A Health Care Discussion With Two Doctors

In 2009, Quarter Twain conducted an interview with two Montana doctors about the American health care system and their opinions on reform.  M is the male doctor, and F is the female doctor.  QT has changed all names out of respect for their privacy at their request.  What follows is a transcript of the recorded interview.  Hopefully, some of this information will prove revelatory for those outside the margins of the medical industry.

HEALTH CARE INTERVIEW

BOZEMAN, MT

SEPTEMBER 6, 2009

START RECORDING

QT:  So my first question is – and this can be current or when you operated the pain resource center, however you want to answer it.  I have insurance.  I come to you for something, when you bill insurance, what percentage of that charge does the insurance pay?

M:  That’s really variable, depending on the insurer.  When I was running my practice, which was back – let’s see.  I closed that in ’95, didn’t I?  So prior to 1995, my company that did collections for me would collect about 80% of my billing.  Now some of that was coming from anesthesia/operating room billing, so it wasn’t just from pain management.  Pain management typically does not pay very well because you’re looking at Workers’ Comp, which is always in litigation, so your payments may be deferred as much as 20 years, in that one case.

F:  It was 15 or 20 years.

M:  And Medicare will reimburse approximately 13% of what you bill, and you can’t balance-bill the patient, so you get 13% of your billed amount.

F:  13 or 30?  13 sounds really low.

M:  It is about 13 now.  Remember, we were talking to Horace the other day up on Drinking Horse Mountain, and he said the invasive cardiology group was down to 12%, and that’s largely Medicare.

F:  Right, but part of what you have to consider, part of the equation is what that is a percentage of, and I think we can probably talk about that in a bit.

M:  Yeah.  That’s a bit of the problem here, trying to figure out what does that mean.  If you get 13% of your billed amount, and that’s your collection, what does that mean?  So for instance, when I was saying I got 80% of my billed amount, that was 100% of my collections was 80% of what I billed.  Medicare will reimburse 13% of what I bill, so you’d have to figure out what is 13% of that 80% to kind of get a reflection of what the other insurance companies are reimbursing.  So it would be kind of 13% of 80%, instead of 13% of 100%.

F:  Right, but the thing I was thinking is if you bill Medicare, you’re getting 100% of what you bill because you know, the people who are billing for you know that they’re not going to get more than a certain amount.

M:  You don’t get 100% of what you bill.

F:  Well, don’t they somehow figure it out?  Doesn’t Medicare tell you what they’re going to pay for each code, so your billing company doesn’t bill beyond what Medicare is going to pay, so in that perspective, you’d get 100%.  Anyway, I guess the point is that when you hear those quotes, it’s kind of confusing what people are talking about, but probably when Jerry was saying those cardiology practices are getting 12% of what they bill, what they’re looking at as their absolute charge is what they would bill a self-pay individual and everything else is compared to that.

M:  Right.  So if you were paying your own bill without insurance, you would be expected to pay 100% of my bill, just like if you went to a mechanic and he gives you a bill.  You’re expected to pay 100% of that bill.  But if you had automobile mechanic insurance, and the mechanic said, “I’ll accept insurance payments on this,” they may say, “Well, we’re only going to pay 80% of your bill,” and he has to accept that.  It’s the same way in medicine.  If I say, “I’ll accept what the insurance company pays for your bill,” then if the insurance company pays 60% of what I bill, I have to accept that.

QT:  And you can’t balance-bill?

M:  You can’t balance-bill under some plans, so if I say, “I will accept what your insurance company pays…”  For instance, if I say I’m a participating provider for Blue Cross Blue Shield, that means I will accept what they pay and I will not balance-bill.  Now if I say, “No.  I’m not going to accept that Blue Cross Blue Shield is only going to pay me a fraction of the 100% of my billing; I want the ability to balance-bill the patient,” it may be the blood out of a turnip syndrome.  Blue Cross Blue Shield reimburses me, but since I’m a non-participating physician, they will reimburse me less than if I were a participating physician, but I do have the option of balance-billing the patient, who may or may not have the ability to pay.  So they really try to put you over a barrel, as far as you can accept getting some of your billed amount, or you can get less of your billed amount and have the possibility of trying to get the balance.

QT:  Are these absolute amounts?  It sounds like with Medicare it is an absolute amount, that you can up your charge and they’ll pay 12 or 13% until you get to whatever cap it is for the procedure code.  Is this true for Blue Cross Blue Shield?  If my provider wants more money…  Is it typical for an insurance company to say, “We’ll pay X percentage up to this, but this is the max we’re going to pay,” so if the doctor charges more, they’re just going to cap it?

M:  That is true, and it varies by region.

F:  It’s not always done on a percentage basis, either.  If there’s a code, whatever the code is, there’s a price that they’ll pay, for say a mammogram or an office visit or something.  I don’t know how all of those things work.

