For many years, starting in elementary school, my mother took me to an ophthamologist for an annual examination. Dr. Itzkovitz was a master in distracting a child just long enough to get a good look at his retina. By the time we arrived, after school, his part-time secretary had left for the day, and he was alone in the office. It’s hard to imagine a physician alone in his office these days. Evidently, Dr. Itzkovitz had not had classes in medical school on how to optimize his practice by hiring a bevy of assistants. He also didn’t have a staff dedicated to filing insurance claims. My mother gave him a check at end of the visit.
For the last decade, at least, Americans have debated how best to extend insurance coverage to most or all people in the country. The result has been steadily rising numbers of employees in the health insurance industry, totalling 539,800 as of April 2016. That is a lot of mouths to feed with medical dollars, but it vastly understates the total because nearly every doctor’s office and hospital has staff dedicated to insurance filings. Some significant amount of rising medical costs must be due to increased insurance. Should we see insurance coverage for regular doctor’s visits as the solution or, rather, as part of the problem?
Doctors have long advocated insurance coverage of routine visits and “wellness care” on the grounds that it would encourage people to have regular check-ups. That may have been a good idea years ago when there was widespread skepticism about the value of medicine—not without reason since only in the last century has going to a doctor improved one’s chances of survival. There are, of course, some who still refuse to get medical examinations. (Sadly, I used to know several.) These days, though, the issue is not the lack of insurance that keeps people away but a deliberate decision. Most people would be better served by canceling insurance for routine examinations and minor office treatments. What remains necessary is what my mother used to call “hospital insurance.” Today this is often called “catastrophic care insurance,” but we need insurance that will also cover so-called “elective surgery” like hip replacement. Hospital insurance is what should be mandated, if anything. It might need to be subsidized in some cases, but it is cheaper than comprehensive insurance and more people are willing to purchase it because they recognize its importance. A medical director of a major insurance provider has told me that approximately 45 percent of insurance payouts are for office visits of all sorts. Most people would gladly give up coverage for office visits in exchange for a premium reduction of 45 percent. The overall savings would be even greater because we would save the labor of the manifold people who are filing these claims, reviewing, approving them, and so forth—that is, the large network of health care “middle men.”
The insurance industry rejects this claim. Major carriers set rates for services that are often below what physicians charge the uninsured. You can see what your physician “writes off” on you bill. However, when nearly all patients carry insurance of some type, a physician’s announced rates are meaningless. If physicians could not rely on insurance companies to cover routine office visits, their prices would likely become competitive and, thus, go down. Of course, some physicians might raise their rates, and they would be able to keep them high if their services were perceived as worth the expense. Most others would compete by lowering prices.
The initial advantage to medical consumers of canceling coverage for routine visits would be proportional to the savings from reduced insurance costs. An increase in the supply of physicians would bring prices down further. We are producing too few doctors. It is not because there is any shortage of potential physicians. Plenty of qualified people apply to medical school. We need more and larger medical schools to train them. Within the past decade, the University of Georgia added a medical school to its Athens campus; it is officially a partnership with the Medical College of Georgia in Augusta. Dean Barbara Schuster did a fantastic job of setting it up, basically from scratch and—full disclosure—recruiting my wife Jaroslava Halper to its faculty. With the new medical school, our local hospitals have been become teaching hospitals with residency programs and, thereby, a significant improvement in the quality of care. According to the New England Journal of Medicine, 30 other medical schools opened between 2002 and 2014, several of them for-profit institutions. Other medical schools expanded their class size. This is still not enough. We simply cannot make medical resources more widely available if they do not exist. Insurance for all creates a demand that cannot currently be filled. Better to increase the supply of physicians to lower prices. Without insurance companies guaranteeing their income, many medical laboratories and medical equipment manufacturers would also be forced to lower prices to compete. We must regulate the supply of medical resources to ensure that there will be enough for all. Best, though, to let market forces distribute this supply. Lower costs for medical services could diminish physicians’ salaries—perhaps it will be enough to deter those who enter the profession for the money and leave those, most actually, who become doctors to help people.
The cost of becoming a physician is high. Medical school is expensive for students. The burden of debt encourages graduates to seek lucrative specialties in wealthy areas. Better, I suggest, to cover the costs of medical school in return for a commitment to practice in neighborhood clinics for four years or, perhaps, for three years for those who go on to complete a residency. (The National Health Service Corps currently grants scholarships to medical students in return for practicing in a “medically underserved community.”) The clinics would pay new physicians at the same rate as residency programs—enough to live comfortably, but below what they will earn in private practice. Low costs for physicians would allow the clinics to keep costs for patients low. Additional work in clinics is a great way to provide young physicians with experience, and they could receive it while providing a kind of national service to those unable to afford to pay doctors in private practice. During service in a clinic, they would be exempt from individual malpractice insurance premiums, and by the time they finish this service, they will be more competent and, so, likely to pay lower individual premiums when they go into private practice. Better care is the best way to diminish malpractice suits and, thereby, the malpractice insurance that adds so much to medical costs.
