The national debate on health reform has uncovered innumerable “health care horror stories” in which cancer patients worry more about their bills than their malignancy or where pregnant women are laid off and dropped from their insurance soon before their due date. These stories are tragic, and unconscionable for the richest country in the world, however, as a physician, this is not my typical experience. Instead, what I see every day is patients with private health insurance who cannot afford the copays for their medications, delays in treatment as I grovel for prior authorization with a non-physician utilization reviewer, and patients stuck with huge bills for routine services that they thought they were covered for.

In my practice, patients have a mix of private and public coverage. While I work with some extremely impoverished patients who qualify for public insurance through Medicaid, it is the people with employee sponsored private insurance who are most at risk for roadblocks to care. As a primary care physician, it is hard enough to fit all of the recommended screening, health education, and chronic disease management that complex patients need into a fifteen minute visit. When the burden of battling with insurance companies is added to the equation, there is no way that I can succeed. My patients, especially the ones with private insurance, are forced to deal with the high copays, denials of claims, and delays in care.

Reflecting on the past week, a bunch of cases come to mind. While these stories may lack drama, it is nonetheless troubling to me how frequently my treatment recommendations are impeded by difficulties with health insurance. And I am sure my patients are not alone in suffering the consequences:

Ms. D, came in Wednesday. She has high blood pressure and very high cholesterol. I had not seen her in over six months, but she works a demanding job, so I figured that she had just been busy. In the office, we did not talk about her blood pressure. We did not talk about diet and exercise. She had not followed up for so long because at the prior visit I had sent her for an echocardiogram of the heart and she was billed $800 for the test. Her insurance would only cover $200. We spent the entire visit talking about how she could not afford to pay this bill. I just don’t get it. She has private health insurance. She was having symptoms that had been worsening over several visits and needed further evaluation. Now, she is receiving daily letters from a collections agency, and she is frightened to come to the doctor because of the bills that may show up in the mail.

Mr. D, a security guard with diabetes, hurt his knee while fishing and had severe pain and swelling. When I initially saw him a few weeks ago, there did not seem to be any major structural damage to the ligaments, so I recommended a conservative approach with rest, ice, and anti-inflammatory medications. Now, several weeks later, the pain and swelling had not subsided, so I ordered an MRI to evaluate for more subtle damage to the knee. After several attempts at prior authorization, the private insurance company refused to pay for the test. Baseball players get MRIs the same day for any bump or bruise, but even going through the appropriate prior authorization process, I could not order an MRI for my patient with private health insurance. I am not looking forward to all the phone calls that it will require to protest this denial of necessary diagnostic test.

On Thursday, Mr. F came in to have his blood checked. He requires blood thinners to prevent recurrence of blood clots which could be fatal. He has twice previously had clots in the blood vessels of his calves, and he once had a blood clot travel to his lungs. He has a clotting disorder that makes any break in treatment with the blood thinners extremely dangerous. Warfarin is an effective and inexpensive blood thinner, but it requires frequent monitoring because its activity is affected by numerous interactions with other medications and foods. His blood test showed that the warfarin was not doing its job, so I recommended an increased dose. It takes about three days for the dosage change to have a full effect, so I also recommended injectable blood thinners, which act more rapidly, until we could demonstrate that his warfarin had reached a therapeutic level. However, he could not afford the copay for the injectable blood thinner, so he must hope that he does not develop another blood clot as we wait for the higher dosage of warfarin to take effect.

Yesterday, I saw Ms. E for a follow up appointment. She is only in her 30s but has already had major back surgery for a disk problem. She stands for six hours a day at work and has recently had worsening of her back pain. Her spine specialist had recommended physical therapy, instead of a repeat operation, but she cannot go because her private insurance company requires a copay for every session. She has been unable to work because of the worsening pain, so she cannot afford these copays and has not been able to follow the treatment plan. I do not want her to become dependent on pain killers, but since the treatment recommended by her orthopedist is not a realistic possibility, we are running out of options.

I could fill many pages with stories like these of my patients whom are hard working, have private health insurance through an employer, but just cannot get the care that they need, because of unreliable coverage. It frustrates me that executives of health insurance companies spend millions on advertising to disparage public health insurance, and Republican politicians are stone walling meaningful health care reform because they are afraid that a public health insurance option would put private health insurance companies out of business. I do not care who provides health insurance for my patients. Whether they have public or private insurance, I just want them to get the best care possible. If private health insurance companies provide a high quality product, they will not be “forced” out of business by a public plan. It makes sense that competition between a public plan and private plans would lower costs, improve quality, and guarantee an option to those who do not have employer sponsored coverage. As a physician, I need to advocate for my patients. Private health insurance companies have thousand of lobbyists and millions of dollars to spend. So why do these companies need so many politicians, including Democrats, advocating for them as well? This is not about ideology. It’s about patients who cannot afford their medications or who face bankruptcy due to medical bills.  We need change, and this will only come with a guaranteed public health insurance option.

- Aaron Fox, MD

National Physicians Alliance

In an editorial titled, “Prognosis: Debt” Fred Hiatt of the Washington Post expresses concern over the (misleading) 1.6 trillion dollar price tag placed on health care reform, but in a way makes a compelling argument for including a public health insurance option in health reform.

