A Physician’s Prescription to Drive Down Healthcare Costs

by Dr Michael Rushnak
America is NOW at the point of no return. Our current health care cost trend is unsustainable IF we want to maintain our current standard of living, IF we want to invest in education, infrastructure, and national defense, IF we don’t want a major devaluation of our dollar due to defaulting on our national debt, and IF we want to continue Social Security, Medicare, and Medicaid. Does this sound scary? It is!! But, YOU can prevent the looming HC catastrophe!
Based on my 35 years as a physician working in the private practice of medicine as well as serving in senior positions in my home state Department of Health in government, in a non-profit major managed care company, in a national pharmacy benefit management company, and in a biotech company making disease prevention products, I believe that I’ve seen it all. In addition to these diverse experiences, I am Board Certified in Internal Medicine and Gastroenterology and have earned a Masters degree in Public Health. Lastly, I also know all too well what it feels like to be a patient in our healthcare “system,” —blessed by God and my fortunate access to healthcare to be a 7 year survivor of a serious cancer. Thus, I believe I have the appropriate credentials to write a prescription. YOU will need to decide whether to take the medicine. The ball is it YOUR court. Truly, I believe if WE as individuals making up our country don’t make some hard decisions real soon, we will have passed the point of no return!
Before I begin, let me state that my prescription will not make everyone happy. That’s NOT my intent. My thoughts are meant to get us back on the right track so we can afford universal healthcare—to reduce unnecessary costs—to save America from being another great power that fell from its lofty position! And, I am using my first amendment rights of free speech to offer my opinion on healthcare industries but I will never talk about specific companies or any particular individuals.
Of the $2.5 TRILLION, we will spend on healthcare this year; there are indispensable costs that cannot and should not be reduced. We must fairly pay for doctors, nurses, hospitals, prescription drugs, nursing home care and home health, as well as dentistry and many other essential healthcare services and technological products. At this time, I offer a point of order. Always remember that for every dollar of cost that we spend, this HC dollar is money which is either a dollar of income for someone in the “healthcare-industrial complex” or a dollar to pay for a technological test, procedure, or medication. MILLIONS of Americans made an honest living working in the health care field providing care to patients, building hospitals and doctor office buildings, researching compounds and protein molecules to develop new medicines to treat diseases and then manufacturing and distributing these products, and so on and so forth. So, what are the solutions to OUR problem?
Before we get to action steps, let’s first ask some critical QUESTIONS: Are we getting VALUE from each dollar spent? Do we want to spend more than 17% of GDP on healthcare and probably not have enough money for other worthwhile values like investments in national defense and education? And most, importantly, is there a plan to REDUCE unnecessary costs while getting more value of each HC dollar to cover everyone in a new and necessary paradigm of HC?
My prescription is a plan to get more for less. I take no credit for all the thinking that has already been done on this subject and in part I am just summarizing “Best Practices” based upon what I believe to maximize VALUE while ignoring whether this prescriptive medicine is popular or not. Let me initially say that there have been studies demonstrating that between 30-50% of our healthcare costs can be lumped into buckets of waste, fraud, and abuse. And, let’s not forget a simple idea that our grandparents taught us – a truism that has been forgotten by many: “An ounce of prevention is worth a pound of cure.” Based on this singular point, we need to change the mindset of Americans and our current HC “system” from a “sickness” model to a “wellness” model. Of course, we can never prevent all diseases but we CAN reduce the number of Americans who develop specific diseases that could have been prevented through personal behavior modification in collaboration with a functional HC system. In addition, some of these diseases could have been diagnosed at an earlier stage through appropriate use of prevention. One of the reasons we are spending more much money than any other country is that the United States ranks dead last among industrialized countries in prevention and diseases first diagnose at a late stage costs much more.
Let’s be mindful that I’m certainly NOT suggesting that we move away from our capitalistic system. And, let me be clear that there is plenty of blame to go around! On the other hand, rapacious capitalism where greedy people use unscrupulous means to achieve the ends of excessive profits and power should be condemned. Leaders need to speak out against greed. GREED IS NOT GOOD! Now, for purposes of organizing my thinking, I would like to group the involved stakeholders into the special interest camp, the provider of care crowd, and lastly, all of us, as consumers and customers of healthcare.
First of all, who are these special interests? I believe this camp includes people who are essentially well meaning but whose industries, intended to serve the general good in healthcare, have gone off track. Recall the aphorism, “The path to hell is paved with good intentions.” And in going along with the corporate culture in order to keep their jobs, many of these folks have become self serving of their own interests WELL BEYOND what a prudent and reasonable person would deem to be a fair amount of balance between self and public interest. A great book I once read called THE RISE AND FALL OF THE GREAT POWERS over the last 1,000 years has shown when the wealth gap between working class and the CEO class widens to current levels that the “powerful” country and its people hop onto a slippery slope that leads all of the people to LOSE vis a vie other countries that have better managed themselves in a fair manner. And, there are blatant examples in the “healthcare-industrial complex” of where these special interest folks have shown they will use any means necessary to attain unconscionable profits or power. Included in this special interest group are SOME, but NOT ALL: Politicians, For- profit insurance companies, Pharmaceutical and Medical device companies, and Trial Attorneys.
