Eliminating the six degrees of patient-physician separation

By Craig M. Wax, DO

Parties and special interests within the US federal government have been trying to passively and actively control the health and welfare of its citizens for a century. With the War Labor Board’s wage and price controls instituted in 1943 during WWII, the US federal government first warped both the employer/employee workplace and healthcare by firmly establishing health insurance as a employee “benefit” in lieu of salary. The premiums were paid with pretax dollars by a combination of the employer and employee.

This gave the employer the power to choose the coverage based on the employer’s needs and wants, not the end user employees needs and wants. This was the first degree of separation.

The insurance premium was used as a bet against the employee getting sick. Today, the insurance companies and other third parties make money by denying the healthcare payment for services, studies, tests and medications. After the insurance company processes healthcare provider claims, they make restrictive and sometimes arbitrary decisions about whether to fund the care, tests and medications. This leaves the patient on the hook for associated costs, despite the insurance premium already paid. This is the second degree of separation.

PPACA/Obamacare mandated by federal law that all US citizens purchase insurance that meets government mandates in three narrow bands of coverage, resulting in both high premiums and high deductibles; this is the worst of both worlds, costly managed care and high deductible plans. Patients are functionally removed from the ultimate healthcare decisions by government, insurance, hospital administrators, multi-state health systems, and other third parties.

These third parties also perpetrate an absurd, inflated retail “chargemaster” price structure that patients have to ask for in order to see. The actual contracted price a facility or physician receives is even more guarded and hidden from view and differs between insurers, plans, and facilities. When patients inquire to actual healthcare costs, they are either denied access to information, or are given an inflated suggested retail price. The patient is not made aware of these costs prior to healthcare service or item “purchase.” This is the third degree of separation.

Physicians and healthcare facilities who participate in insurer provider networks are forced accept insurance payment rules and all insurance mandated policies like medication prior authorizations and study precertifications. This is the fourth degree of separation.

The US federal government has a multitude of laws and programs that govern medical care, e.g., Medicare, passed in 1965, Medicaid: 1965, HIPAA: 1994, PPACA/Obamacare: 2009, and MACRA (the source of MIPS) in 2015.

PPACA/Obamacare is forcing the creation of ACOs, “accountable care organizations,” that are huge hospital health systems will benefit by spending fewer Medicare and Medicaid dollars (i.e. rationing care). Solo and small practice physicians are being forced out of business and to work for these ACOs as employees. Physicians must then, as employees, conform to all money making policies of their hospital health system. This violates patient’s trust and each individual patient’s best interest as physician is now fund gatekeeper for the hospital health system. This is the fifth degree of separation.

Due to government intervention warping healthcare markets, there is an epidemic of insurer consolidation and hospital health system consolidation. This leads to minimal consumer patient choice and higher costs, as supplier/provider competition fades into the past. This is the sixth degree of separation.

Only true charity is true charity. Medicaid and other public assistance plans are inefficient and data shows little to no benefit to patients as billions of dollars of taxpayer-funds flow into the for profit companies administering the government program. (How Medicaid Fails the Poor, Avik Roy, 2013, Encounter Broadsides). “…[Y]ou get no moral credit for forcing other people to do what you think is right. There is great joy in helping people, but no joy in doing it at gunpoint,” says Penn Gillette. We need to return to true charity from person to person, and local charity organizations to help people. Charity should be a local concept, not a federal legal mandate through HHS, CMS and IRS.

Imagine if patients could shop for care by reputation, history, location and actual price. This is freemarket medicine which includes all models of direct care including direct primary care, concierge medicine and fee for service. The patient can choose, based on his or her needs, wants, value system and priorities which care to obtain, by whom, where and when. Healthcare entities would compete on quality, reputation and price for patient loyalty and care without government, employer, insurance or other third party entanglements; zero degrees of separation.

Insurance is intended to be an inexpensive cost mitigation, or stop gap, against financial loss due to health issues. The government regulations have made all medical care more expensive with costly unfunded mandates, mandatory compliance procedures, and now redefining insurance as 3 narrow bands of prepaid managed cost discount care plans that are more expensive than ever. Government needs to be brought out of the healthcare game by patients and physicians through direct contracting. This also removes all the layers of insurance, third party and administration entities that delay, deny and ultimately raise the cost of care.

Real competitive health insurance is a good thing. True low cost high deductible plans or indemnity plans are currently not available thanks to the “affordable care act,” redefining them as not meeting the government’s arbitrary political standard of health insurance. We patients, taxpayers and physicians must all call for their return. There should be as many health insurance options as the industry can dream up to meet patients’ needs and the market will support.

Health Savings Accounts, that allow patient to save for their own health expenses before taxes are levied, must be expanded. Every individual and family should be able to establish their own health savings account to use as they see fit for all aspects of medical care payment. This would encourage fiscal consumer patient responsibility and respect for preventive healthcare.

The US federal government has a long, deep and wide history of warping markets, creating crises, and paying “good money after bad,” on programs that do not, will not and cannot work as intended (Prohibition, War on poverty, War on drugs, EHR/Meaningful Use, etc). HHS, CMS and the IRS, or any other government entity should have nothing to do with each individual’s lifestyle and medical care choices.

Patients can never be satiated when offered a so-called “free benefit,” or “entitlement.” Government “protections,” and “safety nets,” historically are proven to fail and only create more “needs,”(federal government college student loans, fed home mortgage programs, fannie mae, Freddie mac, etc). Only through their own risk taking and benefit seeking can consumer patients learn responsibility for their own actions.

We must strip away and discard the partisan politics that have utterly destroyed the patient-physician healing relationship and restore it to it’s sacrosanct status. Taxpayer independence, physician independence and patient lives depend on it.

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