Health-care Crisis Reconsidered

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The ‘original sin’ of the health-care crisis was the interdiction of the government and its surrogates in the insurance industry into the basic relationship between the patient and the physician.

As an oncologist in private practice, I usually read with great interest the many articles in The ASCO Post on issues regarding the politics of oncology practice. These articles deal with the major topics of the day, ranging from the high cost of oncologic care to shortages of generic drugs, to alleged solutions of these complex problems. Most of the articles are written by academics and other so-called policymaking “experts.” Most cite studies from biased groups such as the World Health Organization and the Institute of Medicine to provide the bedrock upon which their “reforms” are based. Most offer the same tired solutions of decision-making centralization and pressuring the practitioner to become a rationer of care, thereby fundamentally altering the doctor-patient relationship.

Root of the Problem

None of these policymakers ever deal with the real etiology and root cause of these problems. They cite “inappropriate incentives” for physicians to practice what is, in their opinion, appropriate care (ie, the profit motive). Most deny the existence of the sacred relationship between the practitioner and the usually anxious and often seriously ill patient and his or her family.

What has become clear to many of us who have practiced over the years is that the “original sin” of the health-care crisis was the interdiction of the government and its surrogates in the insurance industry into the basic relationship between the patient and the physician. As a result, market prices for health services and insurance have been “abolished and obscured.” This has led directly to an increase in demand for services with little connection to related costs. As in any system where this disconnect occurs (which includes most government programs), the distortion of the marketplace leads to massive increases in health-care costs, and in the case of generic drugs, shortages of the product.

In the late 1980s, we were told that the diagnosis-related group (DRG) would solve all problems of overutilization and overbilling by hospitals. Unfortunately, it perverted health-care delivery to such a degree that health care ceased to be about caring for sick people and instead forced hospitals to become hotbeds of utilization reviews and charge capture, and consequently, moving patients out as quickly as possible to “make the DRG” for reimbursement purposes. As a result of this statist utopian solution, the government was forced to pass more legislation to penalize hospitals for kicking patients out too soon—ie, a new Medicare penalty system for readmissions.

Another example is the Medicare Modernization Act (MMA), which sought to right the wrongs of the past system of chemotherapy reimbursement but has now led to shortages in generic drugs because manufactures can’t make a “profit” on these cheaper drugs with this overregulated, non–free market–based system. Recently, the utopian electronic medical record (EMR) was cited as the cause for increases in hospital reimbursement due to physician up-coding through EMR templates. This incited our Attorney General and Secretary of Health and Human Services to threaten hospitals and ultimately doctors, who in their esteemed estimations, up-code for profit.

The Real Challenge

The real challenge for the experts should be how to wrestle the complexities of care away from those who wish to centralize all decision-making and find ways to give it back to the individuals directly involved in the interaction, ie, the patient and the doctor. This is the only humane and cost-effective way to do this. Anyone with a modicum of intelligence can devise a plan that takes away individual choice and gives it to a centralized power, but the forward-thinking genius is the one who can figure out how to get it back to the individual.

Thus, I challenge ASCO to develop a committee that seeks market solutions to these difficult problems and eschews the tyranny of collectivization championed by so many policy experts in the medical community and so many powerful people in Washington, DC.

Finally, regarding the article “Delivering Affordable Cancer Care: Is It Possible and What Will It Entail?” which appeared in the November 15, 2012, issue of The ASCO Post, the “disclosure” section available online at notes that none of the individuals quoted for the piece reported a conflict of interest. I vehemently disagree with that statement. Although there may be no drug companies involved, most of these speakers are academic physicians or policymakers who stand to gain from the centralization of decision-making and the destruction of private practice oncology, which their policies must and will inevitably cause. ■

—Jonathan Schwartz, MD
Tucson, Arizona