Let’s start with politicians. Why do they believe they know more about our intricate healthcare system and understand best how to fix it than healthcare professionals such as doctors and nurses? Is it their ego with an insatiable need for power? Is it because each of them is followed around daily by six health care lobbyists? Is it because they need the campaign donations from other special interests to get re-elected? Why doesn’t the President surround himself with a team of informed, savvy, and caring doctors and nurses who have spent their entire lives in healthcare and understand best what needs to be done in making HC policy? As a physician, I would never dare to pretend to be an expert on matters of tax policy, or manufacturing cars, or making furniture. So why do WE accept the premise that politicians are experts on such a complex subject as HC? Why do YOU allow them to control your HC? Remember, YOU are the customer.
My first recommendation would be to vote out of office anyone who will not listen to informed and reasonable “rank & file” HC professionals in developing a comprehensive HC reform. To be clear, this plan MUST provide three goals: Universal Health Care, Cost Reduction, and Improved Quality of Care. Why don’t YOU vote out of office any politician making side deals with a special interest group in return for their political support? Examples of conflict of interest side deals include a provision whereby the American Government remains the only industrialized country in the world that does not negotiate drug prices with manufacturers. In return for that deal that has occurred on the watch of both Presidents of the 21st century, the pharmaceutical industry agreed in the recent HC reform debate to contribute $8 BILLION a year to pay for about 1% of the HC reform Bill in return for our agreement not to demand the negotiation of drug prices with them. Since we spend nearly $300 BILLION in the cost of pharmaceuticals each year, if in aggregate, the pharmaceutical companies raise prices just 3% each year, THEY WIN by recouping their $8 BILLION investment and WE LOSE since their 10-30% increases in drug costs are just passed on to employers, individuals, or the government by insurance companies who then have to pay the pharmaceutical industry. Needless to say, the other side bar deals like the almost consummated Nebraska Medicaid give away and the Louisiana give away need to be stopped dead in their tracks. Many politicians are clearly part of the problem and are not part of the solution. Vote them out of office! Every rotten apple increases the chance to spoil the whole barrel.
Next, we all know that for- profit insurers and pharmaceutical/medical device companies are publicly traded companies. Their twofold mission is to maximize shareholder equity value AND to provide helpful healthcare services and cost effective, efficacious and safe products to help US. Can anyone serve two masters? Can these companies fairly serve both Main Street and Wall Street? Are there conflicts of interest here? YOU decide. Be aware that there are many NON-PROFIT insurance companies. Let’s get specific. Sure everyone is in favor of ridding ourselves of the insurer’s right to deny coverage based on pre-existing conditions and we all need to prevent insured folks from being unfairly dropped from coverage. However, going forward, to achieve these worthwhile goals, you must be covered—now is the opportunity to provide universal coverage—otherwise we’re expecting insurance companies to issue HC policies AFTER WE get sick. This makes no more sense than buying car insurance AFTER an accident. Thus we need universal coverage and those politicians who rail against pre-ex but are opposed to universal coverage are being disingenuous. But, HC is unaffordable for so many. The only solution is to temporarily subsidize people until HC costs are reduced. In return for this governmental assistance, people should be asked to volunteer (or even required to serve) in a National Healthcare Corp that should be established (much like The Peace Corp). Proving car insurance is not a right since one can take public transportation but health care is a right since one cannot take out one’s own infected gallbladder or prescribe medication for severe hypertension that can kill you unless treated. The State has laws to save the lives of its citizens. Health Care is NOT an option any more than Civil Rights was an option.
