Clinton’s Mis-Managed Care : Doctors Claim They Are Already Sinking Under a Sea of Red Tape. Some Insist It Will Get Even Worse Under The Proposed Health-Care Plans.

In clamoring for “health-care reform now,” the American public reminds me of the patient who comes to my office demanding to know “What’s the matter, Doc?” and “What are you going to do to cure me?” before I even have a chance to say hello.

“Just a minute!” I have to say. Mere human beings like myself (doctors are not God, you know) have to start by taking a history and doing a physical exam. Only after making a diagnosis--which they hope is the right diagnosis--should doctors reach for the prescription pad.

Sometimes doctors have to tell patients that yes, there is a medicine that will make their heart stop “skipping beats” (suppress “PVCs” or premature ventricular contractions). The only problem is, the medicine that regulates the heartbeat might also stop it altogether. The majority of patients--there’s no room to explain the exceptions here--would be better off to tolerate the aberrant beats.

In some patients with a complex history of seemingly unrelated symptoms, the most useful part of the examination might not be listening to the patient’s chest but looking in the shopping bag filled with the patient’s medicines. The first one might have been prescribed for the wrong diagnosis, the second for the side effects of the first, the third to counteract the interaction of the first two, and so on. And there might be some medicines that are causing idiosyncratic side effects.

Sometimes, one can become a real medical hero very simply: Just stop all the medicines. ( Sometimes.)

This is not the same thing as stopping all treatment and abandoning the patient. Call it a diagnostic test to determine whether the treatment is worse than the disease, or whether it really is the disease.

Many of our politicians hope to become heroes and get reelected by giving the American people a “Health Security Card.” They remind me of myself when I was an internal medicine intern at Parkland Memorial Hospital in Dallas. I saw a man who had come to the Minor Medicine section of the emergency room because he had a cold. On listening to his heart, I detected bigeminy (every other beat was a PVC). The next thing he knew, the man was on a stretcher being whisked to Major Medicine to have an electrocardiogram.

I don’t know what happened to him after that. At the time, I thought I had made a dramatic save. But 20 years later, I am sure that that patient should have stayed home. There was nothing I could do to prevent his cold from turning into “double pneumonia,” and there still isn’t. But our heart medicines could have given him something worse.

Our treatment was given with the best of intentions and the most expert advice.

The Clinton Administration tells us that its proposed Health Security Act was devised in consultation with prominent experts in the health-care field. But unlike the doctors at Parkland or any other hospital, these experts didn’t have to put their signatures on the progress notes or the prescription. In fact, the Association of American Physicians and Surgeons and others had to sue the White House to find out the names of task force members, and, a year later, the White House is still trying to prevent the public from finding out who paid how much to whom to do what. Was the plan drafted by special-interest groups (such as big insurers, nonprofit foundations, vendors of information technology, bureaucrats) who stand to profit from it?

The secrecy of the Clinton Administration’s Health Care War Room is one issue. The actual prescription is now out there for everyone to see--all 1,300-plus pages of it. It has a lot in common with most of the other “health care reform” prescriptions before the U.S. Congress. It creates cartels, empowers bureaucrats and disenfranchises both patients and doctors.

These nostrums do not even consider the possibility that the patient--the health-care system--is the victim of the legal equivalent of polypharmacy (too many drugs): too much regulation, too much management, too many subsidies and too much of the wrong kind of insurance.

What if the chief symptom--the outrageous cost of medical care--is caused by laws that we already have? In that case, the answer is not to pass 1,300 pages of new laws, but to repeal some of the old ones. It would be like stopping highly toxic drugs that are prescribed to “regulate” conditions that are best left alone.

