Doctors are no different than anyone else in spite of us often being placed on pedestals.  The altruistic thoughts that brought many of us into the healthcare field became more and more tempered as time went by and outside forces began to dictate how, when and where we could care for our patients. I can still remember "trading" my services for something like brickwork, hunting lease access, housepainting, or yardwork.  People took pride in their ability to take care of themselves and their families. If a person had insurance, they would pay for services up front and we would sign the forms for them to mail in.  Then we started filing the forms for our patients as a way to "provide" better care than our competion. Next we began taking insurance assignments to minimize the out-of-pocket expense. Since that out-of-pocket expense was no longer a factor in seeking treatment, more sought our services. Some doctors soon realized that since the patient really didn't know what the fees were, and even more-so didn't care since the "insurance company" paid for it, fees began to go up. As the insurance companies tried to get a grasp on escalating fees, "norms" or average fees were established for an area. In order to get properly re-imbursed, almost all of us tried to stay in the magic "75% percentile" range in order to be sure we stayed ahead of the inflation curve of the 1980's, knowing that next year's re-imbursements would be based on this year's charge schedule or percentile ranking.  Confusing?  For everyone, including the patient, who still did not really understand the process since the insurance company took care of everything. As with any "house of cards" the inevitable was about to happen. As technology began to out-strip our ability to pay for it, the demands for hi-tech services went up, costs again went up, and the outcry from un-insured individuals finally reached the ears in Washington.  Reason was removed from the equation in exchange for expedience and political gain.

So just what can be done to solve the problem now that we have raised a generation of doctors who expect to get paid in cash for everything they do, a generation of recipients who have never understood the concept of fee-for service, plus an ever increasing pool of individuals that feel they are "entitled" to healthcare as well as a good life-style simply as a birthright? The current proposals are not sustainable or capable of providing the hightech, timely care we in the United States have come to expect.

                                                      THE OPTION

In order for one to grasp this concept, we must remember that most professionals in this day and time simply want to get "something for something" i.e. if I provide a sevice, what can you give me in return.  At present there are over one MILLION healthcare providers in the U.S., many of whom participate in medicare and medicaid. However, that number is declining even while the healthcare law (Obamacare) is seeing an increase in the number of medicaid/medicare recipients. Indigent care is paid for by increasing hospital costs billed to those with insurance to the point that many young people don't bother with insurance since the word on the street is "they have to take care of you!" Add in the illegal immigrants that show up in ER's and the problem is compounded. What if there was a way to provide 75 BILLION dollars worth of free health care to indigent people, the very people Obamacare was supposed to help?  There is a way, it will just take some forward thinking members of congress. Suppose a tax credit were given to any healthcare provider, a $50,000 credit for $75,000 worth of actual patient care. In order to be elgible for the tax CREDIT (remember, one must have at least that much tax liabilty to get a credit) , the provider also must participate in medicare and medicaid. Now let's provide a National Health Care card to eligible individuals based on need and relative income. Those that want a card MUST file an income tax, in other words, MUST take some responsibilty for their care by participating in a system to monitor eligibility. This card would provide up to $3,000 in free care at any clinic or office (or hospital) during REGULAR business hours as opposed to the frequent non-emergent visits that often clog our ER's at midnight. The end result would be better care in a more timely matter. The individual could decide how they wanted to use the available funds each year (minor surgery, diagnostics, podiatrist, eyeglasses, dental care, etc.) or if they wanted to carry them over for up to 36 months if they needed elective surgery. If there are now 25 million in need of care, this is 75 BILLION in care that would be availible at a cost of 50 Billion in lost "tax" revenue.  Now some might say "those rich doctors don't deserve any more tax breaks", but let's remember they are providing a service at NO CHARGE to the taxpayer who would otherwise foot the bill for indigent care! This does not even take into account that the care provided is likely to be better and in a more timely fashion in an office rather than ER environment. Another consideration is that if the 50 Billion were collected as tax revenue, less than 40% (20 Billion) would ever actually be used to provide care. So which is a better "bang for the buck" ? $75 Billion in actual provided care through this plan, or $20 Billion in care through existing methods, much of which goes to ER's in the middle of the night, the most expensive time to be seen?  The choice seems obvious.