M:  And this is a really screwy part of this, that if you live in New York City, and you bill for a procedure, you may get twice as much for that procedure in New York City as you do in Sioux Falls.  The region of the country defines a bit how much you can bill.

QT:  Is that because your overhead is higher?

M:  It’s based on cost of living considerations and things like that, but nonetheless, you may only be able to get 50% for a procedure done in North Dakota as you can for a procedure done in Philadelphia, and it’s exactly the same thing.  You’re doing all the same stuff, and you can get twice as much in Philadelphia as you can in North Dakota because of the region of the country.  So it’s not equitable across the whole country; it varies from region to region.

F:  Well, especially because in any given region there’s usually only one or two or three insurance providers.  So a lot of this is going to be very region-specific.

QT:  When you bill insurance, how long on average do you have to wait to find out what you’re going to get paid and if you’re going to get paid?

QT:  And consequently, when do you get paid?

F:  Realize that [Jack is] not in a practice now that operates that way.  He gets just a daily amount for working in Butte.

QT:  You’re a sub-contractor, correct?  And they take care of that?

M:  Yes.

F:  So he’s been away from that aspect of it for a long time.

M:  Since 2001.

QT:  So how much operating capital do these places have to have to be able to…

F:  Which places, the insurance companies or the practices?

QT:  The practices, to wait out all of the billing insurance.  I have a medical bill something like two months after I visited the doctor.  That’s a long time.

F:  I was going to say three months.  Usually you figured if you didn’t get something by three months, you weren’t going to get it.  You might get something, but three months was the main…

M:  Typically, when you start with a billing company for collections, didn’t they say it was going to take six months to ramp up to whatever your rate is going to be?

QT:  Good grief.

M:  Because some insurers will pay very quickly, depending on the procedure.  Some will pay very slowly.  They may reject the claim a few times.  They may nitter-natter with the patient, and nitter-natter with the providers.  So I think it was almost six months until you would see your revenue stream ramp up to where it’s going to be, and you may have been producing at the same rate the whole time, but your revenue stream comes up more slowly.

F:  So one way to think about this is when people are holding on to money, like insurance premiums, they can do stuff with that money until they give that to the provider.  There can be interest earned, or it can be invested.  I don’t know what insurance companies do with it, but there is an incentive to hold onto that money for some period of time instead of flipping it around as soon as possible.

M:  Yeah.  You almost never see your money in 30 days.  It’s usually longer than that.

QT:  When you bill $200 for example, where does the money go?

M:  Well, we’ve got a problem here: we’re talking about billing versus collection.  If I collect $200, I can tell you where all the money goes.  If I bill $200, I don’t know where all the money goes.

QT:  Let’s start with this question then, in order to get $200 in the first place, in order to collect $200, in your estimation what would you have to bill?

M:  Probably about 120 to 130% of that.

QT:  Okay.  And then after you collect the $200…

M:  Just a minute.  I’m getting a confused look.  My collections were typically 80% of my billed amount through Mediserve.

F:  And that’s a historical number?  It’s been a while.  All right.  I see how you’re figuring that.

QT:  So after you get the $200, once you collect that, where does that money go?

M:  Again, it depends on what kind of a practice you have.  If you’re running a clinic practice where you have office personnel and you’re paying rent and things like that, 60% of it typically will go toward things like overhead.  A well-run practice will have an overhead of about 55 or 60%, and it’s difficult to get below that in a medical practice.

QT:  Why?

F:  Is that including things like malpractice [insurance]?

M:  No.  That’s paying your personnel, paying the rent, paying for office equipment, the lost things that you can’t collect on, and things like that.  So you paid for some supplies to do a procedure and you don’t get reimbursed for it.  For instance, there is something called a facility fee.  If you are part of a large facility, such as a hospital, and you do a procedure, you can charge a facility fee which is basically designed to defray some of the costs of the facility.  If you have your own office exclusive from a large facility, you cannot charge a facility fee.

So if I have a tray of supplies – some syringes and needles and maybe a scalpel blade and sutures or something – and I’m doing a procedure in a hospital, I can charge a facility fee that will pay for those supplies.  If I’m in my own private clinic, I can charge some supply fees, but you can’t charge for everything.  Not all of the things are reimbursable, and you can’t charge a facility fee, so basically you lose money on the supplies you use.

F:  Is that one of the incentives for physicians now to go into big practices, like the hospital here is buying up big practices?

M:  Yes.  You can charge a facility fee.

QT:  Why can’t you charge a facility fee as a small practice?

M:  I’m not sure.  I have never understood it.

QT:  Is it against the law?

M:  It is.  It is against the law, and I’ve never understood why you’re not allowed to charge a facility fee if you’re running a facility, but it’s not allowed.

QT:  So when you’re talking about overhead, you’re just talking about straight, empirical overhead: cost of the building, cost of the people, cost of your supplies?

