A retired surgeon's perception of health care

(As a vascular surgeon who reluctantly elected early retirement a few years ago I have some thoughts about the current "health care" debate. During a 45 year career I experienced academic, military, and civilian practice, and enjoyed each. But in recent years, for me, the burdens of civilian practice came to exceed the pleasure. I mention this only as background to my perceptions of the current discussion.)

The health care debate—some perceptions from a retired surgeon
Benjamin F. Gibbs, M.D.

Some politicians and insurers want to convince us that everyone needs coverage for all health costs. But do we? For routine dental and medical care the premiums probably exceed the benefit. Do we buy insurance to pay for groceries, gas for the car, heat for the house, plumbing emergencies, or any other day to day expense of living?

Now if you want to buy insurance for these things, fine. Maybe you feel better with the idea of total security against all the contingencies of life. But should taxpayers have to foot the bill?

For most of us, we buy insurance to meet unexpected catastrophes. For auto and homeowner policies we choose high deductible amounts to lower premiums. Why is health insurance different?

It is easy to understand the need for catastrophic coverage. Maybe the law should require it. For some at least, perhaps government should provide it. Reasonable people can differ on their solutions.

Unexpected medical catastrophes do occur. If we rely on insurance, when there is no coverage, everyone pays. So let's consider the insurance option. Catastrophic coverage, say with a $2,000-$20,000 deductible, is within the means of most Americans (especially if that coverage is integrated with tax-favored health savings accounts). How much did you pay for your last TV or car?


What about poor people? Is it proper for citizens to provide a safety net for the poor, whether their poverty is temporary or chronic? I think so. We are a compassionate country that cannot idly observe starvation, homelessness, or treatable illness. Best if private charity addresses these needs through individual generosity, but there may be occasions when taxpayer involvement is justified. When we resort to taxation, however, we must assure that our programs 1) effectively address the problem and 2) don't perpetuate the need.
With regard to current ideas floating around congress I'm not sure either of these criteria are met. Is there a better way for the poor than providing "insurance"? I believe there is.

When I was in Med School, Medicare was in its infancy, and employer-provided insurance coverage was not widespread. Instead, we had a system of tax-subsidized county or charity hospitals that were often part of medical school teaching programs. Care at these facilities for patients was inexpensive, and for the indigent, often free. The trade-off was that care was often given by doctors in training. Generations of medical students, interns, and specialty residents learned medicine and surgery in these places, under the supervision of university professors or established physicians who volunteered their time and expertise. Care was excellent, and not limited to poor people. The system worked well both for patients and for physicians in training. Everyone benefited. Unfortunately, it became politically incorrect to have "charity" programs separating the rich and poor. Legislation of third-party payment systems evolved, diminishing the need for charity hospitals. Ultimately this led to the huge escalation of costs we now see. Worse, patients, medical trainees, and society lost.

I wonder if we should return to a "charity hospital" concept. Rather than buying insurance, tax dollars might better be spent in direct subsidies to hospitals and salaries for providers who treat the poor and others. Trainees could do much of the routine work under professional supervision, volunteer or paid. Retired physicians could contribute their skills. Our military hospitals and large clinics such as Mayo, which pay salaries rather than fee for service, and which provide excellent care and teaching, might be models for how providers are paid.

If we want government to provide health care "insurance" for everyone, it is catastrophic care that we should be talking about. "First-dollar" coverage is simply not affordable. It leads to over utilization, loss of responsibility, and sometimes lack of choice. If you make the same effort in selecting your health care as you do in selecting your groceries, it is likely to be better. You might even take some common-sense preventive measures such as exercise and avoiding tobacco and obesity. When politicians include the word "prevention" in their rhetoric, I'm never sure what else they're talking about. I don't think they mean vaccination of our children against smallpox and polio about which there is little argument.

