         The Health Care Crisis -- One Surgeon's Critical View
                   Stephen D. Leonard, M.D., F.A.C.S.
        
                         Editor's Introduction
        
              An earlier version of this article has become a
        popular download textfile on Compuserve.  When Dr.
        Leonard replied to my reprint request inquiry, in
        addition to graciously allowing non-exclusive reprint
        rights, he added a paragraph that deeply illustrates
        the depth of his feelings.  Dr. Leonard is 47 years
        old.  I've also been given permission to reprint this
        paragraph, which goes:
        
              "As you are obviously aware, everything has gotten
        much worse since I wrote that article. I finally
        couldn't stand it any more, and have abandoned vascular
        surgery. I calculated that if I remained as angry as I
        was for another ten years or so, I would be dead of a
        heart attack before age 60. I am now working for a
        cosmetic hair restoration group in Beverly Hills. It
        lacks the visceral satisfaction of saving lives, but it
        is pleasant, low stress, and safe from government
        intrusion, at least for now."
        
              As for the original and subsequent publishings of
        this article, Dr. Leonard provides the history himself:
        
              "As far as its publication history, the reference
        I have is: Leonard, SD. The health care crisis "One
        surgeon's critical view." Trends in Health Care, Law
        and Ethics 8: (3) 55-60. 1993. This is a quarterly
        journal published by the UMDNJ-Robert Wood Johnson
        Medical School. The editor, Russell McIntyre, Th.D.
        [>INTERNET:rmcintyr@UMDNJ.EDU] picked up the article
        the same way you did --here on CompuServe. It was also
        published in the monthly journal of some county medical
        society in South Carolina, but I don't have the
        reference. The president of the medical society also
        downloaded it from CompuServe."
        
                                                  Steve Leonard
        
        
        
         The Health Care Crisis -- One Surgeon's Critical View
                   Stephen D. Leonard, M.D., F.A.C.S.
        
                            August 26, 1993
                 Updated for ShareDebate International
                             April 4, 1994
        
                Copyright 1993, 1994 Stephen D. Leonard
                          All Rights Reserved
                 Reprinted by permission of the author
        
                       8544 Burton Way, Apt. 407
                         Los Angeles, CA  90048
                       Compuserve ID: 76260,1663
        
              I am increasingly amazed and discouraged at the
        tone of the present national discussion of how we are
        to change our health care system. Even before Hillary
        Clinton began her labors, there was an escalating fad
        to slash indiscriminately at both health care costs and
        physicians' autonomy without regard to the long-term
        results. With the new Administration, a mob psychology
        seems to have taken hold. While Mrs. Clinton's secret
        meetings continue, and as each grandstanding
        politician, self-righteous bureaucrat, and uninformed
        "advocate" tries to outdo the pronouncements of the
        previous one, a climate is developing which is driving
        today's physicians out of the profession, and will
        deter bright, motivated, capable, caring young people
        from entering it in the future. By the time the
        Administration, the Congress, the plaintiff's bar, the
        Health Care Financing Administration, the Occupational
        Safety and Health Administration, the insurance
        industry and the press are through savaging those of us
        who have devoted our lives to caring for America's
        health, the country will be dismayed at what is left of
        a system that once provided the best care in the world
        to 85% of the population, and did the best it could for
        the other 15%. In a few years, not only Medicare
        patients, but all of society will be unable to find the
        kind of physicians they have come to consider their
        "right."
        
              As election-year politicians and the new
        Administration's young zealots have whipped the press
        into a feeding frenzy over the "crisis in health care,"
        the great majority of Americans still get expert,
        compassionate, prompt care when they need it. It has,
        to be sure, gotten very expensive; no one is prepared
        to settle for less than the very best and latest
        therapy.
        