Meanwhile, for the many decades that despised rules like pre-ex have been in place, where have been the State Insurance Commissioners who are supposed to look out for the consumer? Write letters to them. Vote out of office any Governor who appoints an Insurance Commissioner who does not do what’s in the best interest of the public. YOU can do this. On the positive side, the insurance companies try to manage the premium dollar by paying providers what THEY consider a fair compensation for their work based on the relative value system and other factors, to ferret out fraudulent providers who intentionally “up-code” or “mis-code” for their professional services to collect more money that they are entitled to under the time they spent with the patient or in providing an inaccurate diagnosis that pays more, to hire medical physicians (not clerks) as medical directors to review physician orders for services and products that are not always aligned with established professional medical society guidelines, to utilize medical directors to review all appeals on the basis of medical necessity and to overturn a denial of payment for care if appropriate based on all relevant facts, to incentivize providers based on not what is done to the patient but based on how well the patient does clinically (pay for performance and medical homes) and to provide nurses to educate patients on how best to manage their disease states of their members. On the pharmaceutical side, they deserve credit for developing and providing life saving medicines and medications to treat illnesses. Yet, for the most part after their drug patent is over, cheaper generic medications provide the same value. Also, these companies could compare their product against other products within a therapeutic class to ascertain and provide that information to physicians as to what product is the most helpful in achieving the desired outcome and is also the safest and lowest cost. To date, except for the All HAT comparative effectiveness study, there have been few head to head comparisons among many expensive medications with significant side effects. It’s understandable that no company wants to admit that their product is the most costly and yet doesn’t work any better and is not as safe as a less costly product. But, is it right? YOU decide. You don’t have to take something that you feel is not the best medication. YOU have options in consultation with your physician. President Obama has rightfully called for more research, for more head to head comparative effectiveness studies but Congress has passed a law making such research not admissible by insurers in determining which products receive lower co-pays out of YOUR pocket. Boo on Congress! Also, recall from a prior blog of mine that research is given an paltry 3.5 cents for every HC dollar. On another point, does the practice of direct to consumer advertising lead to people to demand drugs seen on TV that look so alluring? Recognize that America is the only industrialized country that permits this practice. YOU can change the channel and not pay attention to “promotion” on commercials. Do YOU do it? How about demanding that manufacturers provide factual information to physicians as to why their expensive product is any better than alterative medicines that are lower cost, possibly safer, and possibly more effective? And, are there gifts and “free” samples given to physicians to prescribe these highly expensive products? Isn’t that a conflict of interest? Could that lead to higher HC costs? Do YOU ask your doctor about lower cost drugs or generics? If not, WHY NOT? Among the medical device companies, do they fund well designed research studies as to whether their product is superior to a competitor’s similar product like a heart stent or pacemaker? And, if they would fund such research in a compelling peer reviewed research paper, would the company making the much more expensive but less effective or less safe product withdraw their inferior product from the market? Does anyone believe that ever happens? Should it happen? Do YOU hold anyone accountable for this? Do YOU elect representatives that pass laws to require companies to prove the cost effectiveness of their product versus other products? If not, I’m beginning to see a pattern developing of why at the point of no return for escalating HC costs.
Last among the selected special interests are the trial attorneys who scare the dickens out of physicians through frivolous lawsuits. More importantly, there is FEAR in the hearts of physicians that they will even receive such a subpoena. Numerous studies attest that the mere fear of getting sued is enough to incentivize doctors to order unnecessary and sometimes risky tests by practicing defensive medicine. Several reports show that many BILLIONS could be saved through tort reform that does not deny a citizen of their legitimate rights to sue for wrongful injury. So, we do need tort reform and not just state by state “experiments” but national reform.
Secondly, let’s talk about the providers of care crowd. It is my belief that many physicians, nurses, and hospitals provide some of the highest quality of care in the world. Yet, reimbursement for providers and hospitals has been consistently on the DECREASE, especially for nurses and primary care physicians. Is that a good idea? What have YOU done about it?
As the “captain” of the healthcare “system” all orders for lab tests, procedures, medications, and education of patients on diseases/prevention/wellness begins the physician. I call upon my colleagues, the physicians, to lead in changing the mindset of their patients from a sickness model to a wellness model. But, physicians cannot do this without the cooperation of their patients and other components of our HC “system.” Insurers need to more appropriately compensate primary care providers who spend time listening and educating patients. However, I believe the real leverage to get patients to change their personal behaviors would be for employers to incentivize their own employees to practice healthier lifestyle habits and to undergo prevention screening procedures as recommended by their physicians. I believe the employers NEED to get more involved. If given an opportunity, ask your supervisor what your Company is doing to demand better value from the dollars your employer takes out of YOUR paycheck and gives the insurance companies so that they can pay the providers and the special interests.
