Docs offer varied cures for ailing health care system

Indianapolis physicians are mixed on the merits of a government-run, "public" health insurance plan. How reforms

                  might affect their
pay is another major concern.

Dr. Ernest Asamoah,
endocrinologist, Community Health Network, Indianapolis

He
supports the creation of a government-run “public” insurance plan, for two reasons:
He views health care as a basic right for all people and he notes that the United States
already has several public plans.

They’re called Medicare, Medicaid,
the Children’s Health Insurance Program, the Veterans Affairs system
and other government programs—which together pay for nearly half of all U.S. health care.

“We already have some form of socialized medicine,” said Asamoah, a native of Ghana who practiced
for five years in the United Kingdom, which has government-run health care.

That being said, Asamoah favors a
fairly limited public plan. It should be structured, he said, to attract only those who can’t afford insurance—not
so employers currently offering coverage can dump their workers onto the public plan.

The Congressional Budget
Office estimated that the public plan, paying doctors roughly 15 percent less than private insurers, would attract no more
than 12 million people away from private insurers.

But the Lewin Group, which is owned by insurer UnitedHealth
Group, projected those payment rates would allow the plan to offer such attractive prices to customers that 88 million people
would join it.

“That is where I don’t want the system to go to,” he said.

He acknowledged
that doctors would probably earn less under the health reform proposals. But he’s OK with that.

“If
I have to sacrifice $10,000 of my salary, that’s OK,” Asamoah said. “I personally don’t care if it
costs me a little bit more so other people get better health care. We owe a responsibility to our fellow citizens because
we earn more than other people do.”

Dr. Heidi Dunniway,
ear, nose and throat surgeon, Otolaryngology Associates, Indianapolis

She worries that the health care
reform proposals would cost the government too much and pay doctors too little.

“For the price tag on it,
it sure has to make you wonder if that’s a good idea,” she said, noting estimates that the House reform bill would
cost $1 trillion over 10 years. Advocates of one Senate proposal say it would cost substantially less.

The House
bill now calls for the public plan to negotiate payment rates with doctors and hospitals—just as private insurers do.

But Dunniway fears that arrangement might not stick. If a public plan moved toward paying at below-market Medicate
rates, she said, many doctors would go out of business.

“There’s a big concern that reimbursement
will be driven down further and further, and you can’t sustain practices on that,” she said.

The
reform Dunniway would like to see is to have the rest of the country adopt medical malpractice laws like Indiana has.

The state caps damages from malpractice lawsuits and makes patients run their claims by a panel of doctors before
going into the court system.

That makes malpractice insurance far cheaper in Indiana, and helps doctors do less
prescribing of tests and procedures to avoid lawsuits.

“You do cover yourself at times,” Dunniway
said. “That’s one of the biggest issues that drives up health care costs.”

Dr. Rob Stone, Bloomington Hospital emergency department

Stone is a staunch
advocate of shifting America’s health care system to a single-payer system, where the federal government
would act as the health insurer for all Americans.

Since conservatives have attacked the
public plan option as a “Trojan horse” for a single-payer system, you might think Stone likes
the House bill, since it includes that language.

He doesn’t.

The bill calls for the public
plan to operate—and therefore cost—more like private insurance plans than Medicare, which
single-payer advocates essentially want to expand to cover all Americans.

“It looks to
me like the House-bill version of the public plan is a pretty emasculated version,” Stone said. “And it looks
like it might get even more cut down as it goes on through.”

Indeed, leading Senate Democrats want to scrap
the public plan in favor of regional health insurance co-operatives that the government would launch but not operate. President
Obama says he’s willing to do that—if the co-ops would truly compete with private insurers.

But many
predict the co-ops would offer much weaker competition for big health insurers, such as Indianapolis-based WellPoint Inc.,
than would a public plan.

Health reform’s other provisions—in the absence of real competition—would
be a boon to private insurers, Stone contends. It would require individuals to buy health insurance and use taxpayer funds
to subsidize those purchases.

“It’s a huge transfer of wealth from the taxpayers to the private insurance
companies and their shareholders,” Stone said.

A better way, he said, is to create a strong public plan
that pays at Medicare rates and covers nearly all the 46 million uninsured.

Doctors would lose some money because
Medicare pays about 20 percent less than private insurers, Stone said, but they would more than make it up by no longer having
uninsured patients who often pay nothing.

“It’s probably not too hard for most physicians to do the
math,” he said.

Dr. Ben Park, CEO of American Health
Network, Carmel

Even though he oversees a 200-doctor practice, Park is a primary care physician who
sees patients four days a week.

And he’d like to see health care reform shift how doctors are paid so they’re
encouraged to make patients healthy, not simply to perform a high volume of services.

“I
would start paying for what I value. And I wouldn’t pay very much for the other things,”
Park said. “I would pay for health. I would help people to quit smoking, I would help people to
start an exercise program, I would help people do healthy eating. None of those are reimbursed [right
now].”

Park echoed many—but not all—doctors in recommending that Medicare scrap its
current fee-for-service payment model. Most private insurers copy Medicare’s model, paying individual doctors only when
they perform a test or procedure on a patient.

