Health Care: Behind the Debate
Health care professionals sound off on reform
TRI-STATE — Four Tri-State health care professionals said they favor health insurance coverage for all.
James P. Hamill, president and CEO of Washington County Health System, the parent company of Washington County Hospital, said there are three key issues — keeping costs down, trying to obtain health care coverage for everyone and taking a comprehensive approach to heading off illness.
“Getting as close to universal care as we can is going to be critical,” Hamill said, noting the large number of people in America without health insurance. According to the U.S. Census Bureau, the number was more than 46 million people in 2008.
Hamill said in an e-mail that universal coverage “would eliminate or minimize cost shifting, in that hospitals today are forced to increase charges to paying patients to cover the costs of those who can’t or won’t pay.”
In West Virginia, Albert Pilkington III, president and CEO of West Virginia University Hospitals-East — which includes City Hospital in Martinsburg and Jefferson Memorial Hospital in Ranson — said there needs to be more focus on home-health services and letting people die at home, which was the norm generations ago.
“We have to change the whole way we treat end-of-life issues,” he said.
In an e-mail, Pilkington wrote, “As a Christian, I simply believe families want to take care of other family members. They simply need clinical and financial support to do so. However, the present health care discussion seems based around a socialist concept that the only people that can take care of people is the government.”
Hamill, Pilkington and two local doctors agreed that the country’s health care system needs to be fixed.
“Anybody that says we don’t need reform is fooling themselves or working for the insurance companies,” said Dr. M. Douglas Becker, a Hagerstown pediatrician.
Becker said it’s uncomfortable watching health care companies spend 15 percent to 20 percent on overhead, while Medicare, a government-run program, spends about 3 percent.
Medicare, Medicaid and Veterans Affairs programs work well, yet partisan politics are fueling a campaign against what some have termed “socialized medicine,” he said.
“Call it that, but it’s working for them and it leaves them a lot of choice,” Becker said. “If you leave it to insurance companies, the rationing is left to ability to pay, and that’s unfair.”
Dr. Stephen Kotch, chairman of Washington County Hospital’s Department of Emergency Medicine, said too many people use the emergency room for primary care.
He said there’s a shortage of primary-care doctors, who face enormous debt when they get out of school.
Meanwhile, “reimbursement from Medicare and providers has increased a lot less than their costs,” Kotch said. And that, he said, “makes primary care a lot less attractive to go into.”
“We treat the doctors like dogs,” Pilkington said. “We treat them like criminals.”
Becker said doctors make good money by working long hours and doing what others won’t do. Some insurance executives, however, get wealthy “by gouging the public for the services they need to have,” he said.
Hamill, Pilkington and Kotch said they support tort reform, which sets a limit on liability awards in medical malpractice lawsuits.
“There won’t be any meaningful health care reform without it,” Kotch said.
Several years ago, many Western Maryland physicians banded together to press the state to rein in the cost of medical malpractice insurance. They said exorbitant premiums were forcing doctors to flee to other states or leave the profession.
State lawmakers made changes, but not as many as the doctors wanted.
“Why we have to take a hit and lawyers don’t is criminal,” Pilkington said. “It creates a culture of defensive medicine,” with doctors ordering expensive tests on patients only to shield themselves from blame.
Washington County Hospital is part of a physician-hospital organization planning a clinical integration program through which more than 200 physicians would collaboratively evaluate, treat and monitor patients, and control costs.
The organization, called TriState Health Partners, was formed in 1994. It has components that focus on disease management, case management, pharmacy reviews, health coaching and other areas.
“The mind-set needs to be to improve the health of the community,” which would lower health care costs, Hamill said.
Becker said President Obama hasn’t been forceful enough in fighting for his health care vision — a contrast to President Lyndon Baines Johnson’s successful push for Medicare.
Instead, opponents are keeping the populace scared, Becker said.
Pilkington said politicians are afraid to anger senior citizens, the country’s largest voting bloc.
“I’m not an Obama fan,” he said, “but I at least have to pat the guy on the back for at least trying.”
Summit Health, which includes Chambersburg Hospital and Waynesboro Hospital in Franklin County, Pa., declined to comment, preferring to wait for “the finished reform product,” spokeswoman Jessica Walter wrote in an e-mail.
The American Hospital Association says it supports “health coverage for all, paid for by all.”