Rather than providing insurance, I am proposing that we provide care in the form of revitalized neighborhood clinics. Anticipating increased funding from the Affordable Care Act, neighborhood clinics expanded greatly. Our local clinics in Athens, Georgia have had to cut back because of revenue shortfalls. Although the Affordable Care Act increases payments for medicaid, it also mandates the same guaranteed insurance coverage for all. There is no reason for someone who has full insurance to go to a public clinic. Eliminate insurance for office visits, and the clinics will become attractive again. Staff them with newly minted physicians who have completed training in a medical specialty, and they will provide fine care. Again, there is no point in providing insurance for all if there are not sufficient medical resources for all to take advantage of it. What we need is a scheme to provide medical care to the poor. That is what I am proposing. In contrast, universal insurance is a scheme to pay for care, not to provide it.
Some may claim that having people with lower means go to clinics staffed by transient physicians will mean inferior care for them. I do not think this is the case. Our medical schools and residency programs do an excellent job in training physicians to utilize the latest medical advances. Recent graduates may be better in some respects than more experienced physicians. Even so, the clinics may not have the same quality of resources as physicians in private practice.
One persistent root of opposition to universal insurance is the deeply ingrained, American idea that individuals ought to bear the consequences of their own decisions. Thus, people who engage in risky behaviors, such as drug use or alcohol abuse, and people who are obese and fail to exercise put themselves in harm’s way. Universal insurance distributes the responsibility for their decisions to all and, thereby, actually encourages people to continue risky practices. The assumption made by opponents of universal insurance is that these risky behaviors are indeed matters of individual choice, whereas proponents see them as diseases. I am proposing a compromise position. Those who abuse drugs, alcohol, or food bear some responsibility for their plight, but they also deserve care. Those who lack the resources to go to private physicians could rely on lower cost public clinics. But I would not eliminate choice. Thus, even people of modest means might well decide that their conditions warrant the expense of private treatment, perhaps sacrificing other goods in the process. Others might decide to rely on low cost clinics or be forced to do so. Physicians would surely make recommendations. Ultimately, though, it would be up to individuals to make decisions for themselves, and they are often in a better position to do so than insurance companies.
Although I am proposing expanding clinics for the poor, clinic care or, more properly, group practice that includes all specialties, is a good model for all care. Take, for example, the Mayo Clinic. It assigns each incoming patient a primary physician who determines the other specialists he needs to see and appointments are arranged immediately. All the results come back to the primary physician, who is then in a position to evaluate the patient as a whole. This is important. The most frequent alternative is groups of practitioners in a single specialty. Having a group allows one physician to cover for another who is unavailable and all to share the costs of expensive equipment. Physicians in groups with a single specialty frequently refer their patients to groups in other specialties that they work with. But there is not always a primary physician who weighs all the results and coordinates care. In consequence, one specialist repeats test another has done and may prescribe medications that diminish or dangerously increase the impact of medications another specialist has prescribed. This has happened to me: a medication prescribed for my sinuses caused a problem with my prostate. This could have been prevented with more coordinated care had both specialists practiced in the same group and shared my records. Of course, having access to records does not ensure that individual practitioners will consult them for routine cases, and there is little gain for them in doing so. Such inefficiencies increase costs, but more importantly they prevent the patient from getting the best medical care.
So let us transform the way medicine is practiced. The individual practitioner and groups of single-specialty practitioners are inefficient and outmoded models. Let them be replaced with Mayo Clinic models where physicians from all specialties practice together. This holistic approach will deliver better medicine at reduced costs (though even the Mayo Clinic has recently been forced to implement aggressive cost cutting measures). Groups of physicians will be in a better position to buy the best equipment, and individual physicians who receive a fixed salary will not feel compelled to perform unnecessary tests to pay for equipment they share with other physicians. When physicians work with each other, mistakes can be corrected and malpractice suits go down. We have excellent physicians who are not giving the best possible care because of the system they are saddled with. An indication of the lower potential costs is that even though the Mayo Clinic does not charge patients substantially more than other providers, it generates enough income to support an extraordinary research program. Not every clinic can be a Mayo Clinic, but we can expect better and cheaper care from similarly organized clinics. I suspect that the current system of insurance coverage for office visits does a lot to prevent the more widespread adoption of this model. Remove it and provide tax incentives to encourage groups of physicians to amalgamate. Tax penalties, on the other hand, are inappropriate because the model is not feasible in rural areas where shortages of physicians and hospitals presents a real obstacle to adequate care.
One benefit of this kind of coordinated care would be to reduce the staff that is needed to take of insurance—for, surely, some insurance policies will continue to cover office visits—and billing. The need for large staffs has turned private practitioners into business managers. To judge from my experiences, many physicians are deeply unhappy in this role.
As I was getting ready to go college, Dr. Itzkovitz encouraged me to consider going into medicine. Although I did not take his advice, it was clear to me that he loved what he was doing. Pressed to do so much more than medicine, few physicians that I meet feel the same way about practicing today.
