Tuesday, March 31, 2009

Those Who Pay the Bills Run the Business

Several news stories and political developments drive home an important point in health care delivery: Money is power. The person who pays the bills runs the business.

Take for example the dwindling autonomy of businesses and industries that accepted government aid over the last couple of months. 1) The Obama Administration forced CEO Rick Wagoner out of GM after rejecting GM's restructuring plans. The Obama Administration paid to keep GM alive and now runs GM. 2) Recently, the House tried to hammer AIG, another bailout recipient, and passed a 90% tax on AIG's executive bonuses. The federal government owns AIG. It's freedom as a business only extends as far as good favor from the government. 3) Now Barney Frank is pushing a bill that would establish government control of the salaries of all businesses that received bailout funds. If the government pays the bills, they run the business.

Health care providers need to decide who they want calling the shots at their own clinics: do they want government-directed care, insurance company-directed care, or patient-directed care? That will be determined by who they allow to pay the bills.

I believe that most physicians truly believe that patients should be their own health care executives. They should have the final say on all medical decisions. Physicians and other health care workers are contracted to the patient to provide services under the patient's direction. Patients can hire and fire physicians at will. That is the ideal in medicine- the patient is in charge.

Experience and reason show that the responsibility of physicians to patients extends only to the degree that patients pay their own bills. The patient remains the health care executive only as long as they pay the medical bills. As soon as they delegate that responsibility of paying, they are no longer in charge of their care.

Patients' and doctors' experience with health insurance companies supports this idea. When clinics begin working with insurance companies, the whole nature of the practice changes. The insurance company is now making the calls. They determine treatment regimens- declaring some treatments acceptable and ruling others out despite patient wishes. They mandate diagnostics, both requiring redundant screenings and denying more expensive essential diagnostics. They even require additional staff hiring at the clinic, requiring the hiring of billing personnel exclusively for correspondence with the insurance company. Insurance-paid medical care is not patient-driven medical care. Many patients are okay with this- they've contracted insurance companies to manage their care. Insurance pays the bills and insurance runs the business.

What about when the government pays the bills for health care? It seems that the federal government has demonstrated a light touch in the cases of Medicare and Medicaid. Here the government is paying the bills, but they have allowed remarkable autonomy to patients and thus practitioners. Thus the common claim: Medicaid is the best health insurance! However, the reality that government-paid health care is government-controlled health care is present in each health care regulation or bill that rolls through the legislature.

Take for example the conscience-clause regulations that President Obama is about to overturn. Which health care providers do conscience-clause laws and regulations actually effect? Only those who receive federal funding through programs including Medicare and Medicaid. For another example, consider the health care legislation that was buried in the February stimulus package. The legislation establishes a National Coordinator of Health Information Technology with potential powers to establish and enforce a national standard of care. What health care providers will be responsible to this Coordinator? As far as I can see in the bill, only "government-sponsored" health care programs (pp 470) and recipients of Medicare, Medicaid, and state children's health insurance programs (pp 481) are currently marked for integration into the HIT program. When the government pays the bills, government runs the business.

If patients want to control their health care, they must pay the bills. If health care providers want patient-driven health care, they must establish practices where patients pay the bills. As government control increases in the health care industry, the best way to maintain autonomy over a practice may be to refuse third-party funding, especially government funding. Cash-only practices may become the only venue where patients remain health care executives and the doctor-patient relationship is preserved.

The federal government is trying to work up a steam push through government-run health care. They don't call it that, in fact many will sell the package as patient-run or patient-centered health care. But those who pay the bills run the business. You can bet that the same House, Senate, and White House that had so much to say about AIG and GM will have plenty to say about health care. Patient control over health care will be as remote as my control of the House of Representatives. After a few unanswered letters to the legislature, they will be left powerless and blogging.

Rusty Scalpel

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