To my mind, if we do not accomplish changing our efforts to promote maximum wellness/prevention, we will never get our HC costs under control. Concurrent with this, the minority of physician outliers of commonly accepted “standards of practice” need to accept that there is a science as well as an art to the practice of medicine. The science of evidence based guidelines of “Best Practices” can’t be ignored. No physician should just expect to order any test, any procedure, or any medication without their being appropriate justification for doing so beyond the fact that they have a right or license to do so. Managed care is here to stay and some physicians have to accept this reality. The fact of the matter is that appropriate justification for what they order originates from professional peer and scientific studies of what works best. And, lower cost is not a bad thing if it achieves what a higher cost service or product would offer. Moreover, insurance companies by law have provided for rights of a physician to appeal a denial of payment by the insurance medical director based on medical policy for something ordered which is deemed by their professional colleagues to be less than optimal. And, it is well accepted in our profession that many population based studies have shown marked deviations in the ways physicians in one city would treat the exact same patient if the physician practiced in another city. These “community standards” can lead to a waste of money and possible harm to a patient. Most progressive minded physicians, thankfully, embrace “national standards of care” based on professional society guidelines and the latest scientific studies. Furthermore, physicians need to keep in mind that every time they order a drug or a device that isn’t the most effective, the safest, and the lowest cost, they alone are spending the wealth of America to reach unsustainable levels of HC spending. The one tool that leads to the majority of HC spending in America is a ballpoint pen in the hands of a physician. Those ball point pens in the hands of someone licensed to practice medicine can spend MILLIONS & BILLIONS. The good news is that many physicians willingly embrace the process of ordering lower cost products that work just as well and are just as safe, if not safer than more expensive products or services. As long as patient care is not compromised, physicians’, in my personal opinion, have a societal obligation to use their ball point pen prudently. For those physicians who have not yet changed their practices to meet “Best Practices” their unwillingness to do so has become a major problem for all of us. Solution: Do YOU ask your doctor questions on what is ordered? Do YOU do your own research? That said, always seek out and work with the majority of noble physicians, trying their best to be your advocate and proper stewards of the national purse strings. Your employer will also thank you for keeping down the cost they have to pay to provide you with health care benefits since these costs are passed downstream to your employer and ultimately to you. THERE IS NO FREE LUNCH. I sincerely believe that the overwhelming majority of physicians are caring individuals who act in a humanistic fashion to reduce human suffering and to save as many lives as possible. But, there are always a few bad apples in any barrel. Run away from the bad apples as fast as you can. As to our nurses and hospitals, I believe they deserve our highest admiration for what they do every day. Even though I’m not a fan of public opinion polls because they frequently change merely based on how the question is asked, etc BUT the public believes that nurses and then physicians have the highest credibility on HC. THEN WHY AREN”T “RANK & FILE” PHYSICIANS AND NURSES ASKED TO SPEAK ALONGSIDE THE PRESIDENT on HC? And where has the U.S Surgeon General been during this healthcare reform debate? WHY AREN’T REAL DOCTORS AND NURSES the “TALKING HEADS” instead of politicians on cable and national TV shows? Caveat: Any physician who has become a politician, in my mind, has lost his/her credibility as a physician since they have chosen a partisan approach and probably have accepted campaign donations from special interests groups, thereby compromising their trustworthiness. The President is to be commended for having bipartisan ideas included in his health care reform proposal. JFK once said, “Let us not seek the Republican answer or the Democratic answer but the right answer.” Unfortunately, not one Republican vote has been cast for comprehensive HC reform—not now—not when they were in the majority—WHY NOT? WE ARE AT THE POINT OF NO RETURN!
Last, but certainly not the least, let’s look at the behavior of every American citizen with regard to practicing healthier lifestyles. Are all of us doing our part by exercising, by eating healthier foods, by not smoking, by not drinking and driving, by nor wearing a car seatbelt? NO!! NO!! NO!! Whereas, every single American deserves and needs a functional HC system that will aid each of us with the appropriate Rx, WE can’t expect miracles every time from the HC system no matter how skilled our physicians and nurses may be. WE must do our part! But have we? The aggregate data says NO! WE are the most overweight country in the world, less than 50% of us take our prescription medication on a consistent basis, less than 30% exercise regularly, and far too many of us refuse to accept that we must look at ourselves in the mirror and ask ourselves whether we have done our part. Have YOU?
When all is said and done, many HC decisions come down to OUR CHOICES. WE THE PEOPLE! WE can vote out politicians who don’t pass laws to guarantee universal cost effective quality HC. WE can ask our physician whether the ordered services or products have been proven to be aligned with the highest standards of care and at the lowest possible cost. WE can hire the best physicians and fire the worst. WE must make our HC decisions not based on what we think we want but based upon what we really need.
In the final analysis, it’s all up to YOU and ME! WE have been too passive for far too long It’s up to each of us to make the right choices to ACT on what in our hearts we know to be true and to reject what we know to be false. It’s up to each of us to practice personal responsibility by OUR BEHAVIORS to lower HC costs. The future is OURS but only IF we seize it.
The status quo is not sustainable. But if the status quo is to change, WE must act! “The only necessary for the triumph of evil is for good men (and women) to do nothing.” – Edmund Burke. Let’s get to work to demand affordable quality HC for all! WE are the CUSTOMERS for the entire HC industry. Let’s act like informed customers and actively demand cost effective care. Let’s go shopping. It’s up to US!
REMEMBER: We are at the point of no return!


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