The House bill would launch pilot programs to change that model:
bundled payments to groups of doctors for managing of specific diseases like diabetes; payments for primary care doctors to
spend time on preventive care and coordination of care, also known as “medical home” services; and payments to
integrated hospital-doctor systems called “accountable care organizations.”

In the meantime, the
Medicare program under Obama has proposed cutting payments to specialists—such as cardiologists, oncologists and radiologists—while
boosting payments to primary care doctors.

On the public plan, Park has mixed feelings.

He praised
Medicare as far more efficient than private health insurers, devoting less than 4 percent of its funding to administrative
costs.

Private insurers, by contrast, devote roughly 20 percent of their revenue to administration, sales, marketing
and profits. That doesn’t leave enough money for patient care, Park said.

On the downside, however, the
Medicare program has future commitments of $38 trillion for which it has set aside no money. That shortfall threatens to bankrupt
the entire U.S. government.

“Why would we dump more money in a system that has proven it’s going
bankrupt?” he said.

Dr. J.P. Gentile, anesthesiologist,
Indiana Spine Group, Indianapolis

“I spent a lot of sleepless nights with this whole health care
reform thing,” Gentile said. “You worry about, gosh, am I going to be able to make my mortgage
payments, am I going to be able to send my kids to school, do I need to get my house ready to sell, is
my income going to go down by 30-40 percent?”

Gentile, who does interventional pain
management for patients with spine issues, sees some good things in the reform proposals under consideration
in the U.S. House of Representatives and U.S. Senate —portability of insurance, no exclusions based on
pre-existing medical conditions, incentives to use electronic medical records. But for the most part, he thinks they go in
the wrong direction.

He favors giving individuals tax credits to help them buy insurance. And he favors “holding
people accountable” with incentives based on health habits.

“If you’re taking care of yourself,
we’re going to give you a tax deduction for it,” Gentile said. “If you’re going to smoke, you’re
going to pay more for your insurance.”

But Gentile holds little hope for those things happening with the
proposed government-run public plan.

“So far, every public system I’ve seen does not include any
accountability for the patient,” he said. “If they don’t have skin in the game, they’re going to over-utilize
the system.”

He blames over-use of the federal Medicare program for forcing that insurance program for
seniors to continually cut payment rates to doctors. Three out of every four patients Gentile sees has insurance through either
Medicare or Medicaid, a federal-state insurance program for the poor.

To compensate, he said, he sees a higher volume of patients.

He also fears a public plan—in order to hold down costs—would
increasingly limit what procedures and tests it will pay for.

“That’s not going to win the hearts
and minds of physicians,” he said.

Dr. Rick Reifenberg,
family physician, HealthNet Southwest Health Center, Indianapolis

The House bill
would be good for doctors like Reifenberg, who works in an inner-city clinic seeing mostly uninsured
and Medicaid patients.

The bill calls for boosting Medicaid payments to doctors from current
levels up to the same rates as Medicare by 2012. The various state Medicaid programs pay roughly 30 percent
less than Medicare does.

The bill would also cancel a proposed 21-percent cut to doctors’
Medicare payments scheduled for January, replacing it with a system that would give doctors annual payment increases linked
to inflation.

The bill would spend more money on preventive care and offer bonuses to primary care doctors who
practice where there is a shortage.

On top of the health reform bills, the Medicare program has proposed steep
payment cuts in 2010 for cardiologists, oncologists, radiologists and other specialists, while boosting payments to primary
care doctors.

“Primary care physicians would probably do better and specialty physicians would do worse,”
Reifenberg said.

That’s not to say Reifenberg loves everything about the health reform proposals.

He, too, is an advocate of a single-payer system that would provide a basic set of health benefits to every American
but leave individuals free to buy extra coverage from private insurers on their own.

By creating a public plan
merely to compete with—not replace—private insurers, Reifenberg thinks administrative headaches and costs for
doctors will only increase.

“It just seems like the complexity is going up, not down,” he said. “When
we have to comply with multiple different insurance plans, it makes things more difficult.”

Dr. Pete Sallay, managing partner, Methodist Sports Medicine/The Orthopedic Specialists,
Carmel

Sallay organized an Aug. 10 meeting in Carmel, where 15 physicians unloaded their views about
health care reform on Rep. Dan Burton, R-Indiana.

“Every person in the room, to a
man and a woman, said they were absolutely against the idea of a public health care option,” Sallay
said.

As an orthopedic surgeon, Sallay is one of the doctors being paid most handsomely
under the current system. Yet he said he favors reform—particularly of the insurance industry.

“It is a big black hole, where money is getting sucked into,” Sallay said, noting
recent revelations of the “over-the-top lifestyles” of executives at Philadelphia-based insurer Cigna Corp., by
a former executive of the company.

“My plan would be, let people obtain insurance across state lines. Let
[insurers] compete to give better pricing. Let people join a pool,” Sallay said, echoing ideas Sen. John McCain floated
during the 2008 presidential campaign.

But Sallay warned that a new public plan would lead to thousands of doctors
going out of business because the government would try to control costs by cutting physicians’ payment rates.

“It would cause a [physician practice] foreclosure crisis like we’ve seen in the housing market,”
Sallay said. He added, “The current public health options that exist, which are Medicare, Medicaid and the VA hospital,
are abysmal failures.” •