I figure it’s high time I weighed in on the discussion. I don’t claim to have all the answers, but I do have all the questions. Ten of them, to be exact.

1. Why is healthcare reform going so badly?

Healthcare won’t get fixed as long as the stakeholders in health care with the biggest voice in its reform are the insurance and pharmaceutical industries, medical device makers, lawyers and others whose business thrives on the increasing health care expenditures of the American public.

Asking these folks to help us reform healthcare is like asking Master Card, Walmart, Verizon and Best Buy to help figure out your monthly budget.

Real reform won’t happen until the American people take their seat at the head of the table and invite doctors, ethicists and healthcare experts (not industry lobbyists) to bring their best knowledge about what interventions are most important, most effective and most cost efficient. Then we can sort out our priorities (you can call it rationing if you want) and create a budget.

Only then we can begin to negotiate with third parties (insurers, Big Pharma, etc) to sell us what we need at the best price. That’s called competition, and it’s what American capitalism is all about, right?

The problem is, the American healthcare consumer (and I include myself here) still thinks someone else is footing the bill. Who that someone is, I don’t know. Maybe the rich. Maybe our employers. Maybe the Federal Government.

What we have yet to get is that there is no “someone else”. The deep pockets are our own pockets, and they are empty. Our tax dollars. Our pensions. Our companies going bankrupt from paying employee health care costs.

Until the American people get it that it is our responsibility to get our spending in line, and until our representatives have the guts to turn away the industry lobbyists and represent their constituents instead of their campaign bankrollers, we will continue to have uncontrolled health care spending.

2. But what about the Insurers?

You think when you buy insurance, you’re paying for healthcare? It’s not healthcare – it’s insurance.

The way insurance works is this – you pay in, they pay out. Their profits are the difference between the premiums we pay and the healthcare they cover. So, the less they cover, the more money they make. Your healthcare needs will always be secondary to their ultimate goal, which is to increase profits.

And here’s the thing – If we spend less, it doesn’t go back into our pockets – it lines theirs.

That said, the insurance indutry’s goal of us spending as little of their money as possible is aligned with our goal to stop healthcare spending. So if there’s a place for a “win-win” between the US healthcare consumer and one of our vendors, this is it. But there have to be limits on profits, or we get nowhere.

3. What do you think about a public option?

If it’s anything like Medicare, it won’t run well and it won’t work without rationing. Sorry.

I do like the solution offered up by Mayo Clinic chief Dr Denis Cortese. Namely the package offered to Federal employees, which allows wide range of choice but limits the profits of the insurers. Cortese suggests that the program eventually replace Medicare, and I agree.

4. What about Big Pharma?

What is it they say? Oh yeah – Ask your doctor. Well, here’s what this doctor says. We use way too many drugs in this country.

Which is not to say I don’t use or prescribe drugs, because I do both. But the marketing of drugs is out of control. In addition, Big Pharma is driving health care policy and clinical care standards. Not to mention populating the medical literature with ghost-written articles whose goal is to teach docs to write prescriptions for their drugs.

How did it get this way? Mostly, I believe, because the business model for success in the industry (ie, happy shareholders) demands that every new drug be a blockbuster. That means getting it out as fast as possible to as many as possible before the side effects catch up with the marketing.

How do they do it? One way is advertising, disease-awareness and fear-mongering. Because the sicker you are, the more illnesses you think you have or might have someday, the more drugs you will buy, and the more money they will make. (Notice this is the exact opposite of the business model for the insurers, who make more money when you are healthy.)

Another tactic Big Pharma uses is to expand the indication for their drug. Grow the population at risk. It’s not just diabetes, it’s pre-diabetes, pre-hypertension, pre–alzheimers… you get the drill. In fact, let’s forget waiting for the illness (or pre-illness) to strike – let’s treat everyone “at risk”. If they can identify you as high risk for, say, breast cancer, and then sell you a drug to lower your risk – Bingo! No matter if that drug increases your risk of something else (for instance, blood clots)- you’re not worried about that risk because they’re not “educating” you about it.

If all that doesn’t work, they can always pass a law mandating the drug.

Now, if they’re lucky and get market share before the FDA calls them on their ads, and the post-marketing adverse events don’t kill the drug, then they can continue to sell as much as they can till the patent expires, at which point the generic manufacturers (which are increasingly becoming the initial makers of the drug) can step in like Walmart and clean up on the volume.

Bottom line – The pharmaceutical industry’s goal is simple – sell more drugs. Whatever it takes. Asking them to help us cut healthcare spending is like asking the schoolyard pot salesman what you should do with your lunch money.

Healthcare reform has to include restrictions on Big Pharma – limits on direct to consumer advertising, banning of ghostwriting and full disclosure of all conflicts by any doctor, medical center or university who accepts their funding. We also need more watchdogs on the media and their role in fear mongering and disease “awareness”.