              Overlooked in all the hysteria is the fact that
        health care is a service provided by people--doctors,
        nurses, and an array of support personnel. Whatever
        system comes out of the current political chaos, it
        will require doctors to make it work. And those
        doctors, one can only hope, will continue to be people
        with a far greater than usual commitment to their work.
        Despite all the facile comparisons to other government-
        supplied social services like education, fire and
        police protection, Medicine is unique. On reflection, I
        think the vast majority of people will want it to
        remain that way. Educators, firemen, policemen, all
        work their shifts and then go home. Doctors must be
        available 24 hours a day, seven days a week. If I
        operate on someone in the morning, and he has a problem
        at midnight, I am the one who needs to be available to
        take care of him. Quite simply, no one else knows his
        problem as well. No "next shift" can do it. And, of
        course, I am available. Despite all the publicity
        focused on a relatively few doctors who are very rich,
        arrogant, or unavailable, most of the 500,000 or so of
        us are not rich, are deeply concerned with the welfare
        of our patients, and are virtually always available. We
        dedicate ourselves to our patients in a way asked of no
        other members of our society. In return, until
        recently, we had the expectation of making a good
        living, and being free from pointless, spiteful
        persecution by small-minded bureaucrats. The kind of
        care Americans have come to demand can only come from
        physicians who love their work and feel a dedication to
        it far beyond most people's. As the attacks on us
        intensify, that dedication is slowly being beaten out
        of those of us old enough to have been driven by it; it
        is being replaced by bitterness, discouragement, and a
        search for alternative ways to earn a living. As we are
        driven out, we will be replaced by young doctors who
        never knew that dedication in the first place. They
        will put in their 40-hour-week at $24.95 an hour, and
        then go home. If you happen to come in after hours, or
        you are in pain, or just terrified of dying well, hey,
        the next shift should be along soon.
        
              Great torrents of blather have been devoted to
        what is wrong with American health care. Problems are
        real and serious. Millions of people don't have
        adequate insurance. Those who do pay dearly for it, or
        their employers do. A few doctors have been caught
        egregiously ripping off the system; others are
        arrogant, uncaring, incompetent or alcoholic; still
        others overcharge outrageously for procedures that are
        not as difficult as they once were. Eleven, then
        twelve, then thirteen percent of our national
        expenditures go to health care and related expenses
        (though a quarter of that is administrative costs,
        having nothing to do with health care). So a great hue
        and cry have gone up. Business, the insurance industry,
        the elderly, self-proclaimed experts and "advocates"
        all insist, the Government must, by God, do something!
        Led by Mrs. Clinton and Mr. Magaziner, so they will. It
        hardly seems to matter how destructive or ill-
        conceived, just so we get "change." Mandatory HMO's,
        "Managed Competition," DRG's, threaten sanctions
        against doctors who keep patients in the hospital
        longer than what is "medically necessary," then fine us
        for sending them home too soon. Play or pay, national
        health insurance, single payor, slash fees by 20-30-
        40%, encourage "cognitive" medicine, assess fines and
        civil penalties against doctors who can't understand
        the bureaubabble spewing over them, better yet trump up
        antitrust charges and throw them in jail! (Can't we
        hang a few, to make an example of them?) Change the
        forms, change the terminology, change the rules, change
        the codes. Hire more reviewers, previewers,
        precertifiers, utilization managers, quality managers,
        administrators, assistant administrators, medical
        directors. Aha! Now we've got the bastards on the run!
        
              But look whom you've got on the run. The huge
        majority of doctors are decent, compassionate,
        dedicated, extraordinarily hardworking human beings who
        sacrifice first their youth, then their family life and
        free time, and ultimately, often, their own health for
        their patients. Virtually no one else in our society is
        routinely expected to give as much.
        
              Becoming a physician requires more deliberate
        sacrifice than perhaps any other peacetime occupation.
        After graduating from college, my classmates went in
        all directions. Many went straight into business. Some
        spent a year or two getting Masters degrees, or three
        years becoming lawyers. Some very bright, devoted souls
        spent four or five years getting Ph.D.'s. I decided to
        become a vascular surgeon, so I spent the next twelve
        years working sixteen, twenty, sometimes twenty-four
        hours a day, six or seven days a week, depriving myself
        of most of the joys of young adulthood, and immersing
        myself in other people's worst misery. In my twelfth
        year, as a Fellow in Vascular Surgery, I was even paid
        $28,000. It never occurred to me to wonder if it was
        worth the sacrifice--my father, whom I idolized, was a
        doctor, and I hoped to be like him. I loved the work; I
        treasured my growing ability to do seemingly impossible
        things to help people in dire need; I enjoyed the
        respect accorded even a young surgeon in training; and
        I looked forward to working as long as I was physically
        able to do so at a career from which, in return for
        continued long hours and constant dedication to
        excellence, I could expect all those benefits and a
        good income, as well. For it remains an undisputed fact
        that, in this proudly capitalist country which preaches
        to the world about the evils of Central Planning, one
        major inducement to excel remains the hope of being
        rewarded financially for doing so.
        
