” insurance plan, for two reasons: He views health care as a basic right for all people and he notes that the United States already has several public plans.

They’re called Medicare, Medicaid, the Children’s Health Insurance Program, the Veterans Affairs system and other government programs—which together pay for nearly half of all U.S. health care.

“We already have some form of socialized medicine,” said Asamoah, a native of Ghana who practiced for five years in the United Kingdom, which has government-run health care.

That being said, Asamoah favors a fairly limited public plan. It should be structured, he said, to attract only those who can’t afford insurance—not so employers currently offering coverage can dump their workers onto the public plan.

The Congressional Budget Office estimated that the public plan, paying doctors roughly 15 percent less than private insurers, would attract no more than 12 million people away from private insurers.

But the Lewin Group, which is owned by insurer UnitedHealth Group, projected those payment rates would allow the plan to offer such attractive prices to customers that 88 million people would join it.

“That is where I don’t want the system to go to,” he said.

He acknowledged that doctors would probably earn less under the health reform proposals. But he’s OK with that.

“If I have to sacrifice $10,000 of my salary, that’s OK,” Asamoah said. “I personally don’t care if it costs me a little bit more so other people get better health care. We owe a responsibility to our fellow citizens because we earn more than other people do.”

Dr. Heidi Dunniway, ear, nose and throat surgeon, Otolaryngology Associates, Indianapolis

She worries that the health care reform proposals would cost the government too much and pay doctors too little.

“For the price tag on it, it sure has to make you wonder if that’s a good idea,” she said, noting estimates that the House reform bill would cost $1 trillion over 10 years. Advocates of one Senate proposal say it would cost substantially less.

The House bill now calls for the public plan to negotiate payment rates with doctors and hospitals—just as private insurers do.

But Dunniway fears that arrangement might not stick. If a public plan moved toward paying at below-market Medicate rates, she said, many doctors would go out of business.

“There’s a big concern that reimbursement will be driven down further and further, and you can’t sustain practices on that,” she said.

The reform Dunniway would like to see is to have the rest of the country adopt medical malpractice laws like Indiana has.

The state caps damages from malpractice lawsuits and makes patients run their claims by a panel of doctors before going into the court system.

That makes malpractice insurance far cheaper in Indiana, and helps doctors do less prescribing of tests and procedures to avoid lawsuits.

“You do cover yourself at times,” Dunniway said. “That’s one of the biggest issues that drives up health care costs.”

Dr. Rob Stone, Bloomington Hospital emergency department

Stone is a staunch advocate of shifting America’s health care system to a single-payer system, where the federal government would act as the health insurer for all Americans.

Since conservatives have attacked the public plan option as a “Trojan horse” for a single-payer system, you might think Stone likes the House bill, since it includes that language.

He doesn’t.

The bill calls for the public plan to operate—and therefore cost—more like private insurance plans than Medicare, which single-payer advocates essentially want to expand to cover all Americans.

“It looks to me like the House-bill version of the public plan is a pretty emasculated version,” Stone said. “And it looks like it might get even more cut down as it goes on through.”

Indeed, leading Senate Democrats want to scrap the public plan in favor of regional health insurance co-operatives that the government would launch but not operate. President Obama says he’s willing to do that—if the co-ops would truly compete with private insurers.

But many predict the co-ops would offer much weaker competition for big health insurers, such as Indianapolis-based WellPoint Inc., than would a public plan.

Health reform’s other provisions—in the absence of real competition—would be a boon to private insurers, Stone contends. It would require individuals to buy health insurance and use taxpayer funds to subsidize those purchases.

“It’s a huge transfer of wealth from the taxpayers to the private insurance companies and their shareholders,” Stone said.

A better way, he said, is to create a strong public plan that pays at Medicare rates and covers nearly all the 46 million uninsured.

Doctors would lose some money because Medicare pays about 20 percent less than private insurers, Stone said, but they would more than make it up by no longer having uninsured patients who often pay nothing.

“It’s probably not too hard for most physicians to do the math,” he said.

Dr. Ben Park, CEO of American Health Network, Carmel

Even though he oversees a 200-doctor practice, Park is a primary care physician who sees patients four days a week.

And he’d like to see health care reform shift how doctors are paid so they’re encouraged to make patients healthy, not simply to perform a high volume of services.

“I would start paying for what I value. And I wouldn’t pay very much for the other things,” Park said. “I would pay for health. I would help people to quit smoking, I would help people to start an exercise program, I would help people do healthy eating. None of those are reimbursed [right now].”

Park echoed many—but not all—doctors in recommending that Medicare scrap its current fee-for-service payment model. Most private insurers copy Medicare’s model, paying individual doctors only when they perform a test or procedure on a patient.

The House bill would launch pilot programs to change that model: bundled payments to groups of doctors for managing of specific diseases like diabetes; payments for primary care doctors to spend time on preventive care and coordination of care, also known as “medical home” services; and payments to integrated hospital-doctor systems called “accountable care organizations.”

