Dr. Marc answers readers' question every other week. To send a query, click here .
Dear Dr. Marc,
I recently had my first need for emergency medical care. I referred to the insurance plan book given to me by my employer, and picked an "in-network" hospital. In the emergency room, I signed the "conditions of services" required for treatment. One clause stated that certain services in the emergency were provided by "independent contractors." That proved to be true for most everything I was treated with. Ultimately, from that emergency room visit, I was billed separately for the lab, the X-ray, the physician and the CAT-scan. Despite my diligence, virtually everything except the hospital stay itself proved to be "out-of-network" and at a cost considerably higher than the promised coverage.
Who is to blame: my insurer for failing to make certain that "in-network" hospitals use "in-network" subcontractors or the hospital for circumventing the promised maximum fee for services by subcontracting and then benefiting by receiving a share of the profits as a fee from the sub-contractor?
This, in essence, negated much of the security I had thought I had with health insurance. I believe there should be legislation to protect health consumers, especially if this travesty is done with a wink-and-a-nod when contracts are negotiated between hospital and insurance companies.
JOAN H. LEONARD
Sherman Oaks, CA
Your questions are very important but hard to answer. You'd be surprised how much that emergency room visit actually does cost at today's technological prices. ER visits are very poorly covered by many HMOs, without great documentation and even, as you experienced, with all the right paperwork in order. But HMO's are not the patient's advocate, they are businesses, they don't want to have to pay for what costs the most, or even, here I cringe, what is potentially the most lifesaving. The best practical option for the middle class is to get the most comprehensive coverage possible without spending a fortune for it (easy to say, I know). I've said for sometime now that it should be the role of the government to work at getting these costs reduced--though much of our government is otherwise motivated. Not a completely satisfying answer, I know. But it's critical to make every effort to demand that our elected officials take the nation's healthcare crisis more seriously.
Dear Dr. Marc,
Is it absolutely imperative in all cases for doctors to actually see patients in order to arrive at a diagnosis? Will technological innovations displace the need for face-to-face visits with the doctor, replaced by the patient communicating symptoms to the doctor via e-mail or via streaming video from the Internet. Are such innovations afoot? Are they desirable? Have any academic studies been done on this matter?
These changes are afoot. They are not desirable. The loss of personal encounters will sandpaper away at the art of medicine. Much of diagnosis is sizing up the patient with the symptoms sitting before you. William Carlos Williams said that a lifetime of careful listening allowed him to scratch just below the surface of a patient's complaints and find...the poetry.
Dear Dr. Marc,
Why do you suppose Dr. Bill Frist was willing to give up his heart-surgery practice to go off to Washington to join the Senate in 1994, during Clinton's first term? Is there any possible connection between his change of careers and his family's ownership of Columbia/HCA Healthcare? After all, if there were any connection, certainly Frist's choices would have tarnished his boy-scout image and it has not happened; and were he vulnerable for some other undeniable connection, his Banana Republican supporters would have dropped him into political limbo by now instead of elevating him to Senate Majority Leader. Since there has been no significant comment from Big Media on his choice of jobs or his connections, I can only assume it is my "Conspiracies Are Everywhere Syndrome" chiming in. On the other hand, you could do us all a service and tell the world if he is in the vanguard of politicians protecting their own interests from the masses--and masked by the Hippocratic oath!
Great question. I promise you that you are not the only one thinking about this. I don't have any inside information, though I would find it hard to believe that Senator Frist's family's connection to investment healthcare doesn't influence his political decisions in favor of the status quo and the usual corporate interests. I hear nothing but complaints from the little guy that they don't have access to equal or even reasonable health care. With this trend likely to continue, I doubt that Senator Frist will be their champion.
Dear Dr. Marc,
As you are aware, perhaps the greatest problems with the quality of health care is both the over- and underutilization of resources. Structural reform can improve allocation of our resources. An integrated information technology system, as part of a single public program, can identify outliers and promote educational efforts to improve utilization patterns (or, if necessary, disciplinary measures for continued non-compliance). Also, universal coverage would end the financial barriers that limit access to beneficial services for low (and now moderate) income individuals. Using our resources more wisely would enable a giant step towards quality health care for all.
New technology, as with some of the newer pharmaceuticals, is often very expensive without a commensurate increase in value. Budgetary considerations would mandate that new drugs and new technology demonstrate value. Not only would cost increases be constrained, but care rendered might actually be of higher quality. Our $355 billion military budget doesn't chase away military technology firms. Likewise, our medical technology and pharmaceutical industries are not going to walk away from our $1.55 trillion healthcare budget.