It says it is “imperative” that health care reform not happen by cutting Medicare and Medicaid payments to hospitals.
The American Medical Association says health care reform “should include a public and private mix of insurance. The private insurance market must be improved for patients and health care professionals, and the public safety net must be preserved for those in need.”
Also, “there needs to be an increased emphasis on prevention and wellness to help keep Americans healthy and, in the long-run, keep health care costs down,” the AMA says.
The American Nurses Association says “health care is a basic human right. Thus, ANA reaffirms its support for a restructured health care system that ensures universal access to a standard package of essential health care services for all citizens and residents.”
In addition, ANA says it supports “a single-payer mechanism as the most desirable option for financing a reformed health care system.”
As part of a story on possible health care reform, The Herald-Mail asked four Tri-State health professionals for their views. Later, those four people were asked to expand or explain their positions in greater detail by responding to written questions. These are their answers, which were edited slightly for style and clarity.
Dr. M. Douglas Becker
Hagerstown pediatrician
Q: You said you favor universal health care. Why?
A: I favor universal health coverage because I believe that health care is a right. In a society like ours, health care should have an equal status to justice, which is available to both citizens and aliens alike.
I do not consider it necessary to cover noncitizens. I understand that access to care has its limits, meaning that every expensive procedure may not be allowed for every patient who wants it.
Q: What would that mean to your patients?
A: Fortunately, in the state of Maryland, children (my “constituency”) have good access to care through medical assistance, CHIP (Children’s Health Insurance Program) and other existing social programs.
I see very few patients who have a complete lack of coverage. Those who do not have coverage are mainly from Mennonite families who eschew private insurance. They have some difficulty with the purchase of medications.
A universal health care system almost certainly would provide generic and brand-name medications under a better pricing policy, making those medications more extensible to families who clearly cannot afford the high-cost products.
Q: What would it mean for doctors? Would it limit the amount of money doctors could make? (private practice vs. those who work for hospitals)
A: There are about 46 million (people) without health care coverage.
Firstly, doctors would be able to give care to these families. I think it is a good thing. I believe far too much primary care medicine is done in emergency rooms and free clinics. Doctors will have to scramble to pick up these families and incorporate them into the scheme of private medicine. I believe that it can be done. I suspect there will be an increase in patient volume per physician, but no loss of income in the event that the new system has a lower rate of reimbursement.
Hospital-based physicians will likely see very little change in their volume of practice. There may be a reduction in fees for luxury medicine and extremely high-cost/low-frequency procedures. Many physicians do not like the unknown nature of this.
Q: How would tort reform that would limit malpractice liability be a benefit to doctors, hospitals and patients?
A: All doctors like tort reform — myself included. It would probably limit excessively large settlements in malpractice cases.
I see good health as a matter of luck. There is an element of luck in medical practice. It is unfortunate for both the practitioner and the patient. When dealing with human flesh, things don’t always work out, no matter how hard we try. Deliberate malpractice is rare. Human errors are relatively common. If you get all of your legal advice from TV lawyer advertisements, then ...
Q: Are patients who do not have health insurance turned away from the hospital, the emergency room ... private doctors’ offices?
A: Yes — yes — yes. Isn’t that an unfortunate state of affairs for a country that has as much money to spend as the United States? The number of patients who die annually because they lack access to care is in the tens of thousands. That should not happen!
James P. Hamill
president and CEO
Washington County Health System
Q: You said you favor universal health care. Why? Does that mean every person would have health insurance?
A: Universal coverage expects that everyone would have coverage. There could be multiple sources of that coverage, but in theory, all would be covered.
Q: What would universal health care mean to the hospital and to patients at your hospital? Would universal care save the hospital money? How? Would it help you with bad debts? How much bad debt do you write off?
A: The principal benefit of universal coverage is that it would eliminate or minimize cost shifting, in that hospitals today are forced to increase charges to paying patients to cover the costs of those who can’t or won’t pay.
In the fiscal year that ended on June 30, 2009, we had bad debt and charity care that amounted to $22.6 million. You would expect universal care would have a major impact on lowering this amount.
It is important to distinguish between health reform and health insurance reform. Lately, the debate has shifted to health insurance reform, which deals with coverage. Meaningful health reform is about creating the proper incentives for providing care. This is where the real improvements can be made, but it is a massive undertaking.
