For the week of June 12 - 18, 2002

The rift in the health care world widens

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It is hard to know if the conservative, political titans of this country hated President Bill Clinton more or less than his "stand-by-your-man" wife, Hillary. What is clear is that of all the political calculations Bill Clinton made—and he was probably more adept at such calculations than any president in recent history—the one he bungled and the one with lasting consequences for the nation was his appointing his wife to head up a health care reform task force.

The decision cost the country ten years of inaction. The fundamental issues are still with us, and we have some new ones that are potentially even more intractable. We need not look much beyond the Wood River Valley to see the problems coming into focus.

A little while back I received—as did many other people—a letter from my internist who explained that the "practice of internal medicine in the Wood River Valley … is no longer financially viable." This situation was likely a result of both nationwide, systemic problems and local conditions.

The doctor decided that the solution to his particular problem was one that has been emerging in other parts of the country, namely Seattle, the San Francisco Bay Area and in Florida. Patients are asked to pay a flat annual fee, varying across practices from about $1,500 at MDVIP in Boca Raton, Fla., to as much as $13,200 at a group called MD2 ("MD squared") in Seattle. Generally, the fee buys you enhanced service and accessibility to the physician—longer exams, same-day office visits, house calls, delivery of prescriptions, things of this nature. Services offered run the gamut, of course; in some instances, like at MD2, marble lined waiting rooms and monogrammed robes are standard. The practices have been dubbed "boutique medicine" or "concierge practices."

Those that choose not to pay the annual fee are dropped by the physician, and therein lies the rub. It is hard to begrudge a physician trying to make a living in any particular situation. Nonetheless, a problem arises as the trend spreads. It may not be possible to just move on down the road to another doctor.

In this valley there are four internists. Those that are dropped from the one will have to be absorbed by the remaining three. They may or may not be able to handle the load. If not, many people will be left without access to a doctor. Expand the idea nationwide, and it is easy to see that an economic wedge is being driven between the wealthier patients of the nation and the less well off.

A factor that exacerbates the problem is that doctors are increasingly refusing to take Medicare patients, partly because Medicare does not generally pay a doctor’s full fee and partly because there is a mountain of paperwork to fill out for every Medicare patient. And there is a huge demographic group that will enter the Medicare rolls in the next decade.

In a way, what is happening is that doctors going to this "boutique" system are pushing their businesses farther into a market situation, while at the same time taking control of that market. They are, in effect, setting both the price and supply of their services.

The problem as I see it is that, from an ethical perspective, access to health care shouldn’t be a result of economic forces. We are not talking about fancy cars or widgets of some sort, but the difference between life and death. There is a component of moral obligation that doesn’t figure into supply and demand curves, whether or not those curves are manipulated or not. It is analogous to an E.R. doctor looking into whether the victims of a bad car wreck were insured before taking the necessary (and costly) measures to save lives.

Taken on a broad scale, the system is effectively raising the barriers of entry into the health care system. This development ups the ante even beyond the already steep and often prohibitive ante of health insurance rates. Health is a lovely thing, provided you can afford it.

There are somewhere in the neighborhood of 40 to 43 million uninsured people in this country. And if you have insurance, it is easy to take the position that that’s their problem. But it’s not, because those uninsured people do get sick, suffer from diseases, break legs and myriad of other urgent and non-urgent afflictions. So they end up going to the only place a doctor is available to them, the emergency room, one of the more expensive venues in which to be treated. And this is as good a place as any to see the vicious feedback loop of rising costs, rising premiums, declining rolls of the insured, rising costs, and so on.

Of course, there are many other factors that stream into the feedback loop as well. Litigation costs, insurance fraud, malpractice insurance rates, dramatic investments in technology and the increasing specialization of medicine.

Then there are prescription drugs, the bill for which is rising 17 percent annually. Drug companies are going to elaborate means to replace the expiring patents on lucrative drugs. Often they will bring out a similar drug with a marginal improvement in, say, delivery but one that is patentable, thereby protecting their profit margins from generic drugs (Consider Prozac and Prozac Weekly or Prilosec and Nexium.)

All this is to point out that the little health care development in our valley portends bigger problems and questions. By 2007, health care costs are projected to be 16.6 percent of the Gross Domestic Product, the highest by far in the industrialized world. And we don’t necessarily have the best health care as measured by life expectancy and infant mortality rates. We are below average on those counts.

What’s more, demographics are working against us. In 2010, the Baby Boomers will begin to retire. So tackling the problem sooner rather than later would be a good idea. Besides, by 2010 Hillary Clinton might be president.

 

The Idaho Mountain Express is distributed free to residents and guests throughout the Sun Valley, Idaho resort area community. Subscribers to the Idaho Mountain Express will read these stories and others in this week's issue.