An essay regarding what’s going to happen with Universal Health Care in the United States.

By Burton A. Waisbren Sr. M.D., FACP

There is a “given” in regard to this essay.  It is that the citizens of the U.S. are demanding changes in the availability of medical care and that changes will come.  This essay will discuss the present “players” in the field of medical care.  It will give my opinions as how they will have to change their modus operondi.  The players are:

patients
physicians
hospital corporations
pharmaceutical industries
insurance companies
Medical Journals, State and National Medical Societies
academia
judicial and other branches of government
record departments of hospitals

     These changes will not come about in one fell swoop, but will be made step-wise through extensive negotiations between the players.

1. Patients

Patients will have to adapt to the fact that changes will be made.  They will have to see to it that different tiers of medical care are available.  These tiers will be tailored to the diversity of our population.  The changes will have to aggressively address one of the main problems of our medical system – its cost.
It can be assumed that a universal health care bill will eventually pass congress.  It will be similar to the Medicare program that is now in place, but it will have to have provisions for variations in care that many patients will want.  These will demand that some patients will be able to pay extra for some aspects of medical care.  Those who want care from physicians who feel that they cannot give the care that their backgrounds and training demand under the strict Medicare type contracts will be able to contract for plans that allow supplemental payment to these physicians. 
     For this to work PATIENTS MUST AGRESSIVELY DECIDE THAT THEY WILL PAY HOSPITALS ONLY FOR THEIR MEDICAL CARE WITH THE PROVISION THAT THE BILLS ARE BASED ON A FAIR MARKET PRICE.  THIS PRICE WILL INCLUDE FAIR CHARGES FOR THEIR MEDICATIONS, LABORATORY FEES AND FOR THEIR ROOMS IN THE HOSPITAL.  THEY SHOULD DEMAND THAT THEIR BILLS BE ITEMIZED. 
     This will allow them to refuse to pay expenses that hospitals incur for the building of additions, education of their house staff, research, advertising, and bloated salaries of administrators whose job it is to often aggrandize the hospitals.  It is entirely possible that as will be discussed later in this essay that the “fairness in hospital charges” will have to be adjudicated in court.  Billing guidelines in this respect will be written into the contract for supplementary care. 
     It is bad enough that patients are sick and have to come to a hospital but for them to have to contribute to research, education, hospital advertising and to the often unreasonable profit margins of the pharmaceutical bill adds “insult to injury.”
     Patient special interest groups may have to be formed in this regard.  They will see to it that they, or whoever, agree to pay for their medical care will pay fair prices for what they get.  We will discuss later in this essay how the principle of HONEST BILLING will affect other players in medical care and how they each will have to adapt to their changes.

2. Physicians

     Over 90% of the physicians in the Milwaukee metropolitan area are now employees of hospital corporations who are unfairly designated as “nonprofit”.
     Discussion with these physicians reveals that many are unhappy with their being employees of large corporations in whom profit and expansion aspirations do not always seem in sinc with aspirations of individuals who chose their professions with loftier ideas than these.
     Many physicians are unhappy in regard to the number of patients that they are expected to see, and with limitations on aspects of care that are put in place for financial reasons.  Unionization of these physicians has been tried but has not been successful. However, organized activities by interns, residents, and fellows have been successful in some spheres, and might point the way for physicians employed by hospitals to even their “playing fields”.
     Some physicians have already opted not to be involved in any type of managed care and some seem to be doing quite well along this pathway. 
     When the inevitable universal health care system is put into place, physicians will have to aggressively insist that “out of plan” coverages are provided to physicians who deliver care not covered in many plans.
     Does this mean that some patients will get better care than others?  Of course, but denying this option to some seems equally unfair.