              When I first entered practice, in 1979, it seemed
        that my dreams would be realized. I was helping
        terribly sick people with skills honed during those
        endless years of training, and had the joy of seeing
        them get better, and the satisfaction of feeling their
        gratitude. Those who could afford to, or were well-
        insured, paid my fees; others couldn't, and didn't. One
        elderly diabetic, with more pride than money, had her
        daughters bring me gifts of wonderful, fiery, home-
        cooked Mexican food, which I treasured. As my practice
        grew, unlike in my training years, I only rarely worked
        more than sixteen hours a day, and every couple of
        months I even took a day, or sometimes a whole weekend
        off. I also, more than once, canceled long-planned
        vacations because some patient for whom I felt
        responsible had developed a new problem, and I felt
        obliged to be available. As I had hoped, my reward for
        skill, dedication, compassion, and very hard work, was
        satisfaction, appreciation, respect, and a good income.
        Finally, I confess, in 1985, I even bought a BMW. (Nine
        years later, it has 130,000 miles on it, and I'm still
        driving it.)
        
              Foolish pronouncements about "greedy, rich
        doctors" notwithstanding, most doctors make a good
        living, but are not rich by anyone's definition. Rock
        stars, corporate executives, plaintiff's lawyers and
        quarterbacks make far, far more than doctors. The
        average physician in 1992 had a net income of about
        $140,000 to $160,000 before taxes. In a world where
        Congressmen have just raised their own salaries to
        $135,000 a year plus much more than that in "expenses",
        and heavyweight boxing champions make $472,000 a
        minute, that doesn't seem excessive. No one gets
        indignant if a plumber charges $150 to fix a flooded
        basement on a weekend. Why is everyone so furious at me
        for charging $120 (the maximum allowed by law), for
        getting up and going to the Emergency Room at 3:00 in
        the morning to evaluate someone's life-threatening
        illness?
        
              Nine years ago, the regulatory juggernaut began
        in earnest the crusade to bring the health care system
        to heel. In that time, my reimbursement for most of
        what I do has been forcibly decreased by about 40%,
        while my costs for everything from office rent and
        salaries to liability insurance have, on average,
        doubled. Perhaps worse, I now have an army of
        vindictive bureaucrats and largely untrained reviewers
        nipping at my heels, and must waste many hours a week
        defending myself against their overwhelmingly
        wrongheaded second-guessing of my clinical decisions.
        
              Last year, a man came to our emergency room after
        suddenly going blind in one eye. The ophthalmologist
        and neurologist, who saw him first, identified his
        carotid arteries, which are the principal blood supply
        to the brain, as the source of the trouble and called
        me. An arteriogram revealed both of his carotid
        arteries to be over 95% blocked. His eye was
        irretrievably damaged, but there was a massive stroke
        just waiting to happen. I operated on him, and fixed
        both carotid arteries, and he left the hospital in a
        week. The local peer review agency decreed that the
        hospitalization and both operations were "not medically
        necessary," and told the patient so! We got the
        decision reversed after wasting many hours writing
        angry letters, but the patient, who had received the
        best possible care and had done well, had his
        confidence badly shaken. I could find much better
        things to do with my time than argue with idiots. Yet
        this happens day in and day out, not because there is
        anything wrong with the care that I and most other
        physicians deliver, but because the only politically
        acceptable way the government and insurance industry
        have been able to save money is by threatening and
        browbeating doctors.
        
              In the spring of 1972, just when it seemed it
        couldn't get much worse, OSHA landed on us with an
        astonishing--and entirely irrational--set of rules
        governing "biohazards." The rules are convoluted and
        incomprehensible, as always, but one can glean the
        general tone from the fact that if a soiled bandage, or
        a used tampon, that anyone could throw away at home,
        turns up in my office trash, I can be fined up to
        $70,000! I have not met a single physician (and we do
        know about health hazards, after all) who thinks that
        anyone's health will be safeguarded by these rules. But
        by OSHA's own (very low) estimate of a cost of $1200
        per physician per year, they have just added nearly a
        billion dollars a year to our national health care
        bill. The corresponding regulations for hospitals,
        clinics, and school and industrial health offices will
        cost tens of billions more.
        