Long term control of costs and preservation of excellence requires an element of individual responsibility in making choices. Interfere with free markets and costs rise as quality declines. We are seeing this. Everyone knows that costs are excessive. Less well understood is that satisfaction within the medical profession has declined. Applications to medical schools are way down. Surgical training programs go unfilled. Many established doctors are retiring early. Others are refusing Medicare. So quality declines.

Medicare reimbursements have declined to 20 to 50 cents on the dollar for some common medical and surgical procedures, with no end of the decline in sight. Some private insurance is equally egregious in denying or severely discounting legitimate claims. Physicians face increasing burdens from third-party overseers who question their judgment, deny tests, etc., to save money (I wonder what they pay these people?). Paperwork required for payment has become unbelievable, and would not be tolerated in any other industry.

After the time and energy invested in their education, doctors naturally resent the oversight of untrained people who make judgments as to how they should practice and what their fees should be. Physicians are forced to embellish consults with boilerplate verbiage to satisfy marginally educated reviewers that charges are justified. In the case of Medicare, there are $10,000 fines for each coding “error”. I'm not kidding. It has gotten to the point where the medical record is more sacred than the patient.

Decreasing compensation. $10,000 fines for coding mistakes. Arbitrary oversight. All these might be sufficient to discourage a medical career. Now add a legal system that can sue without restraint for any unforeseen unhappy outcome, resulting in huge malpractice insurance premiums, the need to order expensive "defensive" tests that add nothing to good care, and high personal and emotional costs for legal defense even when, as happens 80 percent of the time, the doctor is exonerated from any misdeed. Is it any wonder that fewer bright students choose medicine as a career, or that established doctors are leaving the profession in droves?

We've already mentioned compassion and the need to take care of the poor. I understand that the poor are reluctant to seek certain kinds of non-emergent care because they fear the cost. But when they show up in the E.R. with appendicitis, imminent pregnancy, or a gunshot wound, they are taken care of. It's not only the law, it is part of the compassion and ethics of the medical profession. We understand that caring for patients is a privilege that brings rewards beyond money. Every day, when unfunded patients show up with emergencies, doctors and hospitals give free care. What do they get in return? Satisfaction from doing their job. This point is often forgotten in rhetoric promoting government care. Most doctors by their nature are charitable.

But charity, in a free society, is voluntary, not something that can be conferred by a third party as a “right”. Government, alone, produces nothing of value. When it promises a service or product and then, to save money, demeans the value of the time, skill, and work of those who provide it, it is not charity, but coercion. Under such circumstances self respect leaves little choice but to vote with one’s feet. That's why doctors are leaving the profession.

Are there answers? Can the trend toward higher cost and less quality be reversed? Perhaps.
But first, we need a dialogue that is less politically polarized. Demagoguery and the desire for political power does not solve problems in the long run.

Here is a summary of ideas we have considered: 1) budgeting routine care as a normal expense of living; 2) encouraging the use of tax favored medical savings accounts to help in the budgeting and encourage responsibility; 3) universal low cost catastrophic insurance for unexpected high-cost events; 4) charity or tax-subsidized institutions to provide for the poor; 5) some restraint upon the legal profession to minimize unjustified lawsuits. To these, I would add another: 6) make licensure easily transferable state to state and less costly so that retired doctors like me can affordably work part time or volunteer for charity work.

I am sure that there are other good ideas out there. Now, let's be honest about what does not work well in the long term:

Assume that for his next vote-getting exercise, a politician decides that automobiles are too expensive for senior citizens, so the taxpayers must provide them. In five years, with ownership of a Ford or Chevy established as a “right”, what will cars cost? In ten years, when taxpayers revolt and demand that automakers lower their price, what happens to quality? In twenty years, with ever declining profits created by government interference, do the companies stay in business? There are parallels here to the current state of medicine.

Food, transportation, health care. All are needs. As citizens of a benevolent society, shouldn’t we ask our politicians to require MacDonald's to provide free hamburgers whenever we are hungry?