He writes that President Obama (and others) have defined the major problem with our health care system as being unsustainable growth in costs, while congressional Democrats have primarily focused on expanding coverage to the uninsured:

congressional Democrats and the most involved interest groups behind them are far more passionate about universal coverage than about controlling costs. Thus Obama’s political calculation: Push for health-care reform that delivers universal coverage — and insist on as many levers to control costs going forward as possible.

He explains that this disconnect between the problem and proposed solution comes from the fact that it’s easy to expand coverage but hard to control costs. He states that proposed cost saving measures, such as focusing on prevention, shifting from specialist care to primary care, and changing provider payments from fee for service, all are unproven, and he implies that expanding coverage to include all Americans would inevitably lead to more debt. He gives several suggestions to the President on how to ensure that whatever “new burden” we take on with health care reform “is really paid for”.

As a physician, I do think universal coverage and equitability in our health care system is a “moral imperative” – I see patients without health insurance or with inadequate health insurance who have put off necessary care due to costs and suffered the consequences – but for the sake of argument, let us just talk about costs.

If we expand health insurance coverage without controlling costs, as outlined by Mr. Hiatt, we would have the equivalent of the Massachusetts plan. Their health exchange (“Commonwealth Connector Authority”) and individual mandate to purchase insurance (with subsidies for lower income individuals and families), along with Medicaid expansion and other measures, has achieved more than 97% health insurance coverage. This initially improved access to care (more individuals had a usual source of care besides the ER and a preventive care visit in the preceding 12 months), and decreased the financial burden of health care costs on some families (with fewer people spending more than 10% of their income on out of pocket costs). However, without a mechanism to control costs, there have been challenges in limiting increases in premiums and some of the gains in affordability have been lost.

This is where the public health insurance option comes in. Massachusetts does not have a true public health insurance option. The Congressional Budget Office’s $1.6 trillion estimate on the 10 year costs of the Senate Health, Education, Labor, and Pension committee’s health reform bill did not include evaluation of the public health insurance option. A proposal by the Commonwealth Fund for comprehensive health system reform including a public health insurance option, provider payment reform, and investment in public health infrastructure was estimated to have a net impact over ten years of $3 trillion in savings. While the upfront costs in expanding insurance coverage may appear daunting, as long as it is coupled with a mechanism to control costs, it will be a wise investment that improves access, quality, and slows growth in health expenditures.

And the cost savings are not just wishful thinking – lower administrative costs and the ability to negotiate lower rates from providers and pharmaceutical companies would allow a public plan to offer premiums at least 20% less than those of comparable plans in private individual or group markets. This expansion of coverage would not reduce overall health care costs, but these savings are not included in the 1.6 trillion dollar price tag for the HELP committee’s proposal. If employers or individuals previously with commercial insurance chose to buy into the public plan and its less expensive premiums, there could be significant savings overall.

A public health insurance plan would also likely reduce the costs of premiums of private health insurance through competition. 94% of health insurance markets are “highly concentrated” by FTC standards and most metro areas only have one or two options for consumers. This near monopoly is not good for costs or quality.

The effects of payment reform may be more difficult for the CBO to estimate, but a public plan would have a clear advantage over private insurers in shifting incentives toward prevention, care coordination, and evidence based medicine. Managed care was supposed achieve these goals in the private sector, but it has failed to control costs or improve quality. Medicare has begun to align payment with outcomes through pay for performance and nonpayment of care for preventable complications instead of simply reimbursing for the volume of care provided. A public plan would have the national scope to influence practice patterns across the country; a public plan would offer transparency and could be held accountable if cost or quality measures were not being reached; and a public plan would have the mission of disseminating effective payment innovations to other payers as a public good.

There are many other reasons why we need fundamental health care reform – most pressingly because it is unconscionable to deny sick patients necessary care because of inability to afford health care costs – but the realities of increasing health care expenditures do require a discussion of costs. While it is unfortunate that a misleading CBO estimate on the costs of one version of the health care bill have decreased momentum for reform, drawing on the lessons from Massachusetts, we can still use this information to promote meaningful change. Relying on the private health insurance industry to control costs would be a mistake. However, adding a public health insurance option is extremely popular, with 72% of Americans supporting a public plan in the most recent poll, and would provide several mechanisms to control costs. The American people are correct on this one, and our elected representatives better be listening.

Aaron Fox, MD
National Physicians Alliance
New York City – Local Action Network

A recent New York Times/CBS Poll found that a large majority of Americans support a government run insurance plan. Politicians not supporting a public-health insurance option, are truly out of touch with their constituents. The current draft in the senate promoting co-ops is frankly a bad idea and won’t really do anything to keep insurance companies in check, improve quality, and bring down costs. We need to demand from our congressmen and women to support a real and robust public health insurance option.  I’m not surprised by the results, we all have so many patients who are disgruntled with private insurance companies. Everyone, please call your congressmen and women and demand real reform which includes a public health insurance option and nothing less!

In Poll, Wide Support for Government-Run Health
By KEVIN SACK and MARJORIE CONNELLY

Americans favor a plan for government-run insurance to compete with private insurers, a Times/CBS poll found.