Health Care Reform – How will it affect us?

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The following is the full interview with Dr. Mark Levin, one of four doctors we interviewed in the last issue of Zman magazine.

Dr. Mark Levin has been in the medical field for most of his adult life. He is currently in private practice in Bergen County, New Jersey, where he works as a hematologist and oncologist. In addition, he runs a health care consulting business, mostly in the field of oncology. The Castle Connolly Guide to America’s Top Doctors has included him in their listings several times as the top doctor in his particular specialty. His resume includes stints as chief or director of four different institutions. His most recent position was as Acting Chief of Hematology and Oncology at the New Jersey Medical School in Newark, New Jersey. Over the course of his varied medical career, he has authored over 30 academic articles, as well as several books. Today Dr. Levins deals as a consultant with some of the main players in the health care debate: the insurance companies, pharmaceutical companies, medical education companies, etc. Through his invovlement with the various sides in this debates, he has gained a wider perspective concerning the pertinent issues. In addition, Dr. Levin’s MBA enables him to analyze the debate also  from the financial and macro-ecnomic perspective.

Zman: Let’s get straight to the point. Is the new health care reform bill a good thing or a bad thing for the United States?

Dr. Levin: It’s a mixed bag. It does not address the core issues that have plagued the health care system until today, but the good news is that it will finally impose some changes on the current system, something which has not really happened before.

The most wide-ranging reforms implemented in health care that were subject to public debate occurred 55 years ago when differing opinions were aired concerning the institution of Medicare. Since then, there have not been any truly significant changes to the health care system. In essence, what that means is that the bill will revamp the entire way we approach health care. It will no longer be taboo for legislators or the President to introduce change. The new laws will not bring about the necessary changes, but once the ball started rolling, I believe that it won’t stop here. Over the course of the next few years, the bill will unquestionably be subject to continuous changes and improvements, both by Obama, who I’m sure will continue to tinker with its various details, as well as by his opponents, who will begin passing counter legislation.

There are many stakeholders that are affected, not only patients and doctors, but also big businesses such as the pharmaceutical and hospital industries. All of these individuals and corporations are going to be lobbying and pushing to improve their position in the system. Consequently, what will eventually emerge may turn out to be very different from what we are seeing now. I basically consider the current bill as the opening move, one that is going to be followed by many others. What we are seeing now is nothing like what healthcare will look like 10 years hence. It’s going to be very interesting to see what happens. So the reform doesn’t really change anything basic, but at the same time it changes everything, because it changes the way that the  society is going to deal with health care in the future.

Zman: Aren’t you concerned that the new bill will eventually lead America to Universal Health Care?

Dr. Levin: I don’t think so. It’s very unlikely because it’s just not an American mindset.

Zman: Will the new reforms reduce the quality of health care in the United States?

Dr. Levin: In truth, I must tell you that I don’t believe people were receiving superb care in the United States prior to the reforms either. There are centers of excellence and specialists for specific conditions, but on the other hand, poor-quality care is also unfortunately quite prevalent.

It is true that if an individual who is very bright, educated, well-connected and understands the system is suffering from a particular disease, s/he can find the best doctors specializing in that disease here in America. However, even this advantage is beginning to dissipate in the current system, because insurance companies have started with out-of-network, in-network policies, in addition to all kinds of restrictions on which treatments are covered and which are not, that are a part of many plans. Second, most people are either not aware enough, intelligent enough, or informed enough, and I doubt that most people are getting great care.

Zman: Many people have expressed concern that the new health care laws will eventually transform the United States’ health care into a system similar to that of Canada or Europe, where it is difficult to receive certain life-sustaining treatments, and many must wait weeks and even months before receiving it.

Dr. Levin: I’m not sure it has actually been proven that Canada and Europe don’t have good doctors. It’s just that in those countries, any bureaucrat can make the decision as to whether a patient will or will not receive the requested care. Here in the USA, it’s not some bureaucrat, it’s a committee. There’s some faceless committee somewhere within an insurance company that makes these crucial payment decisions, and it would take legal action to find out who these people are that are denying care.

Still, we’re in a better position than Canadians in the sense that we make it a guiding principle in our society that no one can tell anyone else what to do, whereas in Canada, Canadians accept that someone will decide for them where they must go for healthcare and what they are allowed to  get. In practice, the kind of care available may not make a big difference for many individuals, although it makes a crucial difference for some, but for society as a whole, it makes a big difference.

Zman: If it is indeed true that the new laws will not implement any substantial changes in the system, besides for preventing insurance companies from refusing care, ensuring the coverage of a wider range of people, and imposing more stringent regulation of insurance companies, then why are doctors concerned that they will no longer be properly financially compensated under the new system?