The three proposals receiving the most attention are the Clinton Plan, managed competition, and single payer. The Clinton Plan would force all but the most fortunate citizens into government-controlled, bureaucratic health-care cartels. Managed competition, sponsored by Rep. Jim Cooper (D-Tenn.), is similar to the Clinton Plan but without price controls. The single payer is a Canadian-style government monopsony that forbids patients to pay directly for medical care. All are attempts to turn back the clock to failed systems like mercantilism and socialism, while the rest of the world (even Sweden) progresses toward privatization. Their vision is a nationalized health-care system, marching regularly in lock step under the direction of a central monolith. (The monolith, they imagine, will be under the direction of themselves and their buddies.)

People may swallow the deadly “health” potion because they have forgotten what medicine is about.

Medicine is about healing the sick and the injured. The heart of medicine is the relationship of one doctor to one patient. The patient is at the center of the universe. Not the “health-care delivery system” and its ruling bureaucracy. Patients don’t march in lock step. Every one is unique.

When I see a patient, my job is to think about how to help that patient. Not to build a brave new world, or to save the planet, or to fight the War on Drugs or the War on Poverty or the War on Crime, or to save money so that the health plan managers can have a fancier cellular phone, or to achieve a set of social priorities that may require the sacrifice of that one patient.

WHEN I APPLIED TO MEDICAL SCHOOL, I WAS A FAIRLY typical candidate. I said the right things at my interview, like all the other applicants (“I like science, and I want to help people”). I had engaged in an extracurricular activity (debate team). But most important in the early 1970s, I had good, non-inflated grades.

Medical schools are now having second thoughts. Admitting people like me was evidently a mistake. The idea is to build “a new kind of doctor for the 21st Century,” in the words of former Surgeon General C. Everett Koop, now senior scholar at the C. Everett Koop Institute at Dartmouth College in New Hampshire, but more visible recently as an unofficial member of the Clinton plan entourage. His New Doctor is portrayed as a patient-friendly family physician.

Koop would change medical school curricula to prepare New Doctors, making them, for example, computer literate. But if this idea “doesn’t catch,” he told one reporter, he is prepared to “just push it.”

The New Doctor is supposed to be full of humanitarianism and empty of greed. I do not know how to identify such a person in advance. All the aspirants that I interview for our local medical school seem to be nice, idealistic young people. Not one has ever told me that he wanted to go to medical school to get rich. (I tell them that if they want to achieve financial security in these uncertain times, they should consider another field.)

How do others, such as Dr. Koop, look into the students’ souls? They can’t do it any better than the interviewers of the last generation, who were also looking for good moral character and humanitarianism. What they can do is demean academic achievement.

Although medical school is reputedly a miserable experience, I had a wonderful time. I thought neuroanatomy and biochemistry were fascinating. I was angry at the innovators who shortened the gross anatomy curriculum to less than half a year. That wasn’t nearly enough time to learn all that I thought I needed to know.

But Koop told the New Physician magazine in December that a medical student doing “respite care and helping a family through a health problem, for example, is ever so much more important than learning certain intricacies about the anatomy of the hand that you’ll never use in your life.” But if I’m a patient with an injured hand, I want my family doctor to know all about extensor tendons. I don’t want him to miss a diagnosis. If he makes a lot of money, that’s good. I want him to be committed to medicine, not pursuing a sideline business to put bread on the table.

Patients may disagree about the type of doctor they want to see. To some, willingness to abide by government regulations and take the government fees override all else. One of my patients was furious when she found out that I was no longer willing to accept money from Medicare.

“I paid my taxes,” she said. “Now those doctors should have to take care of me.”

When asked whether her husband, a barber, should have to give $2 haircuts to all who met government eligibility standards, she said, “that’s different.” (Actually, I have treated many poor people at a price they could afford--by mutual choice.)

All patients, poor or rich, are also said to want more family physicians, just as the would-be central planners think they should. Medical students, however, are turning away from family practice and internal medicine.