M:  Yes.

QT:  And that’s medical supplies as well as office supplies?

F:  Right.  So then you take whatever is left, and as I understand it, malpractice comes out of that, professional travel, licensing activities – any of those things that you’ve got to do to stay–

M:  CME activities.

QT:  What is a CME activity?

M:  That’s continuing medical education, so if you go to a meeting and it costs you $1,000, that comes out of that.

F:  And then there are taxes.

M:  And then there are taxes, and what we would always figure we would pay here in Montana was 50%.  So you take the 60% out for overhead, you bring home supposedly the 40%, half of that goes for taxes – and that includes small business tax, that includes personal income tax, that includes any income tax on the practice.  Any kind of taxes, property taxes or anything else, it all adds up to about 50%, wasn’t it, of what we brought home?

F:  Actually, it wasn’t.  The self-employment taxes you were paying because of the structure of your building, it was the income tax on that, and then it was…  I think that was it.  So self-employment tax is going to be Social Security, Medicare, that kind of stuff.

M:  But wasn’t it close to 50%?

F:  Yes.  Oh, and the state income taxes, so there’s the state and federal, so that was 50%.  But you’re kind of left without the part about malpractice insurance and that other stuff that’s not strictly your overhead and it’s before your taxes.

M:  That’s true.  What was malpractice?  Was that about 10%?

F:  I don’t remember.  It goes up and down.  Right now it’s about $13,000 a year for your level of practice.

M:  So that’s about 10%.

QT:  That’s 10% out of your total revenue, or 10% out of that 40% that you would be making.

M:  That would be 10% out of the total, but again, I’m not doing an office practice right now.  But anyway, basically what we’re saying is that by the time you take out all of your expenses, your actual captured take-home pay is on the order of 15 to 20% of what you billed–no, of what you collected.

QT:  Of what you collected, because what you said before was that if you collect $200, that means you’ve had to bill somewhere in the neighborhood of $250 to $300.

M:  Yes.

QT:  Can you make that generalization about somebody working in, like, the hospital clinic environment, like the OBGYN, the Children’s Clinic, as well as someone in private practice?  Is that fairly true across…

M:  A person who’s in private practice, not in a larger facility, will have somewhat higher overhead costs because they’re not split between so many people.

F:  The other thing is a lot of the practices that you’ve visited in Bozeman or Billings have been part of a large group like the Billings Clinic or the hospital building or whatever it is here.  Because it’s a larger operation, you are spreading those costs over those people, and like you said, the overhead may be less.  The other thing, though, the big difference between those types of practices is that a practice like Jack’s, and a lot of individual physician’s practices, cannot offer health care insurance to their employees.  That’s a huge driver right now into physicians joining those groups that can provide the health insurance for their employees.

M:  And that includes the physician who is running the practice.  We couldn’t–I shouldn’t say we couldn’t afford to buy it, but it was extremely expensive to buy insurance as a physician running a solo practice, compared to someone in a group.

F:  Well, you couldn’t join a group policy, and we did have one through AMA, but that was associated with AIG, and that went up significantly after the first of this year.

QT:  We’ve got some questions about that toward the end, about your personal health care.

M:  But anyway, when you see a bill from a physician for $300 or something like that, you can be pretty assured that that physician is going to take home 8 to 10% of that amount.

QT:  Even in a clinic?

M:  Even in the clinic.

F:  Yeah.  Because they’re running those big hospital clinics as a business, and if somebody above the individual medical practice is deciding -

QT:  Like stockholders or a board or something?

F:  Depends on how they’re run, but usually a board is deciding, “How are we going to expand the building or the endeavor this year?” so everybody pays a part of that.

M:  Okay.  So again, my favorite example: A friend was very annoyed at the bill he got for 40 minutes of service, burning actinic karitoses off his head.  He got a bill for $200 or so.  And he said, “This is terrible.  This guy gets $200 for doing this.”  Number one, this friend is on Medicare, so he didn’t have to pay anything, but he’s still up in arms about the idea of this doctor gauging so much money for this simple procedure that took 40 minutes.  If you consider that that physician took home maybe 10% of that $200 when all was said and done, he got 20 bucks for 40 minutes of work on this guy, and that’s all he took home and put into his pocket.

QT:  The public Medicare/Medicaid is being put forth as a potential solution, or a part of a potential solution in the health care debate we’re talking about right now.  You had mentioned that Medicare paid approximately 13%.  What about Medicaid?

M:  Don’t know the answer to that.

QT:  Did you deal with much of that?

M:  Some.  Not a lot, because Medicaid often goes to children, and my practices, with the exception of putting tubes in kids’ ears, now we get Medicaid payments, but again, I’m a subcontractor, so I don’t know what the billing office is getting.

F:  But I always had the impression from the pain clinic practice that it was less that what Medicare was paying.

