More on "Defrauding"

I was surprised to read the letter to the editor in your most recent edition, March-April 2001 by Dr. Joanne Berkowitz in response to an article by Dr. Hause, To Defraud or Not. Dr. Berkowitz's criticism prompted me to repull and reread Dr. Hause's article because her perspective was for an article I did not believe I had read.

The point I got from Dr. Hause article was the only way to help solve the health care crisis in California and America today is to re-empower the patient, and that would be by making the patient responsible financially for the decisions made.

Attacking Dr. Hause as the messenger and taking several of his examples to the extreme certainly seems to be an attempt to avoid the harsh realities of financing medicine.

The only fraud I understood in Dr. Hause's article was intentional misinformation the insurance companies provide their patients as well as contracting physicians.

I believe that Dr. Berkowitz also missed the point about the car repair analogy; the issue was that insurance is insurance. Whether it is health care, car repair or life, it is just different in how it is administered.

People tend to be much more conservative and cautious with their own money rather than somebody else's. I believe that Dr. Hause is correct, that if patients had control of the purse strings, it would untangle much of the complicated bureaucracy surrounding health care in America today.

- Brian R. West, MD

I was nervous writing the editorial. I feared my colleagues would take it as the ranting of an insensitive and greedy cosmetic surgeon. I am pleasantly surprised that casual feedback has been laudatory and supportive. I'm encouraged that the soon-to-be Dr. Tobalina sees the incomprehensible mess that has become the practice of medicine.

Although my solution may be a fantasy, I forwarded the editorial to stimulate dialog and point out what I believe are obvious truths and disgraceful practices that are nearly universal in health care delivery.

However, it appears the Professional Conduct and Ethics Committee completely misunderstood the crucial points of the article. The article is about maintaining the quality of health care, not how much money ends up in the hands of the "providers."

When I used the word "defraud," it applied to the health care system as I believe it is practiced today. That includes all of the participants, especially third party payers. Some participate by coercion and some by design. It never used to be that way.

"Defraud" was intended to get the reader's attention. That goal was obviously met and, in retrospect the shortened title, viewed in a vacuum, may have given the wrong impression. My original title was "To Defraud or not to Defraud? That is the question."

Obviously the appropriate choice is not to defraud. Although the Editorial Committee did a masterful job of editing my wordy prose, sometimes the intent does not survive the editing.

Frankly I find it tragic that committee members assume that what is good for the physician is not good for the patient or visa versa.

What nonsense. This is not an adversarial relationship. It is, ideally, one of mutual respect and honest interaction.

The reason I described the practices employed in Aesthetic Surgery is to point out that it accomplishes precisely what the current system fails at miserably. That being an honest financial discussion with the person receiving the care. With the current third party payer system, patients have little or no input and are the last consideration, not the first.

The committee stated that medicine failed when it was run as a business. The exact opposite is true.

The reason the "providers" find themselves in such a predicament is that they have never treated it as a business. With all the best intentions they have always subordinated the financial realities to the needs of their patients. Thus, when the business and government establishment took over, it should have been no surprise that they took advantage of this good will and whipped the poor workhorse into near collapse.

How can we expect to care for fellow human beings when our financial house is near ruin? For a while you make up for it by cost shifting (another questionable practice), or increasing production (capitation), all the while relinquishing control to the insatiable for-profit shareholder.

The fact remains: to preserve the quality of care for our patients, the machine that provides this care must be healthy. The simplest and (I believe the only) effective way to maintain the quality of care for our patients is to put the patients in control of the system. However, this requires that they become responsible for payment as well.

Also, no physician, especially me, would ever advocate the denial of care in an urgent or emergent situation for financial reasons or, for that matter, what is usually the case, to satisfy the confining rules of third party payers. On many occasions I have visited the emergency room to care for patients. Since I choose to avoid the hassle with third party payers, I almost never submit a bill.

However, third party payers are obliged to pay for these services. Details could be worked out with emphasis on giving the control of the interaction to the patient, not the insurance company. There would, of course, need to be some sort of oversight.

I obviously ruffled a few feathers. The truth hurts sometimes. Few involved with healthcare in Sacramento would deny that the system is horribly broken. There has been an exodus of talented and dedicated professionals from our area and relations between all of the "providers" are strained at best.

In an effort to cope, the remaining "providers" have been forced to increase their patient volumes and increase the number of personnel that come between the patient and the physician.

However, we as physicians must look inward and realize that to participate in this system is to advocate it. I say we must find a way to empower our patients and discard this disgraceful system of mangled care.

Putting our heads in the sand is not an option if we want to improve the system. So long as patients have little control of and, by necessity, responsibility for their care, they will be relegated to the end of the list of priorities. I appreciate the opportunity to address our membership and hope this is helpful in fostering an honest discussion that will benefit our patients and our ailing health care system.

- Donald W. Hause, M.D.