              Recently, an attorney I know told me that the
        favorite name for physicians among attorneys and
        government regulators is, "Wildebeest." As we've all
        seen on TV, the wildebeest is the large, benign, juicy
        animal that all large predators love to feed on. After
        years of having jackals and hyenas tearing at me, it is
        increasingly hard to focus on the lofty ideals that
        made me want to be a surgeon in the first place. One-
        on-one with my patients, if I can put the big picture
        out of my head, I still savor everything I hoped to
        enjoy about being a surgeon. But overall, I hate it. I
        am 46 years old, and only survive by promising myself
        that I will retire as soon as I can afford to.
        Unfortunately, that day gets farther and farther away
        with each turn of the federal screw.
        
              I expect derisive comments from some quarters
        about spoiled doctors getting our comeuppance. I am not
        soliciting sympathy, but rather offering a serious
        warning. If present trends and policies continue, no
        young person with the combination of qualities you
        would hope someday to find in your doctor, will go to
        medical school. All that attracted some of the best of
        my generation to become doctors--intellectual
        challenge, freedom to do the very best we knew how for
        people desperately in need, based on our best
        understanding of science and humanity, rewarded by
        trust, respect and, yes, financial security--is being
        taken from us. Indeed, applications to medical schools
        have dropped over the last ten years. (There has been a
        slight rebound in the past three years, mainly young
        people from tormented Asian countries, newly come to
        this country.)  There is no reason why a smart college
        student should make the enormous sacrifices necessary
        to become a surgeon to live the way surgeons can expect
        to live fifteen years from now. As the word gets out,
        smart college kids won't even consider it.
        
              Maybe the biggest irony in all of this is that
        the heaviest burden of current policies is borne by
        exactly those physicians whom most people would select
        as the best our profession has to offer. Since the
        Federal Trade Commission, backed up ultimately by the
        Supreme Court, decreed that doctors could not be
        prohibited from advertising, a class of slickly
        packaged doctors has appeared, filling magazines and
        telephone books with expensive self-promotion unheard
        of since the snake-oil salesmen were banned at the turn
        of the last century. As the Health Care Financing
        Administration cuts, and cuts, and cuts reimbursement,
        they include further reductions to account for the
        cheating which they assume will follow. They then add
        threats of truly draconian penalties to keep us
        "crooked doctors" in line. Those of us who remain
        scrupulously honest must swallow the insult along with
        the reduction in fees. The more entrepreneurial of my
        colleagues have hired expensive consultants to find the
        loopholes in the ever-more-bewildering regulations, to
        maximize their incomes; again, those of us who choose
        simply to do the right thing for our patients are the
        ones who suffer a further reduction in income. A whole
        new class of "managers" has appeared, trying to teach
        us to think of our patients as "clients" or
        "customers," and to market our "product lines"
        accordingly. Those of us who simply want to sustain the
        healthy and heal the sick are increasingly treated as
        obsolete relics of a bygone age. A quarter of our
        staggering health care bill pays not for health care,
        but for "administrative" functions--bureaucrats and
        opportunistic businessmen who contribute nothing to
        solving the problems of the sick, but siphon off a huge
        chunk of the resources, as they cry crocodile tears
        over the size of the bill.
        
              Mrs. Clinton and the present government-business-
        "consumer" coalition certainly have the power to
        continue to abuse and humble physicians, be it for
        sport, profit, or out of dog-in-the-manger resentment.
        But if they do, they will find themselves with a health
        care system that, as someone predicted, will combine
        the compassion of the IRS, the efficiency of the post
        office, and the cost-cutting skills of the Pentagon.
        