There are a lot of personal reasons for preferring one specialty over another. Some choose pediatrics because they don’t like old people. Some choose internal medicine because they can’t stand screaming babies. Some choose non-patient-care specialties like radiology because they don’t much like patients. Some opt for highly paid specialties because they like the field--or because they are deeply in debt. So what should we do if not enough students choose to follow the socially desired path? Just push? (The Clinton Plan has lots of coercive provisions related to medical education: For example, some physicians who are gifted in a specialty such as orthopedics will not be allowed to qualify in their field of interest if that field already has its nationwide quota of residents. They would have to study something else.)

Koop’s New Doctor is supposed to be more “caring.” In fact, I think the New Doctor will be just as human as the old ones but will care less about certain things: He or she won’t mind being pushed around. Actually, she will have a whole different perception. What I call being “pushed around” may seem entirely normal and acceptable, and resistance or noncompliance may be called disruptive and divisive and even antisocial.

Here are some examples of managed-care and Medicare situations that are pushing Old Physicians right out of the profession:

1. Spending hours on hold waiting to talk to a clerk. Doctors have to explain why a patient needs an operation to someone who may never have heard of the procedure. That anonymous someone has the power to deny insurance coverage.

2. Being forced to work under a Medicare fee schedule devised by Harvard economist William Hsiao. He purports to know how many hours of psychotherapy equal a dislocated toe, but he is blissfully ignorant about rent, the cost of supplies and liability insurance premiums. The fee schedule is infallible--there is no appeal. (Under Medicare, doctors who “overcharge” by as little as 51 cents may have to pay fines of $2,000. The Clinton Plan and some others would extend governmental price fixing to all medical services and supplies.)

3. Having to answer threat letters from bureaucrats. Going to see a sick patient in the hospital--and billing for it--often brings an accusatory letter from Medicare, especially if a consultant also saw the patient the same day.

4. Being constantly in a fight. Doctors who happen to see many patients with potentially serious problems can choose between fighting with their conscience or with the powers that control their livelihood.

Coping agreeably in the New World will require both New Doctors and New Patients, not the kind we had at Parkland, which received a constant stream of the most “disadvantaged” patients in society--poor, unwashed, often illiterate and “low sick.” One such patient asked a highly outmoded question: “You the doctor?”

He wanted to see somebody with the responsibility and the authority to do something about his illness. Not a lady with a clipboard. Not a committee. Not a patient advocate or representative. Not a social worker. He was waiting to see the doctor.

The Parkland resident, who was no doubt very tired, fielded the question expertly by firing back another one: “You the patient?”

It has been said that “the patient is the one with the disease” (Law IV in “The House of God,” an irreverent novel by Samuel Shem). It is also written: “They that are whole have no need of the physician.” A patient and a doctor: one on one. Singular, not plural.

Some call that a “disease orientation,” as opposed to a “wellness” orientation. The focus is on the sick individual, not on society’s well-being.

Will we have a New System in which there is “universal access” to “health care” that is “delivered” by various “health-care providers,” including New Doctors and mid-level rationers? What will that mean to a patient--a sick person--who is waiting to see the doctor?

AT THE SAME TIME REFORMERS say we need universal access to health care, they complain that in the United States we have too much access to medical care, especially high-tech services for the seriously ill. This is irrational, they say.

One model for reformers is the Oregon Health Plan: a scheme for explicitly rationing medical care. A group of Oregonians labored for 20,000 hours and finally delivered a list of some 700 health services, ranked in order of social utility--the greatest good for the greatest number. The idea is for the Legislature to draw a line, based on budgetary constraints. Services above the line are covered under Medicaid, and those below the line are simply unavailable to Medicaid patients. (Medicaid patients are the experimental subjects; the idea is to later extend a similar program to all.)

The list has a wellness orientation. Near the top are preventive services (No. 141 for children and No. 74 for adults). Much farther down are certain treatments for conditions that the “preventive” services might uncover. In pediatrics, we were taught always to check for a congenitally dislocated hip. In Oregon, the social value of surgical hip reconstruction was ranked No. 552 in 1991. It has now been changed to No. 85, which is still considered less valuable than a general checkup for an adult. Treatments to improve problems caused by cerebral palsy range from Nos. 203 to 425. Not very many people have those conditions, so the societal benefit from treating them is small. Also, many treatments do not restore the patient to a normal condition, so, in the view of people who don’t suffer from the problem, treatment isn’t worth the cost.