Q: You mentioned a comprehensive approach, i.e., clinical integration, as one of three important issues in the health care debate. Could you define what you mean by that? Do you want this to be part of a health care reform bill? How does it tie in?
A: One of the ways that we see of effecting change in this area is clinical integration, which we define as physicians and hospitals working in an interdependent way to produce better outcomes in the most cost-effective manner. It requires that there is the discipline to develop and implement clinical- and evidence-based guidelines for best practices, as well as working together to assure the most effective exchange of information.
Dr. Stephen Kotch
chairman
Department of Emergency Medicine,
Washington County Hospital
Q: You said you favor universal health care. Why? What would that mean to your patients?
A: I am in favor of the concept of universal health care — meaning access to health care for all people. However, this does not necessarily translate that I support the concepts of health care reform as proposed currently.
“Universal health care” would idealistically mean the majority of my patients in the ED (emergency department) would have access to primary care, subspecialty follow-up, routine well-checks and immunizations. Again, speaking only from the standpoint of emergency medicine, this would mean ED physicians could focus more on acute-care medicine.
Currently, limited access to primary care physicians, coupled with a lack of insured, leads many to utilize the ED as their primary care providers. This creates a twofold problem.
First, EDs become overwhelmed with nonacute medical problems, potentially causing delays for those in need of emergent intervention.
Secondly, this has significant financial implications in that this patient population generally requires more testing/evaluation, typically at increased cost.
Q: What would it mean for doctors? Would it limit the amount of money doctors could make? (private practice vs. those who work for hospitals)
A: I am really not sure of the financial impact on the physicians. From an ED standpoint again, volumes have been increasing over many years, while EDs are closing across the country due to financial strains.
Q: How would tort reform that would limit malpractice liability be a benefit to doctors, hospitals and patients?
A: Tort reform would, without a doubt, decrease expense incurred by physicians and physician groups. This has already been demonstrated in states with tort reform, such as Texas and Missouri. Premiums have decreased up to 40 percent. Theoretically, these savings should be passed along to consumers, i.e., patients, through decreased insurance premiums and cost of care.
Q: Are patients who do not have health insurance turned away from the hospital, the emergency room ... private doctors’ offices?
A: All patients presenting to the ED across the country are entitled to a medical screening examination to determine the presence of an acute life-threatening condition. Therefore, no patients are turned away from the ED. Private physicians often require insurance or some form of payment in advance for services. Again, this need is reflected in the rising cost of practice operations, malpractice, etc.
It certainly is a large problem, summarized with increasing costs, increasing risk, increasing volume of patients, and decreasing reimbursement from government and private sources. A solution which will lead to universal health care will need to address all of these issues. It is my opinion that this (solution) is currently not available.
Albert Pilkington III
president and CEO
West Virginia University Hospitals-East
Q: You said that you might favor some form of universal health care. Can you explain your position in more detail? Does that mean every person having health insurance?
A: Yes, I believe that everyone should have health coverage, whether it is insurance or charity of the hospitals. If everyone has health insurance without a system for the individuals’ accountability for managing the cost, then universal health care is a disaster.
Stated another way, everybody deserves health care universally, but we have to be careful because everyone will not be prudent in use of the resource.
Q: What will the proposed changes to the health care system mean to your hospitals and to patients at your hospitals?
A: No one knows what the proposed changes are, as the government is all over the place, so I can’t honestly give a good answer. We are still going to treat everybody that walks through our door, regardless of their ability to pay.
Q: Would universal care save the hospital money? How much bad debt do you write off, and for which hospitals?
A: If they eliminated our bad debt expense and charity care, it would save us millions. In 2008, we wrote off about $22 million in bad debt and charity care (that’s the total for West Virginia University Hospitals-East, which includes City Hospital in Martinsburg and Jefferson Memorial Hospital in Ranson).
Q: You listed psychiatric services and home-health services as areas that should be emphasized. How would you like to see them addressed in a health care reform bill? Compare that to how those areas are currently handled.
A: I would completely reform the payment system and focus on home health to deinstitutionalize health care service for chronically ill patients, so that patients could receive care at home without having to be “homebound.” I would create financial incentive for families that care for other family members in a home setting, as opposed to putting them in a nursing home.
Generally, I would expand home-health services to act as a support mechanism for families to be able to take care of family members in the home setting, where the cost to the overall system would be less. The goal being to reduce the amount of admissions required for patients with chronic illness, or health issues associated with the twilight of a person’s life.
