Ramblings of a Clinic Administrator

Foreword: This post was inspired by a message board discussion. I'm not a big politico and don't normally dabble in this arena, but I do feel strongly about healthcare as it is my livelihood. If you're interested, go ahead and read and let me know what you think. If not, skip it.

As a manager of medical clinics, I hope that I have a good grasp on many of the issues that have been discussed on this thread. I'll admit I'm not nearly as informed as some, but I think a lot about universal healthcare and have come to the following conclusions, take them for what they're worth:

1) Things on paper look a lot better than they do in application. I like to use HIPAA as an example. It seems to make sense that you would want to protect personal health information and I believe most clinics and hospitals took reasonable steps to do so. I'll bet few people on the board know that the impetus behind HIPAA was the "portability" of healthcare insurance and had very little to do with "privacy." Thanks to the political machine, the bill was back loaded with requirements and regulations that ensured the privacy of protected health information. Good idea, right? In application, however, large healthcare groups spent millions implementing programs to conform with HIPAA while smaller, private groups struggled to meet the requirements. We are still operating under fear of an audit where a slight deviation from HIPAA requirements will result in outlandish fines. There are a lot of good ideas in HIPAA, but the cost of implementation and continued compliance, I think, was pretty much overlooked.

2) I am of the opinion that private enterprise will always be more cost conscious and efficient than large government. Healthcare is a business and profits drive efficiency. The government does not seem to believe in due diligence or cost comparisons. They rely on contractors to give them honest bids for services, but usually end up taking the lowest bid. Healthcare on the lowest common denominator is a scary proposition.

My argument is "How would you like to go to an ER that is run like a post office?" It may seem extreme, but government employees and contracted employees aren't the most efficient. I think everyone has complained about seeing a road construction crew where one guy is actually working while four others stand around holding shovels. There is no incentive to work. Their jobs are secure whether there are results or not. I don't think doctors would act this way, but support staff may. I think this is where a lot of the inefficiencies of the Canadian system come in to play. It's not that the doctors are sub par or the system itself is broken, but a demotivated government employee working as a receptionist drops the ball and someone falls through the cracks.

Then who do we sue? This may sound counterintuitive coming from a healthcare executive, but our legal system is another check that weeds out incompetence. I am a huge proponent of tort reform because it can get out of hand and malpractice premiums are scaring people away, but the fear of being sued keeps many doctors in check and helps ensure a quality of care.

3) I think another major part of the debate is whether you believe healthcare is a right or a privilege. I think if people are honestly seeking the help, it's there to be found. There is a lot of misuse, however. Too many people use the ER as their sole source for all healthcare needs. You DO NOT need to go to the ER for a runny nose. Some people wait too long to be seen while others go too frequently for every little cough or cold. I also think that our system puts too much emphasis on curing the acute before emphasizing prevention. Is this the system's fault? HMO's have been trying to steer people to PCP's who act as gatekeepers to avoid a lot of this. HMO's usually pay 100% of preventive services, annual physicals, eye exams, etc. The fact is that the people who go straight to the ER don't have a "gatekeeper" anyway. They're treated and told to follow up with their PCP and sent on their way wondering what a PCP is.

The larger issue here is that politicians give the public in general WAY TOO MUCH CREDIT. The utopian idea that persists is that everyone will jump on the bandwagon and learn to use a universal system correctly. I think it will get worse when people realize they don't have to pay for it. Most do, anyway, as the cost for treating a patient in the ER who is unable (or unwilling) to pay is subsidized by overcharging the HMO, another reason premiums continue to rise while payments to physicians and hospitals dwindle.

4) Healthcare doesn't follow the normal rules of economics, so you can't apply the same economic principles as other service industries. In fact, healthcare is backwards from any other industry. The patient has very little choice. The services are recommended rather than sought. I think some of this can be countered through health savings accounts and high deductible insurance plans. This will bring more attention to what a person actually pays for healthcare. Limiting what a doctor can charge doesn't really solve much as fees are usually contracted by your healthcare provider and Medicare sets the standards. Most contracted fees are based in some way or another on the Medicare Fee Schedule. A doctor could charge $10,000 for an office visit, but any insurance is only going to reimburse their contracted rate.

There are many more issues I could discuss. I don't pretend to have all or even any answers, but I think the practicality of a lot of these proposals gets tossed out the window. Most politicians have an extremely myopic viewpoint of issues, especially ones they see as important or use as platforms. The problems arise where the rubber meets the road.