The new “compassion” is the opposite of old-fashioned charity. Charity means that those who are better off choose to help those who are less fortunate. The new compassion means that the healthy are literally to take resources away from the sick and the disabled (through the intervention of a third party, of course).

Resources are always scarce. Therefore, there must be some method of allocating them. (Many, including Hillary Rodham Clinton, call that “rationing,” but I use the R-word to mean forcible allocations by the government, which has the power to say, “You can’t have that even though it is available and you can afford it or someone else will help you pay.”)

Today, decisions about medical care are the product of complex interactions of individuals--including patients, some of whom are so desperate that they will spend themselves into bankruptcy pursuing pain relief or a reprieve from cancer.

Patients, in the view of academic physicians and many other reformers, are not to be trusted to make decisions for themselves. As Rep. Pete Stark (D-Oakland), one of the most powerful players in the reform debate, explained to an audience of managed-care administrators, patients either consider themselves “invincible” when feeling well or they are “absolutely irrational, brain dead, sniveling, begging, and fantasizing ills and pains.” So who is to make decisions? Surely not physicians, who are all supposed to be evil and avaricious. Instead, there is to be a new class of policy-makers, decision makers, managers, medical directors, and ombudsmen. I call them wonks, bureaucrats and pooh-bahs now, but the New Doctor will have to be more respectful.

To see the result, we do not need a crystal ball. We can buy a Canadian newspaper. At times, hospitals there buy ads begging for charitable contributions so they can obtain a defibrillator (the device used to restart the heartbeat in patients who have an “acute dying spell” due to ventricular fibrillation, a complication of heart attacks). There are numerous articles about the crisis of rising costs, even as hospital wings are being closed by provincial governments and patients wait months or years for potentially lifesaving surgery. There are also plenty of examples from the U.S. side of the border. Visit the waiting room of your local VA. I used to work at one--part of my job was to certify that veterans who had waited all day didn’t really need medical treatment.

Or try to find a copy of the secret contracts signed by doctors who work for some managed-care entities. They may have promised not to say anything critical about their plan. Also, they might have agreed to take a pay cut if too many patients received too much care. The plans refer to family doctors and internists as “gatekeepers.” The idea is the same as at the county hospital, where the interns used to say, “Put a rock at the front door.”

WHEN I EMERGED FROM the bureaucratic morass at the VA and went into solo private practice, I made an astonishing discovery. When I called a consultant about a patient, he said “thank you” instead of something unprintable.

The medical community was a vibrant one. The prevailing attitude was “Yes I can.” (At the VA, it was “Oh no you can’t.”) We knew we could never defeat death or restore perfect health; the idea was to think of something that would help as much as possible.

The physicians’ purpose was easy to understand and was right out of the Hippocratic Oath: “I will prescribe regimen for the good of my patients according to my ability and my judgment and never do harm to anyone.”

Doctors could enjoy the fruits of their long years of study. They had respect. Patients appreciated them and brought in homemade jelly, pickles and tamales. As the Hippocratic Oath states, “While I continue to keep this oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men and in all times.”

Things are different now. A literal translation of the Hippocratic Oath is used in only 6% of U.S. medical schools, and a modified version in 42%. Instead, many New Doctors take oaths that emphasize their responsibility to society with its social ills and delete the inconvenient moral absolutes, such as “do no harm to anyone.”

The oath concludes with “may the reverse be my lot” (if I swerve from the Oath or violate it).

Could that be the reason why many physicians are so embittered and unhappy?