              Solutions to the very real problems in health
        care must be found. It is vital that we find ways to
        address the spiraling costs and the problems of access,
        and do whatever we can as a profession and as a society
        to be sure that the care we provide is expert,
        appropriate, and compassionate. I do not claim to have
        all the answers, but would offer these suggestions as a
        beginning, or a basis for a rational dialog to replace
        the current hysteria:
        
              1. Before we hack away at doctors and hospitals,
        look at the totality of health care expenditures, and
        trim the part that does no one any good. It is
        essential to differentiate between those areas within
        the "global budget" that have already been cut as far
        as they can without impacting quality, and those areas
        where there is still fat to trim. I submit that most
        doctors have experienced cuts in the last few years,
        deep enough to discourage them from providing the level
        of care that we, as a nation, want. Further decreases
        in their reimbursement will begin to do real damage to
        physicians, and to their ability, as individuals, to do
        what we need them to do, at all hours of the day or
        night. If we want an excellent health care system to
        emerge from the present process, we must ensure that
        the rewards of providing health care go to the
        providers--not to an array of middlemen who really
        contribute nothing. Though the President wants
        physicians to "sacrifice," a strong case can be made
        that we have already done so. William Hsiao, Ph.D., is
        the Harvard economist whose work on a "Resource-Based
        Relative Value System" formed the basis for Medicare's
        1990 assault on physicians' incomes. In a recent,
        lengthy analysis of the results of that "reform," Dr.
        Hsiao concluded, "The current Medicare fee schedule
        yields too little net income to most physicians. In the
        long run, the Medicare level of payments would not
        attract an adequate supply of qualified people to
        medical careers unless private insurers continued to
        subsidize the services used by Medicare beneficiaries.
        It is clear that legislation is needed to correct these
        deficiencies."
        
              God knows nurses have never been paid half of
        what they are worth, and they have been fleeing
        clinical nursing in droves; cutting the funds available
        to pay them would lead to a real catastrophe. Even
        hospitals have done a fairly good job of reducing waste
        in the actual delivery of care. Where hospitals waste
        vast amounts of money is on the salaries and
        machinations of bureaucrats whose presence is mandated
        in one way or another by the myriad of agencies with
        authority to dictate how hospitals are run, from
        innumerable Federal and State financing agencies, to
        OSHA, to the EEOC, to the American Cancer Society, to
        the Joint Commission on Accreditation of Healthcare
        Organizations. That 28% of the total health care cost
        that goes to administration is an obscenity. Cutting
        that only in half would reduce health care from 13% to
        11.2% of GNP without depriving any patient of anything.
        
              The government spends $300 million annually
        paying "peer review organizations" to scrutinize
        Medicare charts for quality of care. After the almost
        panicky response of seniors to the 1984 cut in hospital
        reimbursement, Congress was thrashing around to make it
        look as if cutting expenses would not impact on care.
        They hit on a scheme of vindictive nit-picking of
        doctors, which has little or no benefit in terms of
        assuring quality of care, and is horribly expensive,
        but does allow them to say, "See, we're getting tough
        with doctors who try to practice substandard medicine."
        In practice, hospital records are reviewed either by
        non-practicing nurses or by clerical personnel, and are
        screened against big checklists for "variations" or
        "quality issues." When such are identified, the
        physician is sent a threatening letter, giving him 30
        days to prove there was no "mismanagement" or face
        demerits. Too many points can result in a fine or
        exclusion from caring for Medicare patients. To the
        totally uninitiated, it doesn't sound unreasonable,
        except that the alleged "mismanagement" usually means
        only that the clinical problem was complex enough that
        the reviewer didn't understand it. The "charges" are
        usually discarded after the physician wastes hours and
        hours educating the reviewer as to what was going on.
        
              Actually, there is a system of verifying quality
        of care, already in place, and it's free! As a
        prerequisite for certification, each hospital is
        required to have a complex quality assurance plan,
        which the medical staff must submit for review no less
        than every three years. As possible problems are
        identified, they are brought to the attention of
        departmental committees, usually consisting of the
        involved doctor's colleagues and competitors, where
        they are studied. Many can be disposed of, but if there
        is a problem, the physician involved will be brought
        before the committee and questioned, cautioned, or even
        have his privileges reduced, depending on the severity
        of the problem. This is done without the stupid
        vindictiveness of the PRO system, but it is far more
        effective. And, to repeat, it is free!JDoctors donate
        their time. The only serious impediment to the
        effectiveness of this system comes from the government:
        federal antitrust law has been interpreted to allow
        doctors who have been disciplined by review committees
        acting in good faith, to sue for monetary damages by
        alleging anticompetitive activities by the reviewers.
        Eliminating the PRO's, and strengthening the free, in-
        house peer review process would provide improved
        quality assurance, and save a third of a billion
        dollars in one fell swoop. There are dozens of similar
        examples.
        
