Good Aspects of Heath Care Reform Bill

The large health care bill has some very good elements in it that should help the average American. One is a provision that will kick in in 2011 that says all health insurers will need to spend 85% of the premium dollar on actually providing care. This means people may actually receive benefits they pay for. What a concept! Before you worry too much about WellPoint and United Health Care, remember that insurance companies make most of their billions in profit by investing your premium dollars. Spending 85% on actual health benefits still leaves them with massive profits.

Reuters reports that the insurance industry is already beginning to game the system and WellPoint has already reclassified more than half a billion dollars of administrative expenses as medical expenses. By shifting accounting practices, these corporations think they can get around the new rules.

Senator John Rockefeller says, "This new data makes clear that too many health insurance companies are still putting profits before people, and they have a lot of work to do to meet the consumer protection requirements of the health care reform law by the end of this year."

It will take a lot of surveillance to make sure health insurers actually do what the law says. It's about time that consumers are being protected.


Gray Somers said…
Dr. Brayer-

The demonization of health insurers, while politically popular, does nothing to solve our nation's health care woes. Most of our problems do not stem from corporate avarice but rather from a health care system that is systemically dysfunctional.

(Full disclosure: I ran a BCBS health plan, left in 2004 and actually signed a proposal calling for a public healthcare option in 2007. If anyone thinks the greed of private insurers is the cause of our healthcare woes then mandate only not-for-profit health insurance with strict governmental regulation of premiums and, by the way, other health care related costs including prices charged by hospitals and other integrated delivery systems, pharmaceutical companies, medical device manufacturers, physician organizations, medical malpractice insurers, etc.)

The real issue in healthcare is unsustainable cost and utilization rates. This problem is left untouched by our politicians because actual reform would be political suicide. Yes, I understand that the calculus provided by the CBO shows an actual savings over ten years for the new health care legislation. This is unrealistic and grossly misleading. (If one has doubts please look to Massachusetts to understand how a well-intentioned goal, universal health coverage, in an environment of uncontrolled health care utilization and costs has devastated the Commonwealth’s budget.)

Furthermore much of Congress’s proposed health care savings come from decreases in Medicare and Medicaid reimbursement to hospitals and physicians. What do your colleagues think of this solution? CMS pricing actions will also serve to reinforce the public’s dismal view of private insurers because the latter will need to charge higher premiums as a result of having to subsidize the losses incurred by health care providers due to reduced Medicare/Medicaid reimbursements. Welcome to the real world.

Seriously exacerbating the health care conundrum is Americans’ unwillingness to take responsibility for their health care. This extends beyond obesity, smoking, alcohol/drug abuse, non-compliance with preventative care protocols, etc. There is no or very little recognition of the actual costs of health care. With what other products/services do consumers exhibit such ignorance? I can’t think of any especially in an economic sector that comprises over 17% of our GDP.

So, what’s the solution? The answer is simple: This country needs to understand that the era of unlimited health care utilization is over. Access to quality health care is arguably a right but unlimited access is not. Yes, this actually means rationing must occur as in done in other countries with single payer and/or government mandated insurance. No one wants to talk about this but it is already done de facto and is the primary reason why private health insurers are so maligned. Additionally and undeniably there must be actual tort reform. The real cost of defensive medicine is largely ignored but objective analyses suggest that it is responsible for 10-15% of all healthcare costs. The use of evidence-based medicine algorithms must also be embraced by physicians and patients alike. If you have any doubts please see Dr. Jack Wennberg’s Dartmouth Atlas of Health Care. Finally, there needs to be much stricter regulation of bricks and mortar medical services including outpatient imaging centers, new hospital construction/additions and other extremely high cost facilities. One need only look at Canada to understand how oversupplied the U.S. is with medical services e.g. how many CT/MRI/PET scanners does the greater Toronto area have as compared to Detroit or Buffalo never mind Chicago or New York?

Real transformation in the delivery and financing of health care in the US will require that all constituents, especially consumers/patients, understand there is no bogeyman to blame. Until we all become accountable for our own contribution to this crisis there will be no real reform.
Toni Brayer, MD said…
Gray Somers: thank you for a well written and factual comment. I agree with 95% of what you said. I also believe the health insurers, as demonized by me, have little place in the new order of things. The obscene profits that go to wall street are part of the problem and there should be strict governmental regulation. I do not blame the corporate insurers. They are doing what they should do to maximize profits. Until we address the many aspects that you outlined (tort reform, rationing, patient self-responsibility, hospital and physician charges, over supplied ancillary services) the insurers need to be reined in.

Your comments are excellent.
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Toni, Like Gray Somers, I am very skeptical that the health care legislation that recently passed will move the ball downfield. It does bring coverage to 30 million uninsured, although half of these folks will be enrolled in the Medicaid system. The HCR does not address the fundamental defects in the system. Rising costs, limitless expectations of the public and inadequate reimbursement and volume of primary care physicians. We don't have enough primary care physicians now, so who will care for the 30 million new enrollees? We all saw from 'Mammogate' several months ago that even whispering about cutting back unnecessary care is politically radioactive. What seems certain is that taxes and medical costs will continue to rise. Nothing else seems certain.
DBenzil said…
While there are many problems and issues with the health care system as it is currently structured, the profits of large insurance companies and the component of premiums that goes to things other than provision of health care is obscene!
I also rue their selection of criteria for tests/surgery/etc that is not evidenced based and not transparent to their policy holders. There is no "truth in advertising" for these mega-companies.
Yes doctors and patients will have to step up and make some sacrifices but I am happy to start with BIG BUSINESS
@DBenzil: I concur. Corporations disgust me.
Mike said…
Many are so into different medical procedures nowadays. It's not bad actually as long as the doctors are really certified and legal ones. But there are cases when there are medical malpractices in some cases. Like my friend who went to a medical procedure, but unfortunately, what happened was worse so he decided to consult some injury lawyers. Ottawa has injury lawyers that will help us cope with these kind of medical malpractices.
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