A Few More Words About Mistrust

Stanley Feld M.D.,FACP,MACE

Unfortunately, all the stakeholders mistrust one another. The facilitators stakeholders, hospitals, insurance companies, pharmaceutical companies, all seem to be trying to grab as much money out of the system as they can. The insurance companies by restricting access to care are also trying to spend as little money as they can. Physicians are trying to do the same, but are less successful. The payment they get from the government decreases yearly even though they raise their fees.

Patients, the primary stakeholders, are the only reason the healthcare system exists. Patients are in a constant state of fear. The fear of losing their insurance. The fear of losing their job. The next job might not have an insurance benefit. The fear of getting sick and being ineligible for insurance. If you are self employed and over 50 years old you might not be able to buy insurance. If they can buy insurance it will be after with after tax dollars. The government should be protecting the people from these fears. They are not.

In recent weeks, I have pointed out salaries of hospital CEOs and benefits of insurance executives. I have used recent examples reported in the press. There is no explanation offered for these high salaries. The high salaries seem to be for the profits they bring to the hospital or insurance company. They have figured out how to make the most from the rules of the system. Also, there is nothing transparent about fees or charges by hospitals, pharmacies, or physicians.

In other words, the system is not focused on how to improve patient care and quality of care while reducing the cost of care. There is no effort to increase efficiency of care and pass some of the savings to the patient.

In our consumer driven digital world, everything should be scalable, resulting in increased quality and a decrease in cost. An excellent example is the development of the PC. The computing power and quality have climbed and the cost has fallen. The same was true for the telecommunications industry.

The Medical Care System and Healthcare System can get there. I define the Medical Care System as the patient and the physician relationship. The Healthcare System is the structure that facilitates the delivery of medical care The mistrust between and among stakeholders must be eliminated from the system. The only one who can do that is the patient and the future patient. They can do it by controlling their own healthcare dollar.

I did not mention the government as a facilitator stakeholder, but it has done a few things to the consumer in the last year that has served to escalate mistrust for the government. One was raising the Medicare premium on patients who earn a certain amount of money. This is a small thing that seems very unfair after paying an escalating premium into Medicare over the last 40 years.

New York Times headline on September 11, 2006. “Medicare Costs to Increase for Wealthier Beneficiaries”. People who paid into Medicare for the last 40 years should have to pay a higher monthly premium if their earning is above a certain amount. Is the message, “Do not earn any money when you retire? If you do earn money, you will not only suffer with a tax on your social security but you will pay a higher premium for Medicare from your salary even though you are still paying into Medicare from your salary check. Is this what we signed up for? A system of disincentives has been created. Is this the American way?

We all expect Medicare to go bankrupt. The government has not done anything to fix the problem except decrease benefits. The timing of the report is strange. It was published on 9/11. We are never secure even in our retirement. The benefits we have prepaid over 40 years of labor are evaporating. Can we trust government’s promises?

Medicare Part D, the drug benefit, was supposed to help seniors pay for their drugs. It can be. If you choose the right plan in an extremely confusing and complicated system you might benefit. The prices of drugs are not transparent. Drugs are sold with multiple prices. Terms such as retail, average wholesale price, tier A, B, and C have been introduced into the system to the disadvantage of the patients and the advantage of the retail drug store and pharmaceutical industry. If we had Price Transparency and control over our money all this opacity would disappear. If you pay retail for your medication you will spend first $225 the insurance pays for very quickly with the Medicare Part D benefit.

After the first $225 you hit the donut, and you are responsible for the next $2,500. Seniors did not understand the implications of the drug plan. The patients can not afford the medication. The patients then do not take their medication. Non compliance simply leads to complications of chronic disease.

I think the government tried to do the right thing. Medicare Part D was contaminated by facilitator vested interest. This action generated more mistrust of the government.

I think Wal-Mart with it $4 fee for 30 days supply of generic medicine is going to have a revolutionary effect on drug prices, accelerate the fulfillment of the Price Transparency issue, and the drug compliance problem of the elderly. The details of the program are sparse presently. If done correctly it can be a win-win for Wal-Mart and patients. It will also serve to get other facilitator stakeholders to start thinking about how they can retain business and cater to our consumer driven society.