M:  Really?

F:  I don’t know if that’s true or not; that’s just what it seemed like.

QT:  Do you have any concerns as a doctor that a publicly run system would pay doctors less?

M:  Yes.  I do.  Everybody keeps bringing up the idea that Medicare works so well – it’s only got 3% overhead costs.  Well, a lot of the reason Medicare works so well is it reimburses physicians very poorly.  In one of the examples – I can’t remember if I was talking with you about this the other day or somebody – but my favorite example from a surgical point of view is that we do two things that really, really, really make a huge quality of life difference for people.  One is cataract surgery, because all of a sudden, it’s like the blind can see.  It’s huge for these people.  The other one is total hip replacements.  And we do them very, very well.  A cataract operation can be done basically under local [anesthetic] and it takes about 40 minutes start to finish, and it’s life-changing.

A total hip [replacement] is similar, it’s a little more involved anesthesia-wise, but it can basically be life-changing for people that just have been so miserable that they can’t get around.  And you see people who are so depressed from the pain and inability to move that they’re in that they’re willing to commit suicide if they can’t get it fixed.  It’s life-changing.

These are the two worst procedures reimbursement-wise for the surgeons.  For cataract surgeries, you have to pare everything down to the absolute minimum, as far as the supplies you use and who is involved personnel-wise.  And total hip [replacements] are a write-off for the hospital.  They cannot even get the cost of the prostheses reimbursed effectively from Medicare.  So basically they have to make up the difference from doing total hip [replacements] by doing other procedures that pay better.  And yet total hip [replacements] are one of the most beneficial things that we do for people.  And Medicare doesn’t recognize that.  You know, they talk about all this pay-for-performance kind of stuff, if you’re talking about pay for things that really improve peoples’ lives, they’re coming up way short on what they say they want to be doing.

F:  So if you extend that to the wider population – and I frankly think there are some things in favor of considering a public option – but you’ve got some real problems in that most people that I’ve ever met who’ve gone to medical school intend to have half-way decent lifestyles.  They’ve also got 100, 200 – maybe more hundreds of thousands of dollars in loans to pay back, plus the costs perhaps of setting up a practice or moving to another part of the country.  None of that stuff, by the way, is usually paid for physicians.  So it seems to me you’re going to run into a real quality issue eventually because of the types of people that you might attract to medicine aren’t going to be the kinds–there are certainly lots of easier ways to make money.  That’s certainly true now, but it’s going to get worse, the more you stress the system that way.

QT:  If a public option were to pass, and you had any say in what doctors were paid, what’s your opinion on that?

M:  Pay me a salary.

QT:  What kind of salary?

M:  I think it should be decided on how many hours are you spending, what was your training, what’s the level of intensity of care that you’re giving.

F:  Whether or not you’re solely responsible for absolutely all malpractice issues.

QT:  Are you talking about being an employee of the government, basically?

M:  Yeah, basically.  If they want to do a public option, they can’t do it on the backs of the providers.  I don’t think there is a very large percentage of physicians that are going to complain about getting paid a salary because it makes their lives so much easier.  They don’t have these mounds of paperwork that they’re always having to deal with, they don’t have to field calls from insurance companies saying, “Why are you doing this?” kind of thing, justifying what you and the patient have decided is the best course of action.  That would eliminate all of that stuff.

Now, the salaries would be less than what people can make now.  There’s no question about that, but you can’t make it a 3% kind of salary, or a 13% kind of salary.  There would have to be some kind of a schedule where you would know what you were going to be getting.  So yeah, a physician, I think, should reasonably be expected to take home the kind of salaries that executives in other kinds of activities take home, salaries that are commensurate with that.

F:  Ten million dollars? [LAUGHTER]

M:  You can get onto the web and you can look up salary calculators, like what should a CFO in a small company in Bozeman, MT be making as far as a salary?  And it’s right there.  You can calculate it and say, “Okay, this is reasonable for that position.”  And it would not be difficult to come up with the same kind of thing.  A physician who’s seeing somebody for an ear infection obviously should not be getting the same amount of reimbursement for that as somebody who’s seeing a patient to take out a brain tumor.  The levels of care are entirely different, but that should be something we can calculate and say, “Here’s what it looks like.”

QT:  Are you concerned that doing away with a billing-based system of pay for doctors would negatively impact the quality of health care?

M:  Only in one way.  When you get a employee mentality, then people want the same rights as other employees.  The doctor wants to go home at 5:00.  He’s getting paid a salary to work from 8 to 5; he doesn’t want to work until 9.  That’s the one thing I do get kind of concerned about, is you’re going to see that kind of an attitude develop, that, “I don’t want to work any longer than I’m getting paid for.”

F:  That attitude’s already out there.  A lot of physicians put up with call without too much complaint, understanding it’s part of the picture; there are a lot of them that are out of their offices by 5.