5. What Happened to Malpractice Reform?

It seems to have dropped off Congress’s “to do” list as far as reforms go. Too bad. We won’t get anywhere without it (see my rant on expectations below.)

6. How about the docs?

We docs have got to get our act together, stop fighting over the pie and help America solve this thing. Unfortunately, we are part of the problem. One reason is that we’re too busy seeing patients and trying to survive. That’s because our current business model demands volume for survival. As our costs of doing business (insurance overhead, malpractice, cost of wages and healthcare for employees, rent, the EMR) have risen, real reimbursement has dropped. Ergo the 15 minute visit, now the 8 minute visit.

Proposed solutions that include cutting reimbursement to docs will only make the problem worse, especially for primary care, which is going the way of the dinosaur.

The good new here is that, overall, docs will follow the money. You wanna’ reimburse specialty care at a higher rate than primary care? No problem, we’ll churn out nothing but dermatologists and back surgeons. You’re willing to pay us cash for Botox and fillers? Sign us up! You’ll reimburse AIDS care at a higher rate? Why didn’t you say so? Look, we built you an AIDS Center!

Not to mention that deep down, a whole lot of us really do have our patients’ best interests at heart, but are just as trapped in the maelstrom as you are. Tap into that interest and make our business model fit your needs, and we’re on our way to fixing this Magilla.

Some docs have decided they can’t wait for national reform, and are taking matters into their own hands, offering quality healthcare at a price they can afford to deliver it. It’s called Concierge Medicine. Unfortunately, Concierge Medicine currently defines only a small portion of the healthcare market. Critics say it cherry picks the healthy and the wealthy, and won’t work for the average American. Others say it’s a choice that most sensible Americans can afford if they choose to use their dollars this way.

I think it’s a step in the right direction.

7. What about the patients?

Or should I say “healthcare consumers”? As I said, we are part of the problem. The American consumer has unrealistic expectations, both in terms of outcomes and costs, when it comes to healthcare. We expect perfection, 100% certainty in diagnosis, and have no tolerance for any delay in diagnosis. We want every test that can be done, damn the cost, when it is us or our family who is sick. We want every last second of life, regardless of the price to society. We want to smoke as much as we want, eat as much or as poorly as we like, and have our cardiac cath and CABG covered, no questions asked. And we want cheap premiums to boot, with unlimited access.

At the same time, we are being sold to, fear-mongered and pushed in every direction by those whose major goal is profits. Which feeds perfectly into our skewed expectations.

8. Can’t we just ration?

It’s a good idea, but it ain’t happening. Not yet. We might accept gas lines, but we won’t accept having anyone tell us what we can or can’t have when it comes to our health.

Bob Wachter at the excellent Health Care Blog has written a fabulous post on healthcare rationing that I encourage you all to read. He concludes that Americans will never accept rationing in other than the imperfect form that currently exists in our capitalistic society.

Twenty years ago, the great Princeton healthcare economist Uwe Reinhardt observed that there are two kinds of rationing: “civics lesson rationing” and “muddling through elegantly.” … The muddling through option, which Reinhardt felt was far more likely, involves limiting the resources available – the number of ICU beds, or MRI scanners, or CT surgeons – and allowing docs, patients and administrators to duke it out at the bedside. The evidence is that they do a decent job at triaging to provide the most good for the most people.

Of course, these limits are naturally present when resources are truly scarce – like livers for transplantation – and in these circumstances we developed thoughtful rationing approaches. The point is that health care dollars increasingly resemble livers.

I happen to think he is right. For the moment.

This first year of national discussion is a preamble. At some point in the not too distant future, reality will set in and we will begin to understand that we need to ration healthcare. Maybe by then, someone will have come up with a better word than “rationing” that doesn’t have such negative connotations to most Americans. Whoever it was who came up with the term “Death Panels” seem pretty good at this sort of thing, maybe we can ask them…

9. It’s a mess, isn’t it?

Darn tootin‘ it is. There’s no way we’re fixing it in one year. But we seem to be finally getting our heads out of the sand, and that’s a start.

I do happen to like much of what Paul Levy is recommending – except I would keep insurance premiums pretax and allow the self-employed to deduct them as well.

10. What’s going to happen this year?

Here’s what I predict will come out of healthcare reform this year –

The insurers, Big Pharma, lawyers, hospitals and others with big profits at stake will be sure to prevent any meaningful change to their bottom line. Healthcare consumers as a whole will continue to expect blood from a stone, which aligns perfectly with industry’s need to keep healthcare growing.

Which will leave the docs with a pie that is unchanged in size, but that they will be forced to split differently. In the one good thing to come out of this whole mess, primary care will win a bigger piece at the behest of the specialists.

And the spending will go on.