There are trade-offs in replacing private health plans and government programs with a single, universal, publicly administered program, but most of the tradeoffs are beneficial.
DON McCANNE, MD
President, Physicians for a National Health Program
It is absolutely true that a centralized system could bring to bear more quality control and cost containment when it comes to medication and technology. Exorbitant advertising costs would also be reduced once the target is a well-informed organization not geared to respond to hype. I still say that administering and evaluating the plan on a patient-by-patient basis will have its difficulties, especially when it comes to who gets something and who doesn't. Whereas in Denmark, for example, a professor friend of mine always refers ironically to the EKG machine getting "dusted off" whenever he asks for one, here in the US, our culture of entitlement makes it much harder to ration services. We prefer to waste and want to "waste not, want not."
Dear Dr. Marc,
Why is there now such a vast amount of money being spent on combating bioterrorism when so many equally or more threatening health care needs are so underfunded?
I fear too much emphasis is placed on expensive high-tech gadgetry and not enough on adequately funding local communities to enable them to better support their Emergency, Outpatient and Neighborhood Health Clinics--the whole infrastructure that would be the first line of defense in any infectious disease emergency.
Seems like we would do better by spending our money fighting infectious diseases of the here and now such as TB, malaria, and AIDS. Perhaps we would make more friends than enemies and give the terrorists less fertile breeding grounds.
As a nurse, I am concerned that the smallpox immunizations planned for health care workers may backfire, especially when the threat level is still so unknown. I have read where it would be possible for a recently immunized health care worker to transmit the virus to immuno-compromised patients--like those receiving chemotherapy or AIDS patients.
What are your thoughts on the advisability of mass immunizations for health care workers and the population at large? Is it too paranoid to think there is a political component--to heighten anxiety and build support for the war in Iraq?
Jamaica Plain, MA
You're right, the public is being fed information that distorts perception. I agree with you that there are hidden political agendas behind all of this, the goal of which is for the group in power to remain popular, even if it comes at the expense of the public's well-being or exploits and breeds fear. Undue fear of smallpox, a virus that, if it appears at all, will spread slowly--has stoked unnecessary fear and led to a panicked call for a vaccine which can cause harmful side affects. It is one thing for emergency responders and the military to take an old vaccine when they may be put at some risk. It is quite another to ask the public to consider the same vaccination, especially when newer, safer vaccines are in the offing. Furthermore, since the risk of smallpox remains theoretical, there would still be time to vaccinate using the old forumula if the disease were to suddenly appear here.
Dear Dr. Marc,
Are there any statistics on trends re the per capita cost annually of health care, say in Sweden and Canada, vs the US? I chose Sweden and Canada because I believe they deliver health care as effectively as or better than that in the USA. Are costs also rising 15 to 20 percent per year in these countries, which has been the case with my recent HMO payments?
No--health care costs are under much better control in those countries. However, there is not the same access to the latest technologies there, which Americans tend to crave. Also, prescription drugs cost less because they act as a cohort which the drug companies must respond to by giving these countries lower prices at the risk of losing them altogether. Any loss of profit is then passed on to US consumers in the form of exorbitant drug prices in America.
Dear Dr. Marc,
This letter regards your recent Nation editorial, "The Hungry Physician ," from the December 30, 2002 issue of the magazine:
With graphic-intensive advertisements for expensive prescription drugs bombarding us daily and doctors being persuaded to use drug company stocks for their retirement funds, the day when the health of the economy is directly proportional to the health of the phamaceutical industry and inversely proportional to how healthy we are as individuals does not seem far off.
Your Nation editorial is a shocking firsthand account of a drug company's heavy-handed efforts to tighten its control over a community of doctors. Had your article included the name of the drug company, my wife and I would have sent them a brief but strongly worded critique of their flagrantly unethical marketing. Instead, the drug company's name is conspicuous by its absence from the article, and I am left to wonder why.
Will you reveal the name of the drug company? If not, will you, or The Nation, at least tell us what constraints you felt when you considered whether or not to divulge the drug company's name? Was it legal action by a megacorporation? Harassment by economic interests? Badmouthing by PR mouthpieces? Please tell me. It's important that we know things like this.
Asheville, NC 28804
You're asking a reasonable question. First, let me state unequivocably that I am not afraid of the drug companies and I would be quite willing to "name names" if I felt it appropriate, as I did in my article "Drug Ad Wars " in the June 17, 2002 issue of The Nation, followed by a segment on Bill Moyers's NOW program that evolved from these same ideas. But my recent editorial, though it certainly does involve a specific drug company, is really not about one company, it's about all of them. If I gave the name in this context, I fear an important sense of universality would be lost that I feel is crucial to my message.