Health Care Financing

Paul Manganiello: Health care reform needs systemic changes

This commentary is by Paul Manganiello of Norwich, a physician, an emeritus professor of obstetrics and gynecology, and co-medical director of the Good Neighbor Health Clinic in White River Junction.

Recently, Lee Russ wrote a commentary for VTDigger. He prefaced his commentary with how do you “solve a problem when you ignore all the facts about that problem. Which leads me to the unmitigated disaster that we call American health care?” 

I agree; how we deliver health care in this country is an unmitigated disaster. But I’m not going to dazzle you with data. I am going to give you my perspective as a health care provider, but I want to caution you, as they like to say, “The delivery of health care is not rocket science; it is more complicated!!” 

Our elected officials have created this dysfunctional health care “non-system” — and by the way, with the help of organized medicine. It was during the time of President Franklin Delano Roosevelt that the decision was made against having a publicly financed health care system, but instead rely on a predominately employer-based third-party insurance system. 

It didn’t work for everybody back then, nor does it work for everybody today, and it has only gotten worse. Financing and delivering health care for all is very complex; it can always be done better. We need to continually strive to improve how health care is delivered and how it is financed. It is not either/or, but both. 

We need to stop looking at this problem as being binary. It is not only fee-for–service that is the cause for our current health care financing crisis, but it is certainly part of the problem. We will never be able to eliminate fee-for-service, nor should we. There are some services, such as the administration of vaccines, where it is very cost-effective.  

But if one looks at the studies that have resulted from the Dartmouth Atlas, they clearly show that there is a lot of unwarranted variation throughout the country in how health care is delivered. It is clear that fee-for-service is fueling inefficient and at times inappropriate health care consultations, and potentially harmful testing and treatments. These can all contribute to not only rising cost of health care services, but bad health outcomes. Fee-for-service is a contributing factor to administrative costs, and not attaining “value” (better outcomes for comparable/decreased costs) when it comes to the delivery of health care and how it is financed. 

Take one example. When I was working at the Dartmouth-Hitchcock Medical Center in Lebanon, I would need to travel to Nashua and Manchester to offer specialty consultations at satellite clinics, spending hours in my car traveling up and down Interstate 89. I pleaded to be able to use telehealth consultations, so as to see more patients without having them, or me, using precious time, not to mention gas (not very environmentally kind), in travel. It took a pandemic for insurers to realize the benefits of telehealth. The reason they wouldn’t consider telehealth, then and now, was/is over concerns of fraud.  

When I was working at Dartmouth-Hitchcock, I wouldn’t think twice about ordering tests and X-rays, all legal of course, just to make sure I wasn’t missing “something” (defensive medicine), since I knew the insurance company would pick up the charges anyway; or worse, I would then find something that needed to be further investigated, that might require a biopsy, that might result in a complication. I might have a patient come in for a visit that could have been handled over the phone, but then I wouldn’t be reimbursed for my visit, which wasn’t face-to-face, etc., etc. Just multiply my experience with the thousands of other health care providers and you can see we have a problem here.

What’s the answer to this health care finance/delivery crisis?  Is there only one answer? No. Will single-payer solve the problem? It might help, but not by itself. We can see that in other countries that have publicly financed health care systems.  

So what may help? This is going to take systemic changes. I know, this might surprise you, but that means it will take political solutions. 

There are too many groups and individuals with vested interests in maintaining the status quo. This is a commentary, so I will need to be brief.  

For starters, the least Vermont should do is get a Medicaid/Medicare waiver to offer a mandated public option. We all need to be covered, and you should have choice in that coverage. It is not a question of if I am going to need health care, but rather when I am going to need health care. If the public option is competitive, employees may want to petition their employers to pay them higher wages and drop the employer-sponsored health care insurance package at their worksite.  

Maybe we could encourage health care providers to phase out private practices and become employees of integrated health care systems, and allow providers to participate in binding arbitration when they need to negotiate salaries, benefits and workplace safety.  

Malpractice should be converted to no-fault insurance, whereby injured patients are compensated, while requiring the various specialty boards to evaluate claims against individual providers and, if necessary, revoke their license to practice. 

We also need to be moving to a system where medical centers need to be given a global budget for a capitated population and bundle certain services. The onus should be on the medical centers and providers as to how to best cover the costs of their services — for instance, should we offer telehealth, rather than require patients travel to their providers, if care can be effectively be delivered in the comfort of their homes?

Is it more practical to have teams of different health care workers, physicians, physician extenders, and for complicated specialties possibly even social workers and pharmacists? 

Educating health care providers is expensive, and if we want students to go into underserved areas to practice medicine, we need to financially incentivize them to consider becoming primary care providers, physician assistants, nurse practitioners, etc. 

This crisis will not be solved unless everyone puts aside their own vested interests and works for the common good. That’s what it means when someone chooses to work in health care: It isn’t just a job, it is a profession.