M:  That’s really my only concern.  I think you will see a demographic shift in who goes into medicine.

QT:  We’re seeing that already, aren’t we?

M:  Yes.

F:  Yeah.  And the thing I’m worried about, having taught a lot of these people, is that you want the brightest people going into medicine – or you want bright people going into medicine, not just people who can memorize things and spit them back on tests, but people who are inquisitive and lifetime learners and kind of the cream of the crop.

QT:  I’m inclined to call it the Sullenberger wager, because Chesley Sullenberger, the Hudson ditch pilot, testified before congress that if you don’t pay well, you’re not going to get the best and brightest behind the yoke of an airplane.

QT:  Which is true anywhere, but it’s much more important when we’ve got lives at stake.

F:  It is true.  It is important.  That is a big concern about trying to reform health care because people are not really addressing that issue.  The perception is that all these doctors are making all this money and there’s enough out there in our American system to pay to take care of all the individuals who are going to need care if we extend care to everybody in the country – which of course we should do.  But that’s not true.  If you’ve got this – what – one-sixth of people without adequate insurance or something like that and you all of a sudden put them into the system, right away you’ve created lines like they’ve got in Canada, I would think.  You’ve created a problem, anyway.  Nowhere in that equation is there any kind of allowance for people working longer hours anymore.  So there’s some balancing of the equations that has not happened in Washington, as far as I can tell.

QT:  I have a quick tangent to go off on.  Does the Montana Pain Resource Center still exist?

M:  No.

QT:  Why did it go out of business?

M:  It went out of business primarily because I wasn’t taking home a salary.  There were many, many months, when after paying all the bills, I didn’t take home a paycheck.

F:  In fact, that’s why he started part-time operating room anesthesia, so that we got something out of your work.  Yeah.  For a long time, you did not make money.

QT:  Were you losing money, or just breaking even at the office?

M:  Well, if you count me not paying myself a salary, I guess I was breaking even at the office.

QT:  I guess that’s my question.

QT:  What service did the clinic provide?

M:  It was a fairly aggressive pain diagnosis and management service, and some physicians felt it was useful, and some physicians didn’t think it was really something that was needed in the community.

QT:  When you’re talking–from the patients I saw that you had, these are not your average people.  They’re not average citizens.  They’re people who were in a lot of pain, chronically.  And a lot of them were from Worker’s Comp injuries, and I don’t know if the Worker’s Comp issue is something that should come into this discussion or not, but [these were] people who were injured badly enough that they could not work.

M:  And consequently couldn’t pay.

QT:  Couldn’t pay, couldn’t function in their life.

M:  Usually their case was in litigation with Worker’s Comp, so Worker’s Comp wouldn’t pay.  So no one was paying.

F:  So what’s the question then?  Did you ask it?

QT:  I guess my point is that these were not people who were going in for their yearly checkup.  These were people who were in really rough shape.  Some of the people I remember seeing were at the very, very last ragged edge of being able to handle anything.  But not old–they weren’t old people.

M:  This is a population for which suicide is a definite choice.  They have to confront that choice.  Would it be better to just end it?

F:  And some did.

M:  Yeah.  And some did.

QT:  I mean, if they can’t get health care.

QT:  Do you think the clinic failed because there was no public option to pay it?

QT:  I don’t know that a public option would pay for that anyway.

QT:  From the standpoint of an entrepreneur, starting a clinic that addresses patients in chronic pain on Worker’s Comp with no income is a fool’s errand.

M:  It is.  And that’s what that clinic was.

QT:  But as a physician, it sounds as if–you don’t really strike me as a fool, so why start the clinic?

M:  Because people needed the help.  That was the main problem, and frankly I didn’t put enough thought into, “Can I make a living at this?”  I think Jill was always concerned about that–

F:  Not smart enough to put my foot down, though.

M:  –because she saw that this is not a remunerative field of medicine to go into.  You can’t make money at chronic pain management.  The way you make money is you see 30 patients in the morning and you do 15 procedures in the afternoon.  So basically, you spend 5 or 10 minutes with each patient, and then you do 15 or 20 minute procedures in the afternoon.  You can make money doing that.  The question becomes do you provide a service?  And my answer is no.  You’re not doing chronic pain management there, you’re doing entrepreneurial pain management, and you’re just raking in money, but you’re not helping anybody.

QT:  You’re prone to misdiagnosis.

M:  You bet.

QT:  Where you get 15 minutes, and if the doc can’t figure it out…

F:  They get a contaminated urine sample, “Well, good.  We’ve got an answer for you.”

M:  These are people who have spent 5 to 10 minutes with multiple physicians, none of whom were able to figure it out.  They’re not a lot dumber than I am, so is it reasonable to expect that in 5 to 10 minutes I’m going to figure it out?  No.  I mean, these are the kinds of people you need to spend an hour or two with to begin to understand what the issue is.