Dr. Levin: First of all, the insurance companies can still deny care. I don’t see anything in the bill that stipulates that they are required to pay for care that is “not medically necessary” – that’s one term – or that’s “experimental or investigtional,” or that’s “not appropriate.” The only thing they cannot deny is preexisting conditions, and they will now have to pretty much accept everyone who applies.

Second, what the doctors are afraid of is very simple. If the insurance companies are required to accept people who cannot afford to pay, it will translate into a loss of profit for the insurers and they will find a way to control their costs. One of the easiest ways to control the costs is by reducing the financial compensation offered to doctors, because if I am some medical guy running an office and I have to deal with Oxford, let’s say, they don’t really care if I’m not a participating provider in their network. They can afford to lose me. Since I don’t have a lot of negotiating power, the chances are that they will either cut my rates or put up all kinds of barriers when it comes to collecting payment. What I mean is that my payments will start coming within 90 days instead of within 30 days, and I’m going to be required to complete various kinds of pre-authorizations. Plus, I’m going to get a lot of denials. And since the doctors are getting a lot of that already, they see this as just another problem they are going to have to struggle with.

Zman: Many doctors are complaining that the legislation they believe is most crucial is missing from the bill: Tort reform, reform that would bring an end to the sky-rocketing malpractice lawsuits. These lawsuits continue to raise doctors’ insurance costs, which are eventually transferred to the patients in the form of higher costs.

Dr. Levin: We can’t dismiss all malpractice lawsuits as inherently wrong or bad, because it does put pressure on the doctors to be careful while administering care and that is actually one of the reasons why this country boasts some of the best doctors.

If you take a look at the different systems existing in other countries, many of which do not give the patients any rights, you eventually come to the realization that the ability to sue does make the individuals in charge somewhat more careful. It makes doctors and hospitals more accountable. It forces hospitals to set up all kinds of systems to prevent errors. In some European countries where the concept of malpractice lawsuits is nearly unheard of, patients have no say at all.

Has it gotten out of hand? Probably. You have many, many attorneys making a very nice living off these cases. Nevertheless, the truth is – and I know the system pretty well, because I’ve been consulted in these situations as well — it’s not easy to win a lawsuit. If you live in the Bronx, which is probably the worst place in the country for a doctor to be sued in, you settle every case. However, in rural areas the doctors win almost all the cases. Right now in the United States, two-thirds of all lawsuits that go to trial are won by the doctors. That means a lot of them are being settled, of course.

There is, however, another problem that has been caused by the lawsuits, namely, that doctors have become so fearful of getting sued that they often order tests for patients that are unnecessary from a medical standpoint. These tests are just done to ensure that no one will ever be able to accuse the doctor of not being vigilant enough. It is estimated that 20 to 30 percent of medical care in this country is administered as a precaution against lawsuits. It’s not only doctors; hospitals do it, too. And that’s what raises the costs. It’s not the lawsuits per se.

Ordering more tests is not really the way to prevent lawsuits. The best ways for doctors to protect themselves are, first to ensure open communication with their patients. If things are clear between patient and caregiver, in the event that something does go wrong, the patient will not be as inclined to blame the doctor. Second, doctors must document very clearly what tests/procedures they are performing, and why. These two things give doctors all the protection they need, protection that is far better than the ordering of unnecessary tests.

Zman: Some doctors claim that it is not prudent for the United States’ health care system to have everyone in the country insured.

Dr. Levin: First of all, as a moral individual who cares for others, I believe it’s good that more people be covered. I have to tell you though, that the 30 million illegal aliens are still not going to be covered. That means that there will still be many, many people who are not covered and the problem of emergency rooms needing to provide non-emergency care to the uninsured will not disappear, especially in cities like New York. It’s a problem that’s going to remain. I think that we should try to provide care to everybody.

Zman: One of the dire predictions the pessimists have been touting is that, due to the new health care laws, American students will view medicine as a profession controlled and regulated by the government, and many will eschew a career in medicine in favor of a career in law. Lawyers do, after all, make more money than doctors, and are not regulated by anyone.

Dr. Levin: That’s already been happening to a great extent. There are very few doctors who actually advise their children to become doctors now but I still think it’s still a great profession.

Medicine used to attract some of the brightest people, but it’s already no longer doing that. When I went to medical school, there were 20 applicants for each available space in the class, and it’s much fewer than that now. It’s more like two or three. Much of it is due to the hassles and the difficulty of the lifestyle. People are not really interested anymore in working 12 hour days with no weekends off. When I went to school, it wasn’t an issue. People who were working hard were not resentful. It was okay. People had a sense of mission.

