ASA December 2002 Newsletter

During my eight years in the Texas House of Representatives, I have witnessed a slow evolution of the health care issues confronted by state governments. In the early 1990s, much of the hubbub centered on the fight to mandate that certain services be covered by health maintenance organizations (HMOs). (Remember the tales of “drive-through mastectomies?”) Later, we sat dumbstruck over encounters where physicians were told they could not discuss hospitalization with patients without first consulting the insurer. Doctors pleaded for relief from hassles regarding treatment options, unfair negotiations and overzealous utilization review procedures. All the while, reimbursement rates fell behind general medical inflation. Accordingly, state legislatures responded with laws to address each of the various grievances. Insurance plans and the businesses that contracted with them cried foul, and a rift developed between the business and physician communities.

The late 1990s and the dawn of this century have seen a new wrinkle in the fabric. State budgets have expanded to cover the growing uninsured population and the higher cost of insurance for state employees. This in turn has forced governments into the position historically assumed by businesses: deciding how to cut costs (meaning reimbursement) or reduce services. It has not broken into open warfare yet, but here in Texas, we are facing tough decisions with workers’ compensation and the rising costs for state employees. A similar situation exists with Medicare payments from the federal government. Meanwhile, legislators themselves continue to side with doctors and patients.

Take a step or two back from the huffing and puffing of elected officials (yes, including me) over “patients’ rights,” and you might just notice a large piece of irony sitting in the middle of the floor: we try to use the law to fix these things, yet much of the problem has been caused by government itself.

For half a century, the federal government has, through the tax code, gently coerced businesses into offering health insurance to their employees in lieu of higher wages and salaries. By offering companies, but not individuals, tax breaks for the cost of insurance premiums, steady pressure has built up over time which almost guarantees that people do not think of buying medical coverage for themselves. Rather, we have come to see it as a right due us from our employers.

Patients use health care services without much thought to costs. Health plans must cut services and/or raise their fees. Businesses pay higher premiums rather than higher wages, but at some point, they fail to keep up and then drop coverage. This leads to more people living without insurance.

My point in all this is that we must engage patients in the discussion of costs and give them more responsibility for the tough decisions we face. As long as they see themselves as spending someone else’s money, they will treat each small effort to cut costs as a personal attack. Physicians share much of the blame here. The historical precedent of filing claims for patients further insulated patients from the misery.

If you agree with the assumption that resources are not infinite, then you must also concur that someone has to be responsible for deciding the rules of care delivery. The central question then becomes: who decides? We have been decidedly unhappy with letting insurance plans call the shots. Efforts by lawmakers or bureaucrats have been derided as rationing (Oregon’s Medicaid debacle). Employers do not want to get in the middle of all these fights; they are just trying to get their widgets out the door and into stores.

I believe the only viable solution will require that patients decide how much and what kind of health care they will receive — and pay for. To do that, we must change tax codes and other laws to give patients more responsibility to go along with their rights. A darn good start would be to repeal the mandates for coverage of services ordered by various states. We have some 70-odd such mandates in Texas. With repeal, we must substitute clearer language in policies so that people know what their insurance plans cover. Those plans that promise “all the health care you deserve,” as one famously did in Texas some while back, had better be prepared to pay for just that.

To get patients to confront the reality of costs, I would like to see states allow their employees to place money in medical savings accounts, flexible spending accounts or other vehicles to encourage savings while discouraging the use-it-or-lose-it approach to insurance. This summer, the U.S. Treasury Department gave its blessing to certain accounts (called Healthcare Reimbursement Accounts) that let patients accumulate funds from year to year rather than losing what they did not spend by the end of the year. This could be the stimulus that gets employees engaged in making their own health-care-spending decisions. The gradual accumulation of funds to pay for deductibles, co-payments or uncovered services will put power back in the hands of patients and their doctors. Along with these accounts, we can still have true insurance that covers expenses if they exceed the amounts available in the account — basically, a high-deductible catastrophic policy.

Importantly, this will allow patients to assume greater control and responsibility for their medical decisions. It will help to get employers out of the health care business and back to their main focus. Since these accounts are portable, they will let employees seek new, better jobs without worrying about insurance coverage in the interim.

Now some will question the ability of patients to make rational health care decisions. After all, this business is extremely complicated, is it not? Actually, we must not forget the most important allies patients have: their doctors. Far from being left to sort out their illnesses and treatment options using the Internet, this will foster closer discussions and a strengthening of the doctor-patient relationship. It may even mean we start to use plain language with our patients.

I will close with an anecdote that demonstrates what can happen when we put patients in charge. Some years ago, a long-time friend called to ask me what a labor epidural would cost as his wife neared full-term. I told him it probably would be worked out between the plan and the anesthesiologist. He surprised me by telling me his insurance did not cover expected expenses of delivery; rather it would only cover any costs incurred if his wife or baby had complications. This was especially surprising since my friend sells insurance. Sure enough, he had saved the extra premium for several years and held it in escrow. When it came time to start a family, he paid cash to the obstetrician, the hospital and the anesthesiologist — and he negotiated discounts since he was paying for the services before they were given. No waiting for the HMO to pay, no hours spent on hold waiting for a clerk to approve a procedure. Now that’s power.

Dual Position Players: For Some, Giving to ASAPAC Just Isn’t Enough

ASA wishes to acknowledge the following anesthesiologists for their selfless work in both the medical and political realms. Each is a respected physician in his home city and state, yet each has answered a call to do more. Because of their tireless and selfless dedication to improving the lives of their patients through medicine and through politics, ASA is proud to recognize the following:

Andrew P. Harris, M.D. (R), a Maryland State Senator, has represented Baltimore County as the only physician in Maryland’s Senate for the last four years and will be doing so for four more, having won re-election as State Senator. Dr. Harris was elected Maryland Senate Minority Whip.

Tom M. George, M.D. (R), an anesthesiologist from Kalamazoo, was elected to the Michigan State Senate. Aside from his duties as a physician and state representative, Dr. George served as a volunteer physician in ASA’s Overseas Teaching Program in Tanzania in 1998.

Kyle L. Janek, M.D. (R), won election to the Texas Senate and remains the lone practicing physician in Texas Legislature. He is a partner with Greater Houston Anesthesiology.

Sam L. Page, M.D. (D), was elected to the Missouri State House of Representatives. Dr. Page practices in St. Louis and will represent the 82nd District in Missouri.

Greg H. Lind, M.D. (I), ran a strong yet unsuccessful campaign as an independent for the Montana State House of Representatives.

Kyle L. Janek, M.D., is a Staff Anesthesiologist with Greater Houston Anesthesiology, Memorial-Hermann Hospital Southwest, Houston, Texas. A Texas state legislator for eight years, he was elected in November 2002 to the Texas Senate.

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