The next question that arises is "what about catastrophic injuries etc.?".  In order to fund a national catastrophic illness/injury insurance pool, I propose a national 1/2 cent sales tax, the only fair tax for all involved. Everyone should have some inward sense that they are contributing to their own care. This is called "self-worth", a concept we have been taking away from the poor for a long time. One has to wonder if this is a subliminal way of making the wealthy or more advantaged people, or even those with a "high moral conscience", think they are superior. Has that concept escaped those who insist on continuing certain entitlements ? I can remember doing medical missions work in Central America when as many as 500 people would line up for "free" care. Most did not need any care and came for the free medicines (ibuprofen, aspirin, antidiarrheals, antacids etc) we provided. I finally put up a sign "cost is $1 to see Doctor" and the number waiting dropped to 200...but they REALLY needed to see us!

In summary, a Tax Credit plan for particpating health care providers would accomplish the following: 

      1) Provide necessary care to those in need in a timely fashion, primarily in an out patient setting.

      2) Return many health care providers back to the medicare/medicaid rolls they are now fleeing.

       3) Free up our overcrowded ER's making room for those truly needing emergent care

       4) Save the tax payer the cost of funding a system doomed for failure.

       5) let everyone have "skin-in-the-game" with the 1/2 cent sales tax.

This idea is certainly not the answer to all the problems with healthcare, but at least it addresses the indigent care issue in a simple, straight forward way, eliminating much of the bureaucracy and waste.

My last question is "What are your thoughts to improve our healthcare system? "  When working on a solution, consider something that will continue to insure our nation's well-being as well as encouraging many of our best and brightest young minds to enter the healthcare field.

                                                                       Dr. Dennis Spence

As the VA situation continues to evolve, one must wonder if political correctness will continue to trump a real solution to the problem.  In order to get to the bottom of the problem, one must truly understand the mindset of the military in general and the VA in particular. Having worked as a doctor in the VA during my residency, as well as in a miltary hospital while on active duty, followed by 30 years in private practice, I can personally attest to a system that runs on an 8-5 mindset and one that uses budget requirements, not for what is really needed, but to insure the next year's monetary requirements. While on active duty, I can recall being instructed to see 2 patients in the morning and 2 in the afternoon in order to insure that our schedule always had patients listed. This in turn insured that the staffing requirements remained intact and thus the number of officers and enlisted personel in the clinic avoided the dredded RIF, reduction in force. We all knew that we were capable of seeing more patients in an efficient manner. Another source of the problem is the number of veterans who look at VA care as an entitlement regardless of what they actually did in the service. Front line soldiers are certainly entitled, but quite a number of those who served from 1975-1990 saw little or no activity in a combat zone and although some may need care, many turn to the VA even when capable of recieving private sector care. Some would say that these veterans gave up private sector jobs to serve their country but the truth is that many during those years of a crowded job market, turned to the military for a paycheck. This same philosphy exists in the VA since much of the personel are military trained and budgets are set the same way. Would such a system survive or even exist in the private sector ? Not likely.  The bottom line is that a person needs to be brought in to run the VA that has both military (short term) and real world, private sector hospital experience. If political correctness is allowed to continue, the choice of leadership for the VA will likely be another rank and file officer from within the military and thus the same ethos will continue.

