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Health Care Reform: Ideas of a Lowly ER Doc

Hossfeld, George MD

doi: 10.1097/01.EEM.0000365502.85381.49
You've Been Served

Dr. Hossfeld is an assistant professor of emergency medicine at the University of Illinois-Chicago. He is a past president of the Illinois College of Emergency Physicians, and has been involved in the legal side of emergency medicine for more than 25 years.



I don't know about you, but I get more fried all the time hearing those who know nothing about health care dictate to an industry deemed the finest in the world. Sure, it's an imperfect system with imperfect doctors. Funding for that system is not always fair either. The most unfair of those insurers are the current government options, otherwise known as Medicare and Medicaid. Are we really going to believe that with a third vast health care bureaucracy to manage, they will suddenly get it right? Still, there are some changes to the existing health care system that seem too obvious to ignore. I am humbly putting forth some ideas. Call them low-hanging fruit, but there is a fortune to be saved in their totality.

The insurance industry has been labeled the big villain in all this debate. Is it guilty? I don't know, but I seriously doubt the government can do it cheaper. I've never seen the government do anything cheaper and better than private industry. An easy change that we all seem to agree on is to eliminate denials of new coverage for pre-existing conditions and add insurance portability from job to job. The insurance industry is ready to make these changes. To them, it's a zero-sum game in which the costs are split between all policyholders. It is simply a decision for the rest of us to foot that bill.

Health reform without tort reform is preposterous. Despite heavy financial lobbying by trial lawyers, there are some tort reform measures that the public would overwhelmingly support if they only knew. John Q. Public would never endorse lawyers winning more on a single case than he will ever earn in a lifetime. We need limits on lawyer's contingency fees. For an industry that is so vocal about protecting the little guy's ability to recover damages, they sure don't put their money where their mouths are. The hypocrisy is incredible.



Nor does the public support making families wildly rich from the misfortunes of their loved ones. Is it really appropriate to allow families to recover damages far in excess of the reality that we all live within? Without getting into detail (it is well worth your time to Google these for a better explanation), we need to eliminate joint and several liability, be allowed to explain to a jury the presence of collateral sources of payments to plaintiffs, allow periodic payments as they are needed, and place caps on noneconomic damages (pain and suffering).

Everxyone else is guaranteed a jury of their peers. I can assure you that it is a jury of the plaintiff's peers by which doctors are tried. We need a physician review board by which to judge medical standards.

The medical community needn't be off the hook in all this. We as a profession have been negligent in our passive complicity to do everything for everybody. Physicians need to lead a national debate on providing all care to all persons from infancy to the grave. For every success story from the neonatal ICU, there are many disabled infants, some severely, and all at a huge lifetime cost to society. At the other extreme, it has been reported that America spends more on the health care of elderly persons in the last month of life than in all the preceding years together. Is that what we want? We have been negligent in not embracing hospice and making a broad commitment to inform the public regarding options of advance directives. Most citizens have clearly indicated that they do not want extraordinary means to prolong a meaningless existence when mental faculties and quality of life have ended. If I never attempt to resuscitate a demented, bedridden ghost of a person again, it will be too soon.

Good intentions have gone awry in other areas. Emergency care, as dictated by EMTALA, has provided medical care on demand by everyone at anytime for any reason. The most liberal among us must admit this is shamefully abused. We're smart enough to devise an answer to this.

The United States is the recipient of the best medical technology in the world by a long shot. That's an enormous factor of the high cost of U.S. medical care. Appliances and drugs must pass rigorous, lengthy, and expensive standards before approval. That doesn't excuse pharmaceuticals from creatively advertising their products to a public unaware of the science. Drug companies need to stop advertising their products to the general public. It is just wrong to spend more on advertising than on research and development. Do you really want to hear another patient demand “the little purple pill” for his heartburn?

Last but not least, the general public (also known as patients) must make changes. We need copays for every medical service, be it Medicare, Medicaid, or private insurance. That's because of a principle I learned long ago. The degree to which people value something is exactly what they pay for it. Subtractions from public aid checks can produce the same awareness in the indigent that this stuff is not free. We as an informed public must agree that if we choose obesity, smoking, or drug or alcohol abuse, then we will pay higher costs for our health insurance.

It costs a lot to be the best at anything. And make no mistake about it, we are the best. To trash our wildly successful national health care system would be criminal. We have the finest space program in the world, at considerable cost. We have the finest defense department, again at a greater cost than in any other country. Our existing system surely could use a few tweaks. That doesn't mean you throw the baby out with the bathwater.

Dan Caliendo, MD, of Kansas, a smart guy with great ideas, collaborated with me on this essay. I would highly recommend you joining a group of physicians that truly represent the best interests of our patients and us at

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About You've Been Served

This column is dedicated to the thousands of committed physicians and other health care professionals, who despite their best efforts, devotion, and selfless lives committed to the best patient care, wound up in the defendant's chair on a malpractice suit. At best, I hope this column has an impact on litigation reform, abandoning the unrealistic, unattainable standard of care that has been set as perfection. At a minimum, I hope to serve as a sounding board for the countless professionals who have been subjected to personal attacks by the very patients we have vowed to help. — GH

© 2009 Lippincott Williams & Wilkins, Inc.