In the meantime, the Medicare program under Obama has proposed cutting payments to specialists—such as cardiologists, oncologists and radiologists—while boosting payments to primary care doctors.

On the public plan, Park has mixed feelings.

He praised Medicare as far more efficient than private health insurers, devoting less than 4 percent of its funding to administrative costs.

Private insurers, by contrast, devote roughly 20 percent of their revenue to administration, sales, marketing and profits. That doesn’t leave enough money for patient care, Park said.

On the downside, however, the Medicare program has future commitments of $38 trillion for which it has set aside no money. That shortfall threatens to bankrupt the entire U.S. government.

“Why would we dump more money in a system that has proven it’s going bankrupt?” he said.

Dr. J.P. Gentile, anesthesiologist, Indiana Spine Group, Indianapolis

“I spent a lot of sleepless nights with this whole health care reform thing,” Gentile said. “You worry about, gosh, am I going to be able to make my mortgage payments, am I going to be able to send my kids to school, do I need to get my house ready to sell, is my income going to go down by 30-40 percent?”

Gentile, who does interventional pain management for patients with spine issues, sees some good things in the reform proposals under consideration in the U.S. House of Representatives and U.S. Senate —portability of insurance, no exclusions based on pre-existing medical conditions, incentives to use electronic medical records. But for the most part, he thinks they go in the wrong direction.

He favors giving individuals tax credits to help them buy insurance. And he favors “holding people accountable” with incentives based on health habits.

“If you’re taking care of yourself, we’re going to give you a tax deduction for it,” Gentile said. “If you’re going to smoke, you’re going to pay more for your insurance.”

But Gentile holds little hope for those things happening with the proposed government-run public plan.

“So far, every public system I’ve seen does not include any accountability for the patient,” he said. “If they don’t have skin in the game, they’re going to over-utilize the system.”

He blames over-use of the federal Medicare program for forcing that insurance program for seniors to continually cut payment rates to doctors. Three out of every four patients Gentile sees has insurance through either Medicare or Medicaid, a federal-state insurance program for the poor.

To compensate, he said, he sees a higher volume of patients.

He also fears a public plan—in order to hold down costs—would increasingly limit what procedures and tests it will pay for.

“That’s not going to win the hearts and minds of physicians,” he said.

Dr. Rick Reifenberg, family physician, HealthNet Southwest Health Center, Indianapolis

The House bill would be good for doctors like Reifenberg, who works in an inner-city clinic seeing mostly uninsured and Medicaid patients.

The bill calls for boosting Medicaid payments to doctors from current levels up to the same rates as Medicare by 2012. The various state Medicaid programs pay roughly 30 percent less than Medicare does.

The bill would also cancel a proposed 21-percent cut to doctors’ Medicare payments scheduled for January, replacing it with a system that would give doctors annual payment increases linked to inflation.

The bill would spend more money on preventive care and offer bonuses to primary care doctors who practice where there is a shortage.

On top of the health reform bills, the Medicare program has proposed steep payment cuts in 2010 for cardiologists, oncologists, radiologists and other specialists, while boosting payments to primary care doctors.

“Primary care physicians would probably do better and specialty physicians would do worse,” Reifenberg said.

That’s not to say Reifenberg loves everything about the health reform proposals.

He, too, is an advocate of a single-payer system that would provide a basic set of health benefits to every American but leave individuals free to buy extra coverage from private insurers on their own.

By creating a public plan merely to compete with—not replace—private insurers, Reifenberg thinks administrative headaches and costs for doctors will only increase.

“It just seems like the complexity is going up, not down,” he said. “When we have to comply with multiple different insurance plans, it makes things more difficult.”

Dr. Pete Sallay, managing partner, Methodist Sports Medicine/The Orthopedic Specialists, Carmel

Sallay organized an Aug. 10 meeting in Carmel, where 15 physicians unloaded their views about health care reform on Rep. Dan Burton, R-Indiana.

“Every person in the room, to a man and a woman, said they were absolutely against the idea of a public health care option,” Sallay said.

As an orthopedic surgeon, Sallay is one of the doctors being paid most handsomely under the current system. Yet he said he favors reform—particularly of the insurance industry.

“It is a big black hole, where money is getting sucked into,” Sallay said, noting recent revelations of the “over-the-top lifestyles” of executives at Philadelphia-based insurer Cigna Corp., by a former executive of the company.

“My plan would be, let people obtain insurance across state lines. Let [insurers] compete to give better pricing. Let people join a pool,” Sallay said, echoing ideas Sen. John McCain floated during the 2008 presidential campaign.

But Sallay warned that a new public plan would lead to thousands of doctors going out of business because the government would try to control costs by cutting physicians’ payment rates.

“It would cause a [physician practice] foreclosure crisis like we’ve seen in the housing market,” Sallay said. He added, “The current public health options that exist, which are Medicare, Medicaid and the VA hospital, are abysmal failures.” •



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