Health Insurance Reform Is Not Health Care Reform

While working a shift in the ER, I overheard the news that the US government reformed health care. So I checked out some websites and perused a few newspapers, and I did notice some articles about Obama signing health insurance legislation. But if our health care system was just transformed, I missed it.

Here’s the deal. Health insurance is not health care. We have a health care problem in the United States, not just a health insurance problem. Yes, America does have a shamefully high number of citizens who don’t have insurance, and I hope this legislation will help them. But there are hundreds of millions of Americans who already have health insurance–and as they know, we still have a problem.

Our real health care problem is not a lack of insurance; it’s a lack of trust. Doctors don’t trust patients, and patients don’t trust doctors. This is why we spend about twice as much of our GDP on health care as any other country, without any notable improvement in our health. Fixing this problem requires much more fundamental change than expanding insurance coverage.

Doctors Don’t Trust Patients

In residency, one of my professors told me about an ER physician sued by a patient with a broken nose. While walking into the hospital, the patient collapsed from a heart attack. He fell forward and smashed his face. His heart had stopped beating, so the ER doctor shocked him back into life and admitted him into the hospital. I don’t think the doctor expected flowers for saving the patient’s life, but I don’t think he expected a lawsuit for damages sustained while walking into the ER–the broken nose. The story might be apocryphal, but it’s believable and it changed how I practiced medicine. Doctors can’t trust patients, even after saving their lives.

While there are plenty of lawsuits that shouldn’t happen, there are also plenty of lawsuits that should happen but don’t. Malpractice attorneys turn away a large percentage of cases, some because they don’t have merit, but some because the injury simply isn’t severe enough to be worth the attorney’s time. These injured patients deserve compensation but can’t get it. So patients, not just doctors, suffer from a broken malpractice system.

Our capricious medical malpractice system leads to defensive medicine, with doctors performing excessive testing and treatment in order to protect themselves. Think about every normal test you’ve ever had–every normal chest x-ray, every normal blood test, every normal ultrasound. If those tests hadn’t been performed, would your treatment-or more specifically, lack of treatment-be any different? While some normal test results do affect treatment decisions, in many cases they have no impact. Doctors order many tests to protect themselves in case a plaintiff’s attorney starts flipping through a patient’s chart, not for their patient’s benefit.

For doctors to trust patients, the medical malpractice system has to be reformed. It has to be a rational system, one where patients who suffered injuries due to negligence have recourse even if they can’t pay for an attorney. It has to be a system where doctors know they will be judged by experienced individuals based on the medical standard of care, not by a naïve jury swayed by a sympathetic plaintiff and a polished expert witness who’s in it for the money, not justice. It has to be a system where the majority of the award goes to the patient, not attorneys and the legal system. We do not have that system, and are nowhere closer to that system after this recent legislation.

The closest we have to malpractice reform is a caps system, in which some states cap awards for ‘pain and suffering’ to prevent headline-grabbing multimillion dollar payouts. While this helps–I would probably never practice medicine in a state without malpractice caps–it doesn’t change a fundamentally broken system.

One solution is to set up health courts, where experienced judges who understand health care get opinions from expert witnesses who aren’t selling out to the highest bidder. Doctors need to know they won’t be sued for broken noses that are beyond their control. A reliable system where doctors felt they could trust their patients would limit the billions of dollars spent on defensive medicine.

Patients Don’t Trust Doctors

You visit a doctor for a sore throat, but you’re overweight and you have high blood pressure. You know the sore throat isn’t such a big deal, and you’re hoping to get some advice, or at least some cajoling, about your overall health concerns. He spends about twenty minutes with you, most of which is focused on your sore throat. He starts to ask you about your high blood pressure, when the nurse knocks on the door to notify the doctor that all the equipment has been set up to remove the ingrown toenail of the patient next door. The doctor encourages you to get your blood pressure rechecked and rushes out the door to see the patient with the ingrown nail. He never mentions your weight. The next day, you barely remember the doctor’s name, and you’re certain he has already forgotten yours.

There’s no way you would trust this doctor. He didn’t spend any time getting to know you and your health issues. Even if the doctor did everything medically appropriate, correctly diagnosing and treating your sore throat, and advising you to recheck your blood pressure, there was still no chance for you to form a bond with the physician and develop a trusting relationship.

Speaking from experience, I guarantee you a doctor, if given a choice, would pick a friendly conversation about your longterm health instead rushing out of the room to clean the lint out between someone’s toes before hacking off their nail. So why doesn’t this happen? Not surprisingly, it boils down to money.

Physicians are paid via a complex system based on RVUs: relative value units. Researchers at Harvard, in conjunction with the American Medical Association and a few other interested parties, have assigned a numerical value called an RVU to every single task a doctor does, from anogenital exams to zygoma tumor excision. The more complicated the task, the higher the RVU and the higher the corresponding payment. For example, placing an IV has a work RVU of 1.09, lancing a boil has an RVU of 2.17, and a heart transplant operation has an RVU of 89.5.

Back to our example. The work RVU for a twenty minute visit with your doctor in his office is 0.48. The RVU for the ingrown toenail removal next door is 0.74. So the doctor gets paid around 50% more to remove a toenail than to have a discussion with you about your high blood pressure and weight issues.

The RVU system ends up encouraging procedures and discouraging conversations. It favors specialists, who tend to be procedure oriented–colonoscopies, angiograms, skin biopsies–over primary care doctors, who tend to be conversation oriented. Doctors aren’t paid to talk with you, they’re paid to do things to your body. No wonder trust in physicians has eroded over the past few decades.

The RVU system needs to be transformed, if not completely eliminated and replaced with a new model. Physician performance should be a factor in payments-if two doctors offer the same service, but one does it better, the better doctor should be paid more. Preventative counseling should be emphasized, and expensive, over-utilized procedures should be devalued. In the end, doctors need to be paid for giving patients what they want: an honest, thoughtful conversation with compassionate advice.

Fixing the Health Care System

Those are the fundamentals of health care reform. In order for doctors to trust patients, we need major tort reform–health courts, not just caps on monetary payouts. In order for patients to trust doctors, we need to pay doctors to spend time talking with people, rather than doing things to their bodies. To the tens of millions of people who will be getting health care insurance over the next few years, congratulations. Now that you’re joining the rest of us who are lucky enough to already be insured, maybe we’ll finally have the critical mass needed to tackle the real health care problems facing the country.

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