              2. The thing our government has been worst at
        doing, since the dawn of regulation, has been
        controlling those who break the rules without punishing
        the larger number who really try to live by them. Yet
        it is crucial that new regulations aimed at eliminating
        "unnecessary" tests, medication, and procedures, not
        place such a heavy burden on physicians that necessary
        care cannot be administered. Those doctors who are
        doing exactly what we as a society want them to do
        should be encouraged, not threatened and punished. The
        astonishing vindictiveness of the Health Care Financing
        Administration towards physicians has served only to
        demoralize us and drive a wedge between us and the
        people we serve. Somehow, the decency and humanity of
        the majority of physicians must not be ignored or
        trampled when government makes policy.
        
              3. Establish a central government agency that
        must approve all government regulations impacting on
        health care issuing from the dozens of executive branch
        agencies. Give this new Health Policy Coordinating
        Agency the power to alter or reject any regulations
        that conflict with more pressing policy directives from
        the Congress or other agencies. Too often, we are
        whipsawed between competing bureaucratic entities;
        each, like the proverbial blind man and the elephant,
        only perceives a tiny piece of the picture and,
        thinking it understands the whole thing, promulgates
        regulations that cause terrible damage in some area its
        proponents never considered (or, when informed, don't
        care about). Thus, the recent sweeping, ludicrously
        excessive, OSHA regulations concerning medical waste,
        which will probably cost a billion dollars a year to
        implement in doctors' offices, and ten times that in
        hospitals, would be balanced against the demand for
        cost reduction. They might well be reduced in scope or
        discarded entirely.
        
              4. Encourage an honestJdialog regarding health
        priorities, as only Oregon is attempting to do. If
        dollars are limited, the question of whether an
        indigent care program should pay a million dollars for
        a bone marrow transplant for a sad, big-eyed, dying
        child, should be made on the basis of intelligent
        prioritizing, and not tear-jerking TV shows or
        lawsuits. Society as a whole may decide that it does or
        does not want to tax itself to pay for this, or for
        coronary artery bypasses for ninety-year-olds, or
        experimental drugs for AIDS patients. But these
        decisions to use more or less taxpayers' money (there
        is no other kind) should come from legislatures with
        the full advice and consent of the American people, and
        not from dark courtrooms or TV studios. The recent
        suggestions that Oregon's plan cannot be implemented
        because it might conflict with the Americans With
        Disabilities Act must be eliminated by prompt
        corrective legislation clarifying the ADA.
        
              5. Once we have determined what minimum level of
        care we, as a society, want to provide for every
        American, resist the impulse to decree, in the name of
        "fairness," that no one may purchase a higher level of
        care if he has the means to do so. Our egalitarian
        impulses are often at odds with our devotion to free
        enterprise, and with common sense. It would be as
        foolish to ban those who could afford to purchase
        health care beyond the universal minimum from doing so,
        as it would be to tell successful individuals that they
        were prohibited from spending their money to eat in
        better restaurants, live in nicer homes, drive nicer
        cars, or take fancier vacations, than the poorest
        person in the country. The best we can do in the name
        of fairness is provide everyone an equal opportunity to
        excel. Having a level playing field cannot mean
        assessing a six point penalty against a team any time
        it scores a touchdown.
        
              Philosophical considerations aside, the high end
        of any industry drives technological progress, and
        provides the engine that leads to new discoveries. If
        those who can afford to purchase additional health care
        are prevented from doing so, advances that can benefit
        everyone will be impeded.
        
              6. Refrain from fatuous sloganeering about health
        care. Health care is not a "right," it is a valuable
        service provided by highly skilled people. In this free
        society, at least since the Emancipation Proclamation,
        no one has a "right" to someone else's labor. Food and
        housing are even more urgently necessary than health
        care, and they cost more than health care. In all three
        cases we must formulate policy to assure that they
        remain available in sufficient quality and quantity to
        meet the needs of our population, and we must then be
        prepared to pay for them. We must not constantly punish
        the people we rely on to provide them simply to cover
        up society's inability to plan or prioritize
        intelligently, or Congress' inability to accept
        responsibility for the results of  its actions.
        
