In the national debate about "reforming" of healthcare, several principles have been put forward as being critical:

1. Including all citizens, and apparently many non-citizens, in insurance coverage
2. Eliminating pre-existing conditions as a reason for excluding coverage
3. Eliminating life-time-benefit limits
4. Eliminating or severely limiting profits for health insurance companies without limiting their liability
5. Eliminating patient responsibility for healthy living choices
6. Eliminating patient responsibility for any healthcare cost
7. Eliminating any political objections to a national-health plan by excluding any state from participating in the new health plan when their majority-party Senator, or Congressman objections.

Here are the problems with healthcare "reform" which includes these principles:

1. There is nothing in these principles which contributes to cost containment or cost control.
2. In fact, everything about these principles actually contributes to the driving up of cost, rather than the controlling of costs.
3. Rather than being approached from a problem-solving perspective, these principles are politically motivated. For instance, the demonization of insurance companies is not a principle of statesmanship; it is a demagogic principle of manipulation of public emotions.

What could result in true "reform" of our healthcare system?

1. As previously argued in a three-part series on healthcare reform published in The Examiner in August 6, 13, 20, 2009 the only effective healthcare reform will be the result of the "transformation of healthcare delivery systems" in this county. (see Related Articles below)
2. Reforms must apply to everyone without exception. There can be no Florida, New York State, or Nevada special deal to exclude these states from the Medicare Advantage changes recommended by the Senate bills because it would be politically embarrassing to majority-party Senators from those states.
3. There can be no Louisiana and Nebraska exclusions from the responsibilities of State Medicare costs simply because that is what is required to get the Senators from those states to vote to impose the "reforms" upon other states.
4. Discussions of healthcare reform must be held in public sessions and not behind closed doors.

These are essentially negative issues related to the methodology which has been used thus far in attempting healthcare manipulation without any reform. Here are some examples of these issues.

1. Because I have worked with Medicare Advantage and its predecessor programs for the past 13 years, and because I have recommended that program to my patients, I have felt morally obligated to accept that program for my own health insurance coverage once I became eligible for Medicare. As a result, my wife and I both are Medicare Advantage members, complying with all of the tenets of that program. If we are to have healthcare reform, ALL politicians must be willing to accept the benefits and limitations of the reformed program without exception. This principle seems so obvious but few Congressman and Senators are willing to make this simple pledge. That within itself is enough to create distrust in any program they produce.
2. For all of the disclaimers about eliminating lobbyists from policy-influencing positions in the Federal government, the only real change is that one group of lobbyists has been replaced with another group of lobbyists, which are just as lethal to "real reform," as the previous group was.
   
   In 2000 and 2003, a proposal was made as to how to solve the problem of indigent healthcare in Southeast Texas. That proposal required the limitation of choices on the part of indigents and the standardization of their care. The proposal was rejected as being politically dangerous to the politicians who would propose it. In that discussion the following concepts were presented, which still have validity in today's national healthcare reform discussion.
   
   "There has never been a time when there was a greater need for collaboration between healthcare providers - hospitals, physicians, patients, insurance companies, employers and vendors of healthcare supplies.  The building of new and bigger hospitals and the adding of new and innovative tests and treatments are not solving our healthcare problems.
   
   "In reality, advances in healthcare have created as many problems as they have solved.  Ultimately, technologic advances in healthcare have not taken away the responsibility of everyone for their own health. Ultimately, we each are individually responsible for the choices we make, even though many of us are looking for someone to blame for the vicissitudes which afflict our lives.
   
   "In reality, all of the technologically advanced health interventions in the world cannot remedy the destructive effects of wrong choices made by many people, who then look to healthcare providers and organizations both to provide and to pay for corrective measures.
   
   "We all live with at least three realities in the healthcare industry today.  Each of these realities represent at the same time:
   
   
   • Public policy dilemmas for government,
   • Ethical challenges for society, and
   • Personal problems for individuals and families."
   
   Nothing has changed in the last ten years and no reform has been proposed by either party which is not weighted down with payments to the constituencies of whichever lobbyist group to which one party or the other is obligated.


3. Reform of the healthcare system will never be successful until there is a commitment on the part of payers, providers and patients to the paying for, the prescribing of and the receiving only of evidence-based, scientifically-sound healthcare.
   