The Clinton Plan stands the Hippocratic Oath on its head by making all physicians’ judgment subject to that of the omnipotent, infallible National Health Board of non-physicians. It mandates a stiff dose of harm to many people--not just those who will be forced to pay for it, but the patients whose medical treatment will be delayed, denied or reduced in quality. It completes the process that has already started with the intimate involvement of third parties (including government and insurers and other big corporations).

No more homemade jelly. That might be construed as a bribe or gratuity. The plan will result in severe rationing; people will inevitably become desperate to, say, get their child into a hospital. But if they offer to pay additional money to the hospital or the doctor, that is a bribe, and the exchange of anything of value (I wonder if that includes respect) to influence the delivery of medical services would be a criminal offense. The penalties include five, 10, 15 years in prison. If a patient dies, a doctor who had violated one of the rules could be jailed for life. But patients are subject to jail terms also, as for offering bribes or simply for withholding information from a health alliance (that carries a five-year sentence).

Incredible as it seems, many medical associations have endorsed the Clinton Plan--at least their leaders have. Perhaps many of the profession’s leaders, deep down in their hearts, share Rep. Stark’s opinion of their patients. They think they are much smarter than the patient in medical matters, even if the patient is capable of designing a computer.

My prescription is basically this: We need to empower patients, not bureaucrats.

All patients, of course, need medical advice. Today, they can choose whether to seek advice, and from whom, and whether to take the advice. The Clinton plan will circumscribe those choices for everybody. According to Dr. Daniel Johnson Jr., speaker of the AMA House of Delegates, private practice will be destroyed by Clinton’s reforms.

The single most important element of any reform is its effect on freedom. True freedom is not the same thing as “choice”--especially if “none of the above” is not one of the lawful choices. And to exercise freedom, patients need to retain control of their money.

Patients should not be forced to spend money on compliance with current regulations that protect us against trivial risks. One rule made by the Occupational Safety and Health Administration requires a complicated paper trail for disposing of materials, such as a soiled diaper or sanitary napkin, that individuals can send to the landfill without a second thought. Paper trails require paper sentries: The hospital might not have a nurse to answer your call button, but they surely have a whole wing of administrative staff for complying with Medicare, insurance and OSHA rules. I cannot find out for sure what percentage of your hospital charges go to support this staff, but I’ve seen estimates of 25%.

Patients should also spend their money themselves rather than turning it over, in advance, to a middleman. At present, less than 25% of all medical costs are paid directly by the person receiving the service. The other 75% passes through the hands of a middleman first--an insurer or the government--and a lot of it sticks to his fingers. Big insurers today don’t want to take risks. They want to profit from managing your money.

If you put your money in the bank instead of into an insurance company, it draws interest. Also, when you write a check, the bank just pays up. When you submit a claim to an insurer or the government, you always have a delay and often a fight.

The Clintons want health alliances to control all the money.

Patients should say “no way.” They should take the amount they are now spending on premiums and put about half of it in a special savings account. With the rest, they should buy a low-cost, high-deductible “catastrophic” policy, as opposed to a prepayment plan for consumption of medical services. (Some insurance companies don’t want you to do that because it is less profitable than high-pay, low-deductible plans.)

If most people did this, I predict that medical costs would plummet, care would improve, and the economy would boom, providing productive work for the newly unemployed paper shufflers. (They could answer call buttons in truly competitive hospitals, for example.)

There is already overwhelming evidence of the superiority of privatization compared to central planning. The early results of a few experiments are highly favorable. Since 1989, a utility holding company in Richmond, Va., has offered a high-deductible, low-cost insurance plan. Employees who choose the plan, as 75% do, get to keep the money that is not used in meeting their deductibles. Medical costs have increased only 1% a year since the plan’s inception.

I’m for doing more such experiments.

How about the advocates of the Clinton Plan? Will they agree to a competitive test? Or will they insist on universal coercion to implement a universal plan? Will they really listen to the patient (American medicine) before making a diagnosis? Or will they rush the patient to the operating room, saw through the breastbone and pour ice on the heart, without even bothering to charge their defibrillator?