3. Hospitals

     In the Milwaukee metropolitan area all of the surviving hospitals are owned by large corporations that are erroneously designated as nonprofit.  When and if the “TRUTH IN BILLING” suggestions made in this essay are put into place hospitals and many insurance companies will take “a big hit”.  Here the government will have to step in as will wealthy contributors.  As mentioned before it is patently unfair to have sick patients and their insurers pay for hospital expansions, advertising, often inflated corporate salaries, research, and medical educations. 
     It will take time and major reorganization of hospitals if they are forced to adopt “truth in billing”.  Not only will patients and insurance companies insist on “truth in billing” but the auditors hired by the government universal health care system will do the same.  The money saved by the universal health care program when “truth in billing” is adopted can then be used by the government to pay for needed hospital expansions, hospital educational activities that they provide and for research done in hospitals.  When these profits are added to the billions of dollars that will accrue when drug costs are brought into reason much of the cost of the universal health care plan will be met.
Admittedly, changes in hospitals that are suggested here will be controversial and
hard fought but they will be one of the prices to be paid for universal health care.

4. Pharmaceutical industries

Here again, some hard fought for changes are in order.  First, the “old saw” that huge profits are necessary for the pharmaceutical industries to be able to develop life saving drugs must be eliminated.   The truth of this matter is that the main thrust of the efforts of drug companies now is an attempt to develop “look alike and act alike” substitutes for their most profitable drugs so that they can be marketed under patents when these drugs are replaced by generics. This will allow them to continue to charge the prices that they obtained before generic development happened. 
Third parties are already adapting to the high price of drugs by insisting on the use of generic drugs.  Drug companies are countering this with look alike and act alike drugs which they announce with great fanfare.  It will be interesting to see how this all plays out under the new Universal health care system.

5.  Insurance companies

     Just as financial institutions in our country have had to change their ways due to the mortgage debacle insurance companies will have to change their modus operondi, as well.  No longer will they be able to concentrate on the “creams” of the insurance market by refusing to insure individuals with prior diseases.  I am sure that insurance companies will adapt to the new realities of their market that will emerge.  They will be helped in these changes when the “truth in billing” concept will be negotiated between them and hospital corporations.

6.  Medical Journals, State and National Medical Societies

     A too cozy relationship between the medical journals, pharmaceutical companies, government agencies and state and national medical societies will have to be carefully examined.  Details regarding the conflicts of interest between there important players are outside the realm of this essay.  When one realizes that a state medical society is the entrepreneur that profits from its sponsoring and selling the most influential medical journal in the country and that one of the lucrative businesses of this journal is to publish the official papers of the government agencies a problem of conflicts of interest is apparent.  The other conflict of interest in their endeavor is their dependence on revenue from the advertisements of the pharmaceutical industry.
     All of their questionable relationships will come under scrutiny as the universal health system becomes operative.
     Another conflict of interest that recently surfaced was an official pronouncement of a national medical organization that played into the hands of insurance companies who were refusing to pay for the treatment of chronic Lyme disease.  It took the attention of an attorney general of Connecticut to result in the medical society backing down and forming a committee to reconsider their recommendation. 

7.  Academia

 All but a few of our great universities are now suffering in regard to what they do best, teaching and research, because our present administration feels that much of their  research violates the philosophical feelings of our citizens.
This decrease in government funded academic research forces many professors to support themselves and their research by competing with doctors and clinics that provide routine medical care.  Academics have also had to survive by getting research grants that by their nature cause conflict of interest with industry.  Adjustments will have to be made by the government that will finance many aspects of medical education and basic research that is done in universities. 
At first tax payers will fume at these shifts in emphasis but eventually they will be relieved that our brilliant university scientists are let loose to make their contributions without conflicts of interests.  They will also be relieved that the burden of post graduate education of physicians will be shifted from sick patients to the general public via taxation.

8.  Judicial and other branches of government

It is not within the realm of this essay to dwell on changes in government agencies and the judiciary. They will undoubtedly be involved in the implementation of the changes that have been discussed in this essay.  As with everything else discussed herein, changes will be hard fought. What eventually happens will depend, in a great degree, on the involvement of the public and with their communication with their elected representatives.  It seems that many of the changes that will have to be made under a universal health care system will have to undergo judicial review.
           