The current generation of students is looking to lead a comfortable lifestyle. So I think what the pessimists are saying would be true to a certain extent. I believe that, with the current health care reforms, it will get worse. If being a doctor is harder and you make less money, then over the course of a few years it will translate into fewer people applying to medical schools. However, it will take at least 20 years for the problem to become visible because getting a student though the medical education pipeline and into practice takes almost a decade..

I am hopeful, though, that in the course of the next 20 years, a way will be found to avoid the problem before it gets out of hand. The government will figure out a way. Perhaps a bill will be passed stipulating that a number of training spots can be expanded (now medical education is funded through a Medicare surcharge for teaching hospitals), or maybe there will be a bigger surcharge, or maybe they’ll pay the tuition. There are many ways to adjust to and fix this situation. I don’t see it as a big problem.

Zman: What effect will the healthcare reform bill have on the Jewish religious community?

Dr. Levin: Let me just say one thing about the frum community: We are a society without class divisions. Anywhere else in the United States, people with similar incomes and similar educations live in their own communities, and those with different incomes and different education levels live together in their different neighborhoods. They send their children to different schools. They don’t meet each other except perhaps in the supermarket, as a cashier and customer.

Here, in the frum community, we all interact. People with higher income and higher education interact constantly with others who do not have that. They are parents in the same schools. They shop in the same places. They might even live close to each other, maybe not on the same street, but they live close. They’re constantly dealing with one another, davening in the same shuls, sitting next to each other, etc. So, in that sense, we are a society without a marked separation between the classes.

This situation means that we do not have many of the problems existing in the general population. Our community is not divided into people who benefit from the current system and people who struggle with the current system, since we are fortunate to have a community that cares about everyone. We have referral centers, like ECHO. We have people who help people. Baruch Hashem, we have many frum doctors who care, and will take an effort to make a phone call and get a patient some help. If you look at the society in the United States as a whole, there are many, many people who get no help, and who have no way of getting the best care.

So, in terms of finding the best doctors we have less of an issue, and the portions of the bill that are designed to help the underprivileged will not have much of an effect on our communities. I think that, proportionally, it will help us less than it will help other groups. Of course it will still help us, since more people will be able to get insurance and that’s a good thing for everybody.

Nevertheless, proportionally, we have less to gain and we probably have more to lose. Individuals will now have to puchase isurance, if their employer does not provide it. Most businesses in the frum community are not big businesses, most of them number less than 50 people and they will still not be required to buy insurance. There are, of course many who do employ more than 50 people, but they are not in the majority. Still, eventually I see all businesses having to purchase insurance for their workers. Due to the fact that most of the frum community either runs or is employed by small businesses, I believe the financial impact will be very strong.

Zman: One of the dire results of the bill predicted by its opponents are the so called “death panels,” namely government panels that will determine the kind of coverage patients will be eligible for and will interfere in the doctor-patient relationship, deciding if the patient’s situation warrants the care requested.

Dr. Levin: The government will not control the treatment, but they might say that Medicare will no longer pay for futile care. At this point it’s not going to be the government that determines in any particular case if the care can be deemed futile or not, but the bill will force the hospital to create a panel for that specific purpose.

There will be a few doctors, nurses, patient representatives, chaplains and medical ethicists, who will sit together and decide if it’s futile or not. They will be forced to do it,because the government will have a much harder time not paying for the treatment if the panel determines it is not futile. This si how the government promites change in the healthcare system. Earlier or later, that’s going to happen. I don’t think there’s any way to prevent it. The only thing you can do is work to get exceptions for reasons of conscience or religious reasons. With this, if somebody doesn’t want to pull the plug they will have a right to block it. Nevertheless, I think with or without this bill, it’s going to happen. The society is moving away from the belief that all life matters. This is a process that has been going on for a long time.

Zman: Why were there never any fears about insurance companies themselves setting up similar panels to determine if a patient deserves to be kept alive?

Dr. Levin: The insurance companies actually can only determine what  the “appropriate” care is and nto pay for it or  that the patient no longer needs to be kept in the hospital on life-support. They can do only that. They cannot decide to “deny care.” However, they can say that the appropriate care is hospice care, not aggressive chemotherapy and put financial pressure on the provider to not offer care.

Now, obviously, if somebody is on a ventilator, they can’t say that they could have gone home, but what we’re talking about is somebody on a respirator, who will be at the mercy of some panel that might decide that the care is futile. Futility is a new concept in bioethics. And if it is futile, then why should we pay for it? “He’s going to die anyway. Let’s help him die in dignity.” It’s never expressed as something negative; it’s always something positive.

Zman: It’s like what they say about today’s days, that people are no longer fired from their jobs; they resign…

Dr. Levin: Right, right.

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