Friday, April 3, 2009



We’re only as healthy as we can afford to be.

(April 3, Rochester, MN) The raging health care debate in this country has focused primarily on the role of the insurance providers, and rightfully so. However, they are not the only culprits in the making of this quagmire. Third party payments have created the white-coated monsters we call doctors. Their greed is never mentioned in the debate and there can never be any true, practical, health care reform without a rigorous examination of the role of physicians in the creation and perpetuation of our natioanl health care nightmare.


We are all learning powerful lessons about capitalism today. As our federal government doles out trillions to the private sector, particularly banks, financial institutions, and auto manufacturers, there is unprecedented focus on what form of control, if any, the federal government purchases with its “bailouts.” The inherent weaknesses of capitalism are suddenly front and center; the issues at hand cut to the very core of our economic philosophy. Free market capitalism has provided incredible wealth, success and stability since our founding. Now, however, the flaws in our system are undeniable. The financial industry has been permitted to function in the absence of real oversight and increased deregulation. The years of incestuous relations between the private sector , special interests, and Congress have been exposed to the harsh light of scrutiny. Americans are frustrated and angry by what has been revealed yet demonstrate a collective aversion (and rightfully so) to any influence or control by the federal government in the free markets. Sure, the public is dismayed by the accounts of huge executive salaries, stunned by the size of Wall Street bonuses, and angered by the notion of “golden parachutes” while they continue to tread water during this economic storm barely staying above the choppy surface.


Americans have a sense of right and wrong but a seemingly limited capacity to grasp the intricacies and obtuse functions of our economic machinery. All they care about, naturally, is how they are personally affected by the forces they do not fully understand. How could they not? Their collective common sense is labeled “economic populism”. This term is tossed around by politicians and pundits for no reason other than to assign a label; the need to understand complexity by assigning simple labels to our problems allows the “sound bite” and “bumper sticker slogans” to dominate the discourse. It is as if only by “dumbing down” the particulars of any issue, concern, or crisis, that it can be presented to the masses for consumption. We all are partially to blame for this and the rancorous nature of the partisan approach to discussion and debate only perpetuates this disturbing trend.


Aside from the sectors of the economy that have been garnering all the headlines and attention is the one, long standing, perhaps intractable problem; the cost of health care. Entwined in this single issue are a host of elements that transcend the economics of medicine but also speak to our society, culture and national consciousness. Because of this mutli-headed demon the primary concerns are easily obscured. They simple get overshadowed, if not lost, as the secondary elements muddy the waters of discourse. At times it is appeared that know debate was possible simply because a common definition of the precise problems could not be established. At other times special, entrenched interests have set the terms of the debate often deceptively evoking emotional responses from the general public. No other issue seems to generate the level of intensity, public interest and rancor than reforming our health care industry.

While hundreds of thousands of Americans fear foreclosure of their homes, consider bankruptcy, worry about providing for their families, their children’s education's and live with crushing debt, vanishing pensons and insecure futures, their are many who the ills of the economic recession have yet to infect. Over one million newly unemployed among us have joined the swollen ranks of the un- and underemployed in the last 15 months. Still, the majority of us remain in our jobs, some of us work two or three jobs, but largely we are employed.


The one aspect of the current crisis that does touch us all is the access, affordability and coverage of our health insurance or lack thereof. Not everyone will own a home or become unemployed but everyone, at some time, does require the services of a physician. What the majority of working Americans fear most today is that some illness or injury in their family will occur and destroy them financially. According to recent polls conducted by the Harvard School of Public Medicine, the University of Minnesota, Gallup, The Brookings Institute, The Heritage Foundation, Time Magazine and USA Today, the overwhelming majority of Americans feel their health insurance, if they have it, is not adequate and a huge financial burden.

Conspicuously absent from any health care reform debate are physicians. Big pharmaceutical houses, insurance companies, HMO’s, and hospitals constitute the usual suspects. They are all complicit in our national health care crisis but there can be no denying the role that physicians have played in getting us where we are today. Why are they apparently sacrosanct? Since they play a fundamental and profound role in the health care industry, why are they “off limits” when the debates ensue?

There is plenty of blame to assign in this complex dilemma; enough culprits to vent our anger at. But the physicians themselves are as culpable in this mess as any other entity, perhaps more so than anyone has thus far been willing to admit.


There was a time that physicians in private practice were paid by their patients after services were rendered. Doctors and their patients historically and until very recently enjoyed mutually respectful relationships. Doctors were always held in high regard not only for their education by for the vital roles they played in our lives. From birth through death doctors escorted us through life. many of us are old enough to have memories of childhood illnesses, fevered, sweaty nights with nervous parents hovering about and a doctor coming into our bedroom in the middle of the night to administer a “shot”, deliver care, treatment and for our parents, as sense of comfort and confidence. Those days are long gone and the question is why. What has changed? When did medicine become the cold, callous, money driven profession that it is today? When did the doctor - patient relationship turn adversarial?