9. Hospital Record Departments

            These departments will be important because of the enormous amount of data that are now required to be made available to many diverse parties. 
            From the physicians’ and patients’ points of view, much of these data are unnecessary.  One of the biggest problems in this regard is the present requirement of third party payees that all a physician does or orders must have written indications.  Part of this requirement is being met by many physicians by using a “boiler plate” computer program that produces a record of the type required by a third year medical student.  This tremendous output of meaningless paper would be unnecessary if the third party payee would trust the physicians in regard to what they think is necessary for the patient.  If this trust could be developed, the medical record would consist of one-half page dictation in which the physicians describe patients’ situations, medications, treatments and plans.  Details regarding operative notes, laboratory reports, and taped copies of x-ray studies can be kept, as they are now, in the archives of the departments in which they are done and can reviewed on-line as necessary.  Interested parties could ask for retrieval of these data by request to the department concerned.  The cost of doing this would be met  savings incurred in the production of a single, helpful medical record that would be available in the medical record department’s computer.
            Details regarding this much needed simplification of medical record keeping will be worked out by a task force representing the country’s medical record departments.  
            At this point, interested readers will be asking themselves, “How can the ideas in this pie in the sky essay be implemented?”  Fortunately, there is a manual available that can be used to guide the players involved with this endeavor.  It is presented in a book by Dennis Ross entitled, “Statecraft-And How to Restore America’s Standing in the World”.  Ross outlines in his book principles of negotiation and arbitration that can act as a guide for those responsible for developing a system of universal healthcare in the United States.  These principles are listed at the end of this essay.
            If the “players” discussed here will imagine themselves as entities that are trying to get their fair share of the money generated by the universal health care plan, they will find in this book a road map to follow in the negotiations and arbitrations that will be necessary to achieve their goals.  The first action of the players will be to get together experienced experts in their field in a “think tank”.  Their mission will be to come up with what they can and what they can not give up in negotiations with others concerned with universal health care.  Their conclusions will be the cornerstones used in negotiations with the other healthcare players involved.  The “think tank” participants will have to accept the fact that a time will come when they will be forced into accepting arbitration regarding some points.  Here they will have to decide in advance what they can give up and not give up in arbitration.  Then, hopefully, the players will arrive at a point that a “think tank” comprised of experts from all of the players can come up with a plan that will be acceptable to the members of legislature who will present legislation to Congress.  At that point, more negotiations will be necessary between the two houses of Congress, in which, again, all concerned will have to decide how far they can go to get the legislation passed.  For this to happen, all concerned will have to accept these facts and that the final plan will cost the players and the taxpayers money.
      Finally- It is my dream that the next president will include in his acceptance speech the following:
     “This is to share with all who are listening to this address that I have heard and accept the universal opinion of the American people that they want a Universal Health Care system.  I want to share also that this program, to be successful, will cost a lot of money that will have to be provided by increased taxes.
     Even though I am well aware that a proposal to increase taxes to provide Universal Health Care to all may well cost me the next election, in spite of that, my program will do just that, because I feel in my heart that it is in the best interest of all of us to approach Universal Health Care realistically.

Both presidential candidates have promised to implement a plan for universal health care and both have eloquently presented the case for this being done.  However neither of them have told us how they think legislation to this effect should be developed.  This is the reason for the presentation of this essay.

 

            The principles of negotiation and mediation to follow in preparing universal health care legislation are presented in Ross’ book on Statecraft:

Negotiations
1.Know what you want, know what you can live with.
2.Know everything there is to know about the decision makers on the other side.
3.Build a relationship of trust with the key decision makers
4.Keep in mind the other side’s need for an explanation
5.To gain the hardest concessions, prove you understand what is important to the other side.
6.Tough love is also required
7.Employ the good cop-bad cop approach carefully
8.Understand the value and limitations of deadlines
9.Take only calculated risks
10.Never lie, never bluff
11.Don’t paper over differences
12.Summarize agreements at the end of every meeting

Mediation
1.Identify shared objectives
2.Assess what can be negotiated, and frame the talks
3.Sensitize each side to the other’s concerns and grievances
4.Think outside the box when forging critical compromises
5.Make sure the parties demonstrate their seriousness
6.Get each side to adjust to reality
7.Set aside each side’s principles and focus on practicalities
8.Make agreements where you can
9.Act swiftly to contain crisis
10.Use anger as a tool-but use it rarely
11.Put your drafts on the table.
           
  

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