   A perfect example of this is Chiropractic care. One of the wealthiest lobbies is maintained by Chiropractors who have successfully gotten Medicare payment approval for Chiropractic care. This is the case in spite of the fact that there is little to no evidence-based support for the care provided by most chiropractors and there is scientific evidenced to refute some of the most outrageous claims by the most extreme chiropractors. In its report of Federal funded Chiropractic care for 2006, the OIG declared that 46% of payments made to Chiropractors were inappropriate and CMS' response was that there was little they could do about it (http://oig.hhs.gov/oei/reports/oei-07-07-00390.pdf).
   
   However, the cost of healthcare is also driven up by the use of non-evidenced based therapies by physicians, physician assistance and nurse practitioners. The purpose of quality measures endorsed by the National Quality Forum and by NCQA's HEDIS measures in addition to improving the quality of care is to decrease the cost of care which results from inappropriate treatment. Without reimbursement being tied to evidence-based medicine, any public policy considered to be healthcare reform is just window dressing used by politicians for their own success.
   
   While lack of tort reform is often cited by healthcare providers as one of the reasons for healthcare-cost escalation; the redundant and excessive use of expensive services is most often the result of the philosophy, "This is what the patient wants and if I don't give it to him/her, he/she will just go down the street and get it from someone else," and/or our antiquated medical-record system which doesn't allow effective and efficient sharing of care from one site to another, or from one provider and another. I recently had a patient call for a healthcare need. I asked, "Do you want to be treated according to the best science or according to the way you have always been treated?" The patient was a little shocked at the question. Because the correct treatment involved not getting an antibiotic, but because the traditional treatment involved an antibiotic, it was a legitimate question. The patient chose science and did very well.
   
   Until the payer system rewards evidence-based medicine and stops paying for non-scientific care, healthcare reform will elude us. Until politicians stop listening to ALL lobbyist groups, health reform will be impossible. People have the right to receive non-scientific based health treatment, but they should not have the right to expect someone else to pay for it.

Rationing and Responsibility

There are two other issues related to "true" healthcare reform which have not been being discussed. The first is rationing of care. The second is patient freedom and responsibility. An unlimited benefit with limited patient obligation is not a sustainable model of healthcare reform. One of the hobgoblins of healthcare reform is the threat of "rationing" of care. Those who remember rationing of fuel and other essentials remember that rationing involved not being able to obtain more of a commodity than was allotted for your use. Gas rationing involved coupons and without a coupon you couldn't get gas.

No one is in favor of healthcare rationing. That would involve a public policy that if you were of a certain age or of a certain condition, you would be ineligible for a certain procedure, treatment or medicine as a result of a public-policy decision. Yet, everyone recognizes that there are rationale reasons for not providing a certain procedure or treatment for a particular patient. For instance, the life-expectancy of a 99-year-old without coronary bypass surgery (CABG) is typically the same or better than life-expectancy with a CABG. Thus the procedure would typically not be recommended. That is not rationing of care; it is science-based medicine which is rational.

A corollary to this concept is that healthcare reform does not require that in order to achieve universal healthcare that the public assume responsibility for a person's entire healthcare. It is possible, without the concept of rationing, for society to say that healthcare which will be provided without responsibility by the patient will include this but not that. It might also have a life-time benefit limitation. For instance, it might say that if necessary for medical reasons, a patient could receive one bariatric (weight control) surgical procedure for life, but not a second or third or fourth. Again, this is not rationing, but it is a rational, contractual statement of what someone can and cannot expect.

The second issue essential to healthcare reform is that it must include patient responsibility. It is unlikely that anyone in the USA wants to dictate the personal habits of anyone else no matter how personally objectionable another person's choices are. Did you hear about the passenger on an airplane? At a time when a person could smoke on a plane, one passenger said to the man sitting next to him, "Do you mind if I smoke." The response was, "Oh, no, I don't; I don't smoke but I chew tobacco. If you don't blow smoke on me; I won't spit on you." A little gross? Maybe, but the point is, you have your rights but they end at mine. A person has the right to smoke but also has the responsibility personally to pay for the added cost of their healthcare which results from their personal freedom and their personal choice.

True healthcare reform will decrease cost per patient but will not decrease cost as an aggregate for the entire population. True healthcare reform must include:

• A commitment to scientific, evidence-based medicine
• A contractual statement of what will and what will not be included
• A consensus on patient responsibility and what it will include.

Without these elements, there will be no healthcare reform, there will only be manipulation of the public psyche for political purposes.