If we were to adopt a national healthcare plan to provide FREE care to indigents using a tax credit system, the same system could apply for veterans unable to get to a VA hospital.  A veteran that lived more than 100 miles from a VA or in need of energency care could "swipe" a National Veterans Health Care card for care from any provider, anywhere. The same principles of available dollar amount available per year could apply based on the eligibilty or disability of the veteran. There are many simple fixes to the problem yet the government prefers a complex system for two reasons....power and control. Having worked in a VA hospital during my training, I can personally attest to the quality of care, which was, during my time, quite good. What was NOT good was the fact that all employees, including employed doctors, worked their 8 hour shift and left with little or no concern for what happened in their absence since there was no "incentive" to provide extra care or stay extra hours making rounds etc. This is the very basic difference between a capitalistic or free market system of health care, and a socialistic or salaried system, like what "Obamacare" will evolve into. Beware, America....if you like what you are hearing about the VA system, you're gonna love the nationalized system we are moving towards...

When discussing the ever-increasing costs associated with providing quality health care, one must ask when is the patient's own responsibilty for participating in their own well-being going to become part of the equation ?  The incredible American mindset towards humanity coupled with a home-grown feeling of guilt over personal success compared to others less successful has produced a general philosophy of " it's my duty, my obligation, to take care of others..." regardless of whether others are willing to take care of themselves. As thinking creatures, humans are the only animal that does this.  If a non-swimming bird chooses to land on the water, it drowns;  if a horse chooses to eat too many green apples, it colics and dies. Nature, without the interference of man, has it's own way of controlling every eco-system. In my opinion, and after years of observation, there are two philosophies of medicine. The Western philosphy is where the patient is treated from the outside in. It is where you, the patient come to me, the doctor, and say "fix me ... and hurry because I have to be somewhere in the next 15 minutes..."  Since we doctors are trained in this western philosophy, we say " sure...here's a pill "...or an operation...or whatever. This is much easier than discussing what is really going on and insisting that the patient follow specific recommendations. This, in turn, makes the patient happy, insures that they return to see you, and of course helps to make that car or house payment. The patient is not held accountable or responsible for failing to follow recommendations, and ultimately it is the "doctor's fault" if they don't get better because the doctor gave them the wrong pill ! The Eastern philosphy helps to heal the patient from the inside out. They understand the healing powers of the mind and how simply controlling stress ( 90% of all headaches are tension and stress related ) can affect the outcome of any treatment. However, that involves commitment to changing one's lifestyle, something patients in the west really don't want to do. So this brings us back to the original question, when are we going to realize that the patients must take responsibility for their own decisions and outcomes if the costs associated with healthcare are ever going to level off ? I will predict now that within the next 25 years, heathcare costs will consume 40% of a person's income if something is not done to correct the approach to providing care. For those that insist on being "politically correct", read no further. For those that consider ideas that are outside the realm of what we now consider possible, read on.  Imagine a particular overweight, heavy smoking, alcoholic, diabetic who has basically refused to follow instructions, has a donut and smokes during their morning break, eats a bag of chips with a cola during the afternoon break, drinks 2-3 beers and cigarettes when arriving home, then shows up in the ER at night feeling dizzy. What if this person was given an ultimatum, one that made it clear that if this scenario were to repeat itself, they would be placed on "probation" and be required to report to the hospital once a week (or month) to be tested and weighed to ensure they were following a prescribed program of weight loss, alcohol and smoking avoidance. If they failed the test 3 times, 3 strikes and you are out ! These patients would be "convicted" of a crime against humanity (themselves !) and sentenced to a rehab program in a basic prison environment. One might ask where these prison farms would come from ?  How about closed military bases ? Infrastructure is there, most had a hospital on base and all were good enough for our military. I can assure you that the overall cost would be less than what is now being spent on caring for these people who are all basically "repeat offenders" ! Time of  " incarceration" would be based on weight loss and parameters established relating to the disease process. What about their jobs ? During their period of sick leave, their job, if possible, would be held in reserve much as a reserve soldier's job is held in reserve for those called to active duty. Personal responsibility MUST be part of the solution to escalating costs.  Sadly, the above scenario is not likely to receive any support since it steps on the "personal rights" of self destruction...