This comment is by Paul Manganiello from Norwich, a physician, an emeritus professor of obstetrics and gynecology and co-medical director of the Good Neighbor Health Clinic in White River Junction.
Recently, Lee Russ wrote a comment to VTDigger. He began his comment with how to “solve a problem when you ignore all the facts about that problem. Which leads me to the undiminished catastrophe we call American health care? ”
I agree; how we provide health care in this country is a disaster without fail. But I do not want to dazzle you with data. I want to give you my perspective as a healthcare provider, but I want to warn you, as they like to say: “Providing healthcare is not rocket science; it’s more complicated !! ”
Our elected representatives have created this dysfunctional healthcare system “non-system” and otherwise with the help of organized medicine. It was in the time of President Franklin Delano Roosevelt that the decision was made to have a publicly funded health care system but instead rely on a predominantly employer-based third-party insurance system.
It did not work for everyone then, nor does it work for everyone today, and it has only gotten worse. Financing and providing health care to all is very complex; it can always be done better. We must constantly strive to improve how healthcare is provided and how it is financed. It is not either / or, but both.
We need to stop looking at this problem as binary. Not only is fee-for-service the cause of our current health care crisis, but it is certainly part of the problem. We will never be able to eliminate fee-for-service, and neither should we. There are some services, such as vaccine administration, where it is very cost effective.
But if you look at the studies that have resulted from the Dartmouth Atlas, they clearly show that there is a lot of unwarranted variation across the country in how healthcare is provided. Clearly, fee-for-service is passionate about ineffective and sometimes inappropriate healthcare consultations and potentially harmful tests and treatments. These can all contribute to not only rising costs of health care, but poor health outcomes. Fee-for-service is a contributing factor to administrative costs and not achieving “value” (better results for comparable / reduced costs) when it comes to health care delivery and how it is funded.
Take an example. While working at Dartmouth-Hitchcock Medical Center in Lebanon, I had to travel to Nashua and Manchester to offer special consultations at satellite clinics and spend hours in my car traveling up and down Interstate 89. I asked to be able to use telehealth consultations , to see more patients without having them, or me, by spending precious time, not to mention gas (not very environmentally friendly), on travel. It took a pandemic for insurance companies to realize the benefits of telehealth. The reason why they would not consider telehealth then and now, was / is over concerns about fraud.
When I worked in Dartmouth-Hitchcock, I would not think twice about ordering tests and x-rays, all legally, just to make sure I was not missing “anything” (defensive medicine), as I knew the insurance company would pick up anyway the charges; or worse, I would then find something that needed to be examined further, which may require a biopsy, which may result in a complication. I can get a patient to come in for a visit that could have been handled over the phone, but then I would not get refunded my visit that was not face to face, etc. Etc. Just multiply my experience with thousands of other healthcare providers and you can see that we have a problem here.
What is the answer to this healthcare financing / delivery crisis? Is there only one answer? No. Will single payer solve the problem? It can help, but not by itself. We can see this in other countries that have publicly funded health systems.
So what can help? This is going to take systemic changes. I know it may surprise you, but it means it will take political solutions.
There are too many groups and individuals with interests in maintaining the status quo. This is a comment so I’ll have to be brief.
To begin with, the least Vermont has to do is get a Medicaid / Medicare waiver to offer a mandatory public option. We must all be covered and you should have choices in this coverage. It is not a question of whether I will need health care, but rather when I will need health care. If the public option is competitive, employees may ask their employers to pay them higher wages and drop the employer-sponsored health insurance package at their workplace.
Perhaps we could encourage healthcare providers to phase out private practice and become employees of integrated healthcare systems and allow providers to participate in binding arbitration when negotiating wages, benefits and safety in the workplace.
Malpractice should be converted to error-free insurance, thereby compensating injured patients, while the various specialist boards must assess claims against individual providers and, if necessary, revoke their permission to practice.
We also need to move to a system where medical centers must have a global budget for a capitulated population and bundle certain services. It is the responsibility of the medical centers and providers how best to cover the cost of their services – e.g. Should we offer telehealth rather than requiring patients to travel to their providers if the care can be effectively delivered in the comfort of their home?
Is it more convenient to have teams of different health professionals, doctors, extenders of doctors and for complicated specialties possibly even social workers and pharmacists?
Training healthcare providers is expensive, and if we want students to go into underserved areas to practice medicine, we must financially encourage them to consider becoming primary care physicians, paramedics, nurses, and so on.
This crisis will not be resolved unless everyone puts their own interests aside and works for the common good. This is what it means when someone chooses to work in healthcare: It’s not just a job, it’s a profession.
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