We will be performing site maintenance on AAOS.org on February 8th from 7:00 PM – 9:00 PM CST which may cause sitewide downtime. We apologize for the inconvenience.


Published 8/1/2009
Michael R. Marks, MD, MBA

Healthcare delivery changes: A surgeon’s perspective

Meaningful change requires “all-or-nothing” approach

Although several proposals for revamping the healthcare delivery system have recently been released, there are still major disagreements about what should be done. Any major change is difficult to accept, but I believe that the major obstacle to designing and finally enacting any meaningful healthcare reform is the lack of consensus on who should manage the finances and how the system should be managed.

The aging U.S. population mandates that there be significant changes to the healthcare delivery system now because the current demographics are not sustainable. For the public to embrace these changes, they must understand why the status quo doesn’t work.

The role of insurance companies
Even though the government delivers 40 percent of all health care through programs such as Medicare and Medicaid, healthcare insurance coverage is dominated by public, for-profit health insurance companies. To remain viable, these companies must increase shareholder wealth.

Among the steps that insurance companies can take to achieve this goal are increasing the price of the policies that they sell, denying services requested by the client or physician, and decreasing payments for delivered services. As they are currently configured, insurance companies are middlemen who deliver questionable benefits for a huge cost. As the healthcare percentage of the gross domestic product now exceeds 15 percent, this model is no longer sustainable.

If insurance companies are to be part of any new healthcare system, their structure must be modified from stock companies to mutual companies. This would give policyholders an incentive to try and maintain a healthy lifestyle and prudently use their healthcare services. Any excess reserves or revenues at the end of the year could be distributed to policyholders as a dividend or rebate. Companies that can’t make this transformation should not be permitted to participate in any new program.

Purchasing options
Current methods of purchasing insurance coverage must also be modified. Most individuals obtain healthcare coverage through their employers. Because individuals now in their 20s will have an estimated 7 to 10 employers during their working careers, this system is inefficient. For this reason alone, the method of buying insurance must change.

Of the 45 million so-called “uninsured,” probably only 15 million people are truly uninsured and unable to afford insurance. The remaining “uninsured” are either young, healthy, and do not think they need coverage or are wealthy enough to pay for services when they need them.

The inefficiencies in the system—not the number of uninsured—are why we must change the way we purchase healthcare insurance. The problems with complying with COBRA coverage are evident during the current economic situation. Insurance coverage and employment status must be forever separate.

Healthy, young individuals don’t see the benefit of purchasing health insurance coverage. Many see it as a waste of dollars. Large deductible health savings accounts are best suited for this group. They can purchase insurance through large pools or cooperatives. If they don’t need any services for several years, they will have substantial savings to use later in life. In fact, this option may help save Medicare, because these individuals won’t have to depend on the government to supply their health benefits.

The government currently helps subsidize the purchase of health insurance by not taxing this employer-provided benefit. It can use the same or develop a similar process to enable all individuals to purchase coverage. Many have discussed the benefits of the Massachusetts state program that mandates coverage for all. A major difference exists, however, between having coverage and being able to access services.

Other issues
The Massachusetts program clearly demonstrates the manpower shortage in primary care providers (PCPs). Although this idea may not be embraced by the American College of Physicians, I believe that the PCPs of any new system should be primarily physician extenders—physician assistants (PAs) or advanced practice registered nurses (APRNs).

Physicians can efficiently oversee large numbers of these extenders but, in a community-based practice, overseeing the care of a large number of individuals is an inefficient use of physician time. PAs and APRNs can manage and coordinate most of the care that patients require. These individuals have provided excellent care in underserved areas and should be the cornerstone of any new paradigm.

Another issue that must be considered is the presence of illegal aliens. In many parts of the United States and in many industries, illegal aliens comprise much of the labor force. The result is an enormous underground economy based on cash payments—most of which are sent “home” to other countries. Cash wages are not taxed, resulting in lost revenue for the U.S. government.

These individuals are already obtaining access to healthcare services, and the immigration problem must be addressed before the country can solve the healthcare delivery system problem. Legalizing these individuals may not be popular, but may be necessary. Once that is done, immigration policies for future immigrants can be tightened.

Other issues that also need to be addressed include pharmaceuticals, physician payments and fee schedules, information technology and electronic health records, rationing of care (another taboo subject), and end-of-life decisions. Medical liability reform must be included in any meaningful healthcare delivery reform.

Changing and improving the healthcare delivery system is a complex, daunting task. For any changes to have meaningful impact, we will need to take an all-or-none approach. Tinkering with certain segments will only create more and different long-term problems.

As with any comprehensive plan, those perceived to be on the “losing” end will fight any change. Yet without sweeping changes, we will all be losers. In the end, everyone will be giving up something to make the whole system stronger and more sustainable.

Michael R. Marks, MD, MBA, is the president of Coastal Orthopaedics, PC; chief of staff at Norwalk Hospital; past president of the Connecticut Orthopedic Society; and a current member of the AAOS Board of Councilors. The above opinions are his and are not representative of the above-mentioned organizations. He can be reached at mmarks1988@aol.com