Doctors came to see third party payments as the golden cow that would crap unlimited dollars forever. They steadily increased their fees knowing that whatever bills they submitted, (or their patients submitted to their insurers), would be paid quickly and in full. Physicians began forming corporations and large group practices, purchasing lavish facilities, laboratories, and forming alliances with other physicians “groups” to keep more of the money “in the family’, so to speak. And, the money kept rolling in - in ever increasing amounts. Yes, life was good. Soon everyone wanted in on the action.


For many years hospital based services were major revenue streams for hospitals. The acronyms RAPE and RAPEM represent the hospital based services: Radiology, Anesthesiology, Pathology and Emergency Medicine. (Maternity represents the “M” in RAPEM.) Physicians in these specialties were hospital employees paid by salary. This worked out well for everyone involved until these specialists recognized that they were missing out on the third party payments cash cow. Suddenly these once hospital salaried doctors were forming “Associates” and “Partners” groups, billing patients directly while also depriving the hospitals they were based in the same revenue they’d previously generated. There appears to be no end in sight for the doctors laughing all the way to the bank.

A funny thing happened along the way. Americans began living longer. The technological advances in medicine kept people alive longer; new techniques and treatment protocols, as well as more sophisticated early detection modalities all contributed to greater demands on medicine which, in turn, suddenly meant the insurance companies were paying out increasingly larger sums. The pharmaceutical industry was releasing ever more target specific proprietary medications at greater and greater expense to the patients. The insurance companies weren’t pleased. This had to stop. After all, the actuaries had not counted on the efficacy of modern medicine and did not foresee the edge of the cliff they were approaching.


All these factors and more collided by the early 1990’s. Most Americans had employer provided health insurance which they paid a portion. However, the coverage began to become more and more limited while premiums kept escalating. The insurance companies began to exert greater influence on physicians and hospitals by defining what they would and would not pay for. Suddenly the actual practice of medicine, the treatment a person did or did not receive was no longer based on symptomology and the doctors judgment; insurance companies where making what where essentially clinical decisions. The docs played along because they still wanted to collect that which they still could. The perfect storm was upon us.


This is a very brief, simplistic accounting of the factors and influences that have resulted in the severe crisis far too many Americans face when illness strikes. As more and more jobs are lost, more Americans are loosing their health insurance. Doctors are now opting out of Medicare because the government payments “aren’t sufficient.” Not sufficient?

The cost of medicine has always been arbitrarily set in a captive market. Physicians and hospitals had become like the organized labor operated garbage removal collectives that dominated New York City until the mid 1990’s. Collusion ran that market and it continues to run the medical market today. Mob controlled entities were the only game in town if you wanted the refuse removed from your facility. Doctors and hospital were the only game in town if you were sick or injured. The insured public became commodities. Today, a doctor’s office does not inquire about your symptoms when you first checke in for an office exam; they want to see your insurance card and, based on the robustness, or lack thereof, of your coverage, your care will be determined.

Has clinical medicine changed that dramatically? Why did a gall bladder removal cost $7000 in 1985 and $17,000 in 1995? Why are hospitals charging $8.00 for an aspirin to an inpatient? Why are doctors able to bill you $85.00 for just ducking their head in the door of your hospital room early each morning to say hello?

The entire system has only gotten progressively worse and it will continue to worsen as more and more economic, social, and demographic factors exert ever more pressure on our broken system.


We are back to the beginning; the original premise of the argument made here remains. By what means, if any, can doctors and hospitals become less expensive? Of course, the special interests such as the well financed physicians lobby, will cry foul at any kind of government interference in their business. Soon, the health care industry political action committees that paid top dollar for all the politicians they have in their pockets will start the cry of “socialized medicine”! All efforts towards reform will be disingenuously blocked by the heartless, greedy entrenched interests who will use fear and smear tactics to protect their greed. This has all happened before and it will replay itself out again as the new Administration begins to discuss health care reform in earnest. Just wait and see. They will say you can’t choose your own doctor anymore; that the federal government will control your care. Their billion dollar public relations blitz will spew the same old propaganda as it has before.

Yes, we live in a capitalist system where the free markets reign supreme. Medical services are just another capitalist cog in our economic machine despite its unique nature. Free markets determine what doctors can make; how could it be any other way? Perhaps it can’t. Certainly the federal government cannot set fee for service guidelines. We see today the resistance doctors are having to alterations in Medicare and Medicaid coverage. They are protestinng loudly and petulantly over decreases in such payments. They are like the spoiled child who takes his ball home when the game doesn’t go his way. Doctors are refusing to see new Medicare patients and outright dropping care of others. They are running from those patients in droves leaving more and more ill people out in the cold.

What is the solution? Who knows? The only purpose of this discussion, aside from venting, is to toss out into the light of day the role that our wonderful and dedicated doctors have played and continue to play in this tragic, unjust, national disgrace. It is about time the truth was introduced into the public discourse and the medical community was called on to account for themselves.

That will never happen.

As the old saying goes, “the rich get richer...”

The greed of physicians knows no bounds. Just examine the facts, study the history of our current health care crisis and all that transpired to bring us to the current state of affairs.

The truth hurts. Just don’t tell your doctor that it hurts...that could cost you plenty.


Copyright TBC 2009 © All Rights Reserved

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