QT:  So as a physician, you think to diagnose an elusive problem, like where pain is coming from or…

QT:  Why it’s not responding to typical treatment options.

QT:  You think that in order to address that problem medically takes one to two hours?

M:  Initially, and then follow-up visits after that.

F:  I think there are a lot of problems like that.

QT:  Or a lot more time than we’re spending with our doctor right now.

F:  It’s not just restricted to pain management.  I mean, the big one for me is the thyroid issue.

QT:  I’m just using MPRC as an example.

F:  Right.  I understand that, but I just want to make it clear, but we’re talking 15 to 20 years to figure out… and I started right from the beginning going to the best physician I could identify in town, and it was just totally off base.  So that’s just one example.  We can all think of multiple examples.  They didn’t pick up mono in you for weeks, and that should have been one of the first choices.  We should have thought it, but certainly the physician should have.

QT:  It took three months when I was a teenager for the doctors to find the broken bones in my back.

QT:  After they knew your exact injury, too.

QT:  After they knew my exact injury.

M:  That’s difficult to reconcile from my point of view, that if you know the exact mechanism of injury, you don’t look specifically for a particular problem.  And I’m sure what was fooling them was your age.  “He’s not going to have a problem there in his back at 15,” or however old you were.

QT:  That’s about right.

M:  “That’s not going to happen.”  The youngest acutely protruded disk I’ve ever seen was actually in a 15-year-old, so these things do happen in young people, but so many physicians think…  Well, what happens is they follow the old adage, “When you hear hoofbeats on the plains of Montana, you don’t think of zebras.”  Well, sometimes you do have to think of zebras, particularly when all of the horses that you’re trying aren’t working.  Then you have to start considering zebras.

That’s the error, I think, that a lot of physicians make.  They don’t have the time.  Frankly, a lot of them have become jaded.  They don’t have the interest because they are so besieged by all of this other stuff they have to deal with on a daily basis, and things fall through the cracks fairly regularly.

QT:  Do you think that a salary system will fix that, if a salary is commensurate with the level of expertise a physician has?

M:  And if the workload, if we say, “We’ll pay you X salary, but you’ll have to see 60 patients a day,” it’s not going to change.  It’s going to get worse.

QT:  Well, you’re talking about, from just kind of a rough estimate of what you’re talking about with a salary type thing where people are working more shift work, you know, like salaried manager where you may be there 12 or 14 hours a day.  You’re talking about needing a huge increase in the workforce compared to today, and that’s not accounting for whatever retirements…

M:  You know how they’re doing that?

QT:  PAs?

M:  Nurse practitioners and PAs.  That has been one of the initial responses by physicians, that they can’t see enough patients in a day to get their income up to the level where they want it, so they hire nurse practitioners and PAs to see additional patients.

F:  And the problem with that scheme is so often the person that you see when you go through the door is the person who doesn’t have training.  It seems to me like those individuals who don’t have medical school, who don’t have anything like the medical school and residency experience, should be people who may do follow-up management according to some algorithm or something, but they shouldn’t be the ones who meet the person coming through the door because–

QT:  They do the initial diagnosis?

F:  Yeah.  Because you need really good diagnosticians.  And I think even most highly-trained physicians are not very good at it and need to get a lot better.  The other thing you need to do, though, if you get more toward shift work – by the way, I don’t think that medicine is ever going to look like shift work.  It’s always going to look like 10 to 12 hours a day, probably.

QT:  Well, not accounting for the on-call stuff.  Who’s going to do that?

F:  Yeah.  But if you go to that kind of a paradigm, where you can’t count on people around the clock being available for their own patients, or something heading close to shift work, physicians are going to have to learn to communicate with each other, and they are abysmal at it.  I mean, it’s just a bunch of people with…

QT:  You’re going to need relief briefings.

F:  Yeah.

M:  Well, there is an ego problem in communication.

F:  You said it.

M:  Well, let me tell you about an extreme example of how the PA/nurse practitioner thing functions in maybe not the best way.  We have some very entrepreneurial orthopedic surgeons in Bozeman, one of whom I have observed on more than one occasion meeting a patient for the first time in the operating room before doing the operation.  That’s how bad it gets.

QT:  Holy cow.

QT:  So the PAs are doing the full diagnosis?

M:  The PAs are doing everything.  They may take an x-ray and take it to the physician and say, “This is what I’ve got,” and he’ll say, “Oh, yeah.  He needs surgery.”  Never lays an eye on the patient, never examines the patient, the first time he met the patient was in the operating room.

QT:  Was the patient conscious?

