Steffie Woolhandler, MD, MPH; David U. Himmelstein, MD
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-3775.
Corresponding Author: Steffie Woolhandler, MD, MPH, City University of New York at Hunter College, 2180 Third Avenue, New York, NY 10035; e-mail, email@example.com.
Current Author Addresses: Drs. Woolhandler and Himmelstein: City University of New York at Hunter College, 2180 Third Avenue, New York, NY 10035.
Richard M Fleming, PhD, MD, JD; Tapan K. Chaudhuri, MD
FHHI-OI-Camelot; Eastern Virginia Medical School
February 5, 2020
Medicare-for-All isn’t Quality-Medical-Care-for-All.
Medical billing changed in the mid-1960s when CMS and the Texas State Teachers insurance – later known as BCBS of Tx - began. While the concept of a one-provider method of payment may on the surface seem like a good idea, there is a considerable difference between Government run healthcare and freedom-of-choice quality medical care. The introduction of CPT, DRG and ICD codes may have helped insurance companies and CMS; but it has not helped physicians, patients, hospitals or other healthcare providers. While CMS and insurance companies have the motivation to reduce payments - treating medicine like a business, and telling patients which doctors they may see, what tests patients may receive, what medicines will be covered and which hospitals they may be admitted to – doctors and patients are focused on improving the quality of healthcare. Two diametrically opposed forces.When patients worry about healthcare costs, what they are not told is that it is the involvement of CMS and the insurance industry, which have distorted the billing and payment of costs over the last several decades. When patients worry about prescription drug costs, they are not told that BigPharma has two lobbyists for each member of Congress and that lobbying power has been fine-tuned to control drug prices. In some instances BigPharma has even misrepresented their drugs to the FDA and doctors, increasing sales and profits at the expense of patients who have to choose between drugs and food. When politicians tell voters nothing will change under Medicare-for-All, we should all worry, because the system that exists now has failed and the solution being offered – by those running for election – is cheaper care, but not quality care. Medicare-for-All, or any medical care directed by lawyers in Washington, D.C., or in your State capitals, isn’t better medical care for all; it’s remnant medical care for all. We would encourage the ACP and any other medical group to not repeat the mistakes of the 1960’s, which started us down this pathway. We encourage physicians and other healthcare providers to take back control of medicine - where it belongs – returning it to patients and those of us who went to Medical School, Internship, Residency and Fellowship, and took our Medical Oath on behalf of our patients - an Oath which precedes the origins of the U.S.A. and BigPharma.More government involvement and control is not the answer – it’s the problem.
David U. Himmelstein, M.D., FACP, Steffie Woolhandler, M.D., M.P.H., FACP
City University of New York at Hunter College and Harvard Medical School
February 7, 2020
Response to Drs. Fleming and Chaudhuri
Blue Cross and Blue Shield of Texas started life in 1929 (not in the mid 1960s) as the Baylor plan for teachers, and became the fiscal intermediary that administered Medicare coverage when that program started up in 1966.Like Drs. Flrming and Chaudhur, we abhor Pharma's price gauging, and the complex billing schemes inflicted on doctors and hospitals by insurers as well as CMS. But in our experience, Medicare, unlike private insurers, has not restricted patients' choices of doctors and hospitals, or the tests they may receive. Without health insurance, few could afford the care they need, and no nation has reached universal coverage - or anything close - without government playing the central role. Despite important flaws, Medicare has improved access to care and health outcomes for tens of millions of patients. Its flaws should be fixed, and the program expanded, not abandoned.
CMS is primary reasons healthcare costs have increased for everyone.
We appreciate the enthusiasm of Drs. Himmelstein and Woolhandler’s response, keystrokes and information regarding Justin Kimball’s development of health care in Texas. We appreciate your comments, and should specifically state, that it was in the 1960s that the Federal Government partnered with BCBS, producing today’s BCBS of TX. Doctors – including us – do not actually do the billing for office and hospital visits, testing, drugs, et cetera. We suspect you do not either. Simply filling out a billing sheet does not mean this is what the billing department will turn in to CMS, private insurers or the patients. Fortunately the hard working people in the billing department correct – as is their job – any incorrect boxes we check on the billing sheet. CMS does not pay for all doctors and hospitals, tests and prescription medications. Few patients elect to undergo testing if they have to pay for the test and fewer still will pay for the medications prescribed if CMS has determined a different drug can be used in its place. Harvard participates with CMS, but like everyone and every place else, it does so by increasing the costs of the same office and hospital physician visits, hospital costs, testing and drugs, to other private insurers and those who are uninsured. This is the reason an aspirin can cost – as one patient remarked the other day - $60. It is this increase in charges which others pay to compensate for the lower payments made by CMS resulting in many being unable to afford healthcare in the first place. As more people are covered under CMS, the burden of these costs will shift to fewer and fewer individuals, thereby complicating the problem and making more Americans uninsured. This produces a scenario where Government must cover more people. To be clear, CMS is merely shifting the burden away from itself onto others. This does not solve the problem – it produces it. Further removing patient choice of physician, hospitals, testing and prescription drugs and as Medicare-for-All has shown us in the current Presidential debates, it will do so at a cost the country and patients cannot afford. Having a government lawyer run healthcare system for all is meaningless if the choice and quality is compromised. Then we will be left with a system where only the wealthy can truly receive quality choice healthcare.
Woolhandler S, Himmelstein DU. The American College of Physicians' Endorsement of Single-Payer Reform: A Sea Change for the Medical Profession. Ann Intern Med. 2020;172:S60–S61. doi: https://doi.org/10.7326/M19-3775
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Published: Ann Intern Med. 2020;172(2_Supplement):S60-S61.
Healthcare Delivery and Policy, Hospital Medicine.
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