In regards to psychiatric services, I would again utilize a home-health support model to assist the chronically mentally ill with a structure that supports them being able to be compliant with their medications, as well as therapy (also helping them pay for their medications) in order to avoid the need for readmission to an institution, as well as reducing their impact upon the police and EMS services when they are called upon to assist with a patient that is struggling. The goal would be to help psych be able to be more interventional when possible.
Q: You also said society needs to return to traditional Christian values in which families took care of people who were dying at home. How does that tie in to a possible health care reform bill? Is it an issue of cost, too?
A: As a Christian, I simply believe families want to take care of other family members — they simply need clinical and financial support to do so. However, the present health care discussion seems based around a socialist concept that the only people that can take care of people is the government.
A last thought from Pilkington: We don’t need “health care reform” — we need “health care payment reform.” This is (the) real purpose of the debate. You can’t do universal coverage unless you can fund it. You can’t fund it without cost chaos until you truly understand how health care is delivered. The needs and use of resources of an expectant mother are different than the needs of a cancer patient, and yet we still seem to be trying to find one payment approach for all.
Legislation is crafted on the basis of how the money will be distributed to the providers, as opposed to first developing how we are going to treat the different health care situations and then determining the payment methodology. Single-payer system, two-payer system, paying for screening test or paying for wellness — the discussion is centered around payment, not health care distribution systems.
The American Hospital Association has pledged on our behalf to accept $150 billion in cuts. The American Medical Association has voiced their support of a change in direction and all Americans are expecting some element of significant change, so the timing is right to develop a 21st-century approach that truly evaluates and modifies our system of delivery.
In every industry in America, as executives, we constantly evaluate our systems of manufacturing, service or delivery and adapt them to get the biggest bang for our buck, long before we spend any time looking at how we pay for that service. Yet, our elected officials never evaluate process, only payment. We are going to blow an opportune time for real change because of our focus on image instead of function.
The American Medical Association, the American Nurses Association, the American Hospital Association and AARP have taken stands in favor of some type of health care reform.
Following are excerpts taken from their Web sites that spell out their positions.
The Web addresses of each organization are included for those wishing additional information.
American Medical Association
AMA President Dr. J. James Rohack sent a letter dated Sept. 9 to President Obama and members of Congress urging agreement on health system reforms.
“Our elected leaders need to approach the health-reform debate with a renewed focus on what matters most — health coverage for all Americans, as well as providing stability and security for Americans that currently are insured, including Medicare patients,” Rohack said in an e-mailed release that included information from the letter.
In the letter, Rohack outlined “seven critical elements the AMA has identified as necessary to improve access to affordable, quality care and reduce unnecessary costs in the current system,” according to the release.
They are:
• Health insurance coverage for all Americans
• Insurance market reforms that expand choice of affordable coverage and eliminate denials for pre-existing conditions
• Assurance that health-care decisions will remain in the hands of patients and their physicians, not insurance companies or government officials
• Investments and incentives for quality improvement, prevention and wellness initiatives
• Repeal of the Medicare physician payment formula that would trigger steep cuts and threaten seniors’ access to care
• Implementation of medical liability reforms to reduce the cost of defensive medicine
• Streamlining and standardizing of insurance claims processing requirements to eliminate unnecessary costs and administrative burdens
American Nurses Association
The American Nurses Association’s Web site includes the following information about the organization’s stance on health care reform:
“The American Nurses Association has advocated for universal access to health care for decades, demonstrated by its early support for the Medicare and Medicaid programs in the 1960s. Its 1991 publication, Nursing’s Agenda for Health Care Reform, predated the Clinton health reform plan. ANA continues its role as a leading advocate of meaningful health care reform that ensures access to high-quality, affordable health care for all people in the United States.”
ANA’s principles of health system reform listed on the Web site include the following, and more:
• The current fragmented and costly U.S. health care system is in a state of crisis and stands as evidence of the futility of patchwork approaches to health system reform.
• Health care is a basic human right — all people are entitled to ready access to affordable, high-quality health care services. Care should not be conditioned on income, job status, health status, geographic location, race, gender, ethnicity or any other “qualifier.”
• A restructured health care system must ensure that everyone has access to a standard package of essential health care services.
• Accessible, affordable and high-quality health care will strengthen our health as individuals, and our collective society’s well-being and productivity.