M:  Yes.  Because he said, “Hello.  I’m doctor so-and-so.  I’m going to be doing your surgery today.”  That’s how bad it can get when people are really stressed to see so many patients in a day to make a living that’s commensurate with what they think they should be making.  And that’s the other side of the equation.  There’s always a kernel of truth in everything, and this issue that physicians make way too much money does have a kernel of truth in it.  That kernel of truth is, yeah, a lot of physicians do need to scale back their income expectations to something that’s a little more reasonable.

They shouldn’t be expecting that after five years in practice, to go out and build a $3,000,000 house.  Those things shouldn’t happen.  They should have the same kinds of constraints as everybody else who has gotten a lot of education and then has gone to work and is making money and has bills to pay and blah, blah, blah.  Some physicians don’t believe that.  Some do think they should be able to go right out and buy a Maserati, just like athletes out of high school who sign multi-million dollar contracts with baseball teams–

F:  Except they have more years of experience.

M:  –feel they should have the right to go out and enjoy this lifestyle.  Well, no.  It doesn’t work that way.

F:  So it is a difficult issue to try and figure out how you’re going to do staffing, complications about–

QT:  I’m envisioning a workforce that’s going to be two or three times the size of what it is if you’re going to go to more of a salary-based, fairly constrained – as in 8 to 10 hours, not 24 hours on call or something like that.

QT:  If there is a public option and it goes to salaries for doctors, do you also think the government should provide financial relief for the training?

F:  Absolutely.

M:  That’s the biggest burden that these physicians today face, is paying off their training.

QT:  That’s one of the last questions I have on there.

F:  That’s okay.  They don’t have to be in order from my perspective.  But I’m just going to put on tape, for whatever use you want to have, Jack’s experience versus the experience kids are going through today.  When you started medical school, your parents paid tuition, and I think it was like $2500 a year to go to one of the best medical schools in the country.

M:  1973.

QT:  That was the year or the price?

M:  That was the year that I started.

F:  I think it was like $10,000 – and I don’t know for certain – for tuition.  Of course, you had your living expenses and everything else.  That’s where I came in.  Jack had a couple of jobs off and on that paid a little bit, doing physicals for some…  I don’t remember what that was.

M:  Pre-op physicals.

F:  Pre-op physicals, that sort of thing.  But basically, was there any loan involved when you went to medical school?

M:  Yes.  We had a $1500 loan my senior year, I think.

F:  I think that’s what it was.  So we’re talking about the day Jack starts working, basically, when income starts coming in, all the debts are gone.  At least all the debts for training are gone; the debts for the equipment, because of how you started practice–

M:  Were gone in the first six months.

F:  But that’s just vastly different from people who are now spending $100,000 for that training, and they’re still not getting paid that well.

M:  I remember I had a resident in Hershey – this was in the 1980s – who had over 300k in debt to his medical school for his training.  This was in the 1980s; I don’t know what it is now on average for training.

QT:  So the question I’ve got here – you said the “kernel of truth thing” – the media, tv, new, books, that sort of thing, there is a perception by the general population that doctors make a lot of money.  What I wanted to ask about was how much do people today expect to pay, or can reasonably expect to pay, versus how much can they reasonably expect to get paid after that 8 to 10 years of training?  What is the debt versus income expectation?

M:  I don’t know what the debt expectation is today.  I really don’t.  I gave you that one figure, and I expect that would probably be similar to today, that most people coming into practice have debt in that range.

F:  That sounds awfully high, but I’m out of the loop on that too, so I don’t know.

M:  The perception that doctors make a lot of money is really driven by the press, and it really bothers me when I see articles in the paper with headlines: “Average Physician Salary in Bozeman 170K a Year,” or something like that.  Well, if you’ve got 10 physicians, one of whom is a very highly specialized surgeon who maybe makes 500 to 600k a year–

QT:  At the end of his career?

M:  Anytime in his career, but he’s making that kind of money, and you’ve got 5 other physicians who are family practice types who are bringing home 70 to 100k a year.  Say it’s 100k a year, so you’ve got somebody producing 500k a year and five people producing 100k a year, so together you’ve got six people producing $1 million a year.  What’s the average salary that they’re bringing home?  It’s about 160k a year, isn’t it?  Does that really reflect what physicians bring home?  No.

QT:  And that’s kind of the point I want to get to, because 70 to 100k for most Americans is a lot of money.

M:  It is a lot of money.

QT:  So what is the outlay…?  Do they deserve it for what they paid [for medical school]?  Do they deserve more?  What should that range be, based on their training, what they paid for their training in time and effort and money?

M:  And what they do.

QT:  What should they be paid.

M:  Well, my personal feeling – and this is just my personal feeling – is that a salary in the range of 100k a year for a physician who’s staying up long hours, who has the responsibility of being right a lot of the time on making diagnoses, and who can expect to have his phone ringing any time of the day or night from people with questions that may be absolutely asinine or may be very important questions.  I don’t think that’s an unreasonable salary expectation, to say, “I should reasonably be able to take home somewhere in the neighborhood of 100k a year.”  Now, that’s what executives in a lot of corporations take home–

F:  Sounds low to me.