              7. Merge Workers' Compensation coverage with
        general health insurance wherever both are provided by
        an employer. It is absurd for an employer to have to
        pay two competing insurance bureaucracies to fight with
        each other over which of them should pay for an injured
        worker's care. State Industrial Commissions routinely
        spend $20,000, and several years, on lawyers, second-
        and third- and fourth opinions, hearings and
        administrative reviews to get out of spending $1,500 on
        an operation that could have gotten the worker better
        and back to his job in six weeks. Employers should be
        encouraged to opt out of Workers' Compensation by
        purchasing a single, complete insurance package that
        covers employees' health problems wherever they happen
        to occur.
        
              8. Severely restrict the multibillion-dollar
        malpractice lawsuit industry. Directly and indirectly,
        the threat of lawsuits adds greatly to the cost of
        health care. Insurance premiums alone, at an average of
        $15,000 per doctor (lower for some, much higher for
        others) cost over $7 billion per year. But it is
        impossible to estimate the number of times every doctor
        says to himself, "I'm 99% sure I already know what this
        scan will show, and I could just as well do without it,
        but I'll be damned if I'm going to stand in court and
        be asked, 'Doctor, did it ever occur to you to get an
        MRI scan?'" So another thousand-dollar test gets
        ordered (no, the doctor who orders it doesn't get the
        thousand dollars), and everyone's bills go up a little
        more. If it can be shown that a doctor was incompetent,
        or impaired by drugs or alcohol, or driven by malice,
        or attempted something for which he was unqualified,
        then it makes sense for him to have to make restitution
        to his injured patient. But lawsuits over bad outcomes
        (everyone has one, in the end, after all) are sucking
        health care--and the rest of the economy--dry. "Pain
        and suffering" awards should simply be eliminated. They
        can't undo the pain, and too often are simply a way to
        make bad luck profitable. Punitive damage awards should
        be eliminated as well. In the extraordinary case where
        a physician's behavior is so bad as to warrant
        punishment beyond being forced to pay restitution to an
        injured patient, any monetary penalty exacted should go
        into a general health care fund, not into the pockets
        of plaintiffs and their attorneys. Most importantly,
        all malpractice claims should be heard before
        permanent, expert arbitration panels, not the circus of
        our court system. A full-blown trial can easily cost
        half a million dollars by the time it's over;
        arbitration before a panel of experts can hear the same
        evidence and give a more intelligent verdict for one
        tenth that amount.
        
              9. If insurance companies are to be given any
        role in the new health care system, restrict it to
        necessary management of the flow of payments to
        providers. Their role in the present system is patently
        dishonest and exploitative, and their second-guessing
        obstructionism is the single biggest thorn in doctors'
        sides. If we have resolved as a nation to spend less on
        health care, as close as possible to 100% of that
        lessened expenditure must buy actual health care. There
        can be no possible excuse for squandering any of it on
        insurance companies.
        
              10. Except in urgent situations (AIDS research,
        perhaps?) direct the Food and Drug Administration to
        license new technology only after its efficacy has been
        demonstrated in studies in university medical centers,
        and it has been accepted by recognized professional
        specialty organizations. Until recently, virtually all
        research came out of the relatively pure intellectual
        environment of the major universities. In the last
        decade, hugely expensive technologies have been
        developed by corporate venture capital, with input from
        private physicians, with virtually no balanced,
        scientific studies of their effectiveness. They have
        been brought to market over the objections or at least
        the reservations of the nationwide specialty
        organizations, been snapped up at enormous expense by
        hospitals not wanting to be left behind their
        competitors, and only later been shown to be
        ineffective. (Endovascular lasers are but one
        noteworthy example in my own field.)
        
              We can, as a nation, provide expert,
        compassionate health care to all of our citizens. It
        will never be cheap, but we can make sure it is
        affordable if we approach the problem thoughtfully. The
        vindictive, meat-axe approach that has characterized
        recent policymaking can only decrease our
        effectiveness, divert to wholly unproductive
        bureaucrats money that could be saved or spent on real
        health care, and drive away from medicine the very
        people we should be trying to attract into it. It is
        crucial that the Clinton Administration and the
        Congress, in trying to redesign the system, take an
        entirely different tack, and provide some encouragement
        and reward, not to the innumerable parasites around the
        periphery of the health care system, but to those of us
        who are trying to do our best at an enormously
        difficult job. Those making policy today, and all the
        rest of us, will need caring, dedicated, expert
        physicians someday. How we reshape our health care
        system will determine whether or not they will be there
        when we need them.
        
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