• An adequate supply of registered nurses is necessary for an effective and affordable health care system. The impact of the current nursing shortage will intensify as aging baby boomers place increased demands on the system. Advanced-practice registered nurses must be utilized to expand access to high-quality primary care.
• The nation must increase its investment in community-based primary care, wellness and prevention services, as well as chronic disease management, to reduce the need for more costly and technology-driven emergency, medical and surgical treatments in hospitals.
• Reform must reduce the rate of health care cost growth in the long term. A public health insurance plan will provide a coverage option and help control costs. Ultimately, a single-payer health care system is the most desirable financing mechanism.
American Hospital Association
Following is a Sept. 10 statement by Rich Umbdenstock, president and CEO of the American Hospital Association:
“America’s hospitals applaud President Obama for his continued focus on health reform and are pleased to hear him reaffirm his commitment to expanding coverage to the millions of Americans without health insurance. Our hope is for meaningful reform, that along with expanded coverage, also allows for important delivery system changes permitting physicians and hospitals to better coordinate care and move health care in America towards a system of prevention and wellness.
“Every day, hospitals and caregivers are on the front lines in providing care to all Americans, regardless of whether they have insurance. Without health coverage, patients are less likely to receive the preventive care that could keep them well. Patients are showing up in hospital emergency rooms sicker and with more chronic conditions than ever before. That is why hospitals have stepped forward to be part of the solution.
“America’s hospitals stand ready to do our part to extend coverage to more Americans and to continually strive towards providing high-quality care for patients that is more efficient and affordable.
“We appreciate the president’s willingness to explore better alternatives to today’s medical liability system, and urge that even stronger actions be taken in this area to rein in excessive lawsuits that are currently driving physicians to practice defensive medicine and raise the cost of care for everyone. At the same time, we have concerns on how a public plan would be constructed, but are glad to see that President Obama is open to exploring other ideas that would help us achieve our shared goal of universal coverage.
“We look forward to working with Congress and the Administration to make reform a reality, and hope that a thoughtful bipartisan approach is possible that keeps true to the most important goal of improving care for patients.”
AARP
AARP, on its Web site, tells its members it favors meaningful health care reform, but notes, “To be clear: AARP has not endorsed any comprehensive health care reform bill — but we are fighting for a solution that improves health care for our members.”
And, the Web site tells its members, “We urge you to make your voice heard. Tell Congress not to let myths get in the way of fixing health care.”
AARP’s stance appears on its Web site and was included in the Sept. 1 print edition of AARP Bulletin. The statement carried the names of AARP CEO A. Barry Rand and President Jennie Chin Hansen.
“Health care is dominating the news these days — and it should. All sides agree on the diagnosis: While America’s health care system is known for research and innovation, it unfortunately costs too much, wastes too much, makes too many mistakes and gives us back too little value for our money.
“Rarely does a policy issue touch so closely to each of our lives. We hear every day from members who tell us heartbreaking stories … the 60-year-old who couldn’t afford her insurance and had to declare bankruptcy … the 80-year-old who can’t afford to fill his prescriptions … the 50-year-old breast cancer survivor crushed by health costs for her parents’ care and unable to get insurance for herself because of her pre-existing condition.
“Since health care is so personal, yet big — accounting for a sixth of our nation’s economy — the solutions are complicated and confusing. There are many difficult questions to sort through, and reasonable people disagree on the wisdom of many specific proposals. Each of us owes it to ourselves to get educated on the issue and decide about these tough choices.”
The Web site notes that AARP is fighting to make sure, among other things, that health reform will:
“Lower drug costs and strengthen Medicare. Close the Medicare Part D ‘doughnut hole,’ ensure patients’ access to their doctors, not increase co-pays, and crack down on fraud and wasteful spending.
“Protect your health care choices. Make sure you can choose your doctor, your health insurance plan and where to receive care.
“End discrimination by insurance companies. Prevent insurance companies from denying you coverage because of a pre-existing condition or using age to price Americans ages 50 to 64 out of affordable, quality health insurance.
“Guarantee stable, affordable coverage. Ensure you have the security of knowing that if you lose or change jobs, you will be able to get affordable, quality health insurance.
“The cost of doing nothing is unacceptable. Without reform, a family’s premiums for health insurance will almost double by 2016 to over $24,000.”