M:  –is salaries in that range.  Now maybe it’s 120k a year, maybe 150, I don’t know, but somewhere in that range doesn’t seem unreasonably to me.  500k a year, that’s getting up there.  Yes, they’ve got a lot of specialized training and they take a lot of risk in what they do that things may not go right.  These are usually surgeons that are getting that kind of reimbursement.  They own the patient after that; any complications that occur, they have to be responsible for.  They have big malpractice policies, blah, blah, blah.  Should they make 500k a year?  I don’t know.  That’s getting up there.

QT:  Is that take home [pay] after they pay their overhead and their malpractice and their blah, blah, blah?

M:  I’m talking about take home pay.  So I guess I do have an opinion that there are amounts that are a little unreasonable, and there is probably a reasonable range.

F:  But you look at a lot of people, a lot of engineers – I’m trying to think of people who make on the order of $70,000 to $100,000.

QT:  IT.  That is the most bizarre thing to me.

F:  There’s nothing.  They don’t have to do a thing when they get home, and I’ve been around physicians enough to know that’s not the case with medicine.  The thing about the phone ringing all the time, that’s why Pat Snow got out of private practice as a GP.  After, like, three years in practice, he went to work for an insurance company because of what Jack said – the phone ringing any time of day or night.  Kris said, “You know, he could have a mistress and I’d never know it because there’s just always something going on, always something calling him out of the house.”

M:  And to this day, I still do not like answering the phone.

QT:  I’ve never liked answering the phone, except maybe when I was 15.  We’re going to need doctors specifically, people who have gone through medical school.  What would you tell somebody who was considering medical school?

M:  I have a really hard answering that question, actually.

QT:  Do you encourage them?  Do you discourage them?

M:  I try to duck the question, typically.

QT:  Well, that says something too.

M:  Because I’m kind of torn.  On the one hand, we need medical care providers, we do, in this country.  On the other hand, you know they’re looking at a career that isn’t going to be fun.

F:  Yeah, but it’s one of the most interesting – and I’m saying this from being outside the field.

M:  It can be.

F:  It can be one of the most interesting and rewarding…

QT:  Intellectually interesting?

F:  I think so.  I think if people get intellectually engaged, that would make a huge difference in how they survive.  For instance, that surgeon fellow I’m seeing in Butte, he’s very intellectually engaged – probably not right all the time – but he’s very intellectually engaged and provides a lot of good service for his patients.  But my perspective’s from the outside looking in.  That’s why I don’t have a strong opinion.  If you had said you wanted to go to medical school, I would not have probably discouraged you.

M:  I will admit I’m very conflicted about trying to answer that question.

QT:  That’s not good.

QT:  If the public option passed, would your reticence to answer the question change, or is it the nature of the job that makes you hesitant to answer?  Is it the nature of the job instead of the pay?

M:  There are a lot of ifs, as far as I’m concerned, that I would like to see happen before I could really say, “Yeah, it’s a great career.”  I’d like to see what Mom just said, that we have students who are engaged, who are intellectually curious, who have an urge to help people primarily, who don’t put making a good salary at the top of the list of things, that when they go to interview for a position after training the first thing they ask is, “How much am I going to make?”  So I would like to see those things happen on the personal side.  I would like to see hours reduced that physicians are required to work.

QT:  Are there requirements?

M:  No.  But you kind of feel obligated.

QT:  So there’s no rest?  There’s no maximum?

M:  Unless you decide you have to take it.  A lot of physicians get very proprietary about that after a while.  They get cranky about it.  They don’t like their time being infringed upon, because it’s so valuable to them.

QT:  I’m thinking about an on-call type position.  There’s no…

F:  It’s not like the FAA.

QT:  Well, that’s my question.  But you’re still dealing with being responsible for people’s lives.

M:  Right.  As a physician, you may be up for 36 hours straight and nobody gives a rip.  You’re expected to perform.  That’s another issue, which is the whole expectation of performance.  You always feel like you’ve got… well, when you walk in to talk with patients now, you almost never can walk in feeling like you’re going to have this interpersonal conversation with somebody who could be your friend.  Could be anybody, could be your friend.  Now when you walk into a room, you walk into a room knowing in the back of your mind that this person could be a litigant.  There’s that aspect of it, and you’re always aware that right here, behind your shoulder, is a rapacious attorney, looking over your shoulder ready to pounce if something goes wrong.  That needs to be corrected.

F:  That’s coupled with the fact that they’re thinking, “This guy makes tons of money.  I don’t have to pay him the entire amount.”

M:  Yeah.  But we really do need tort reform.  We do need to get the attorneys off our backs.  We also need kind of media reform, so the media isn’t jumping all over something where it looks like there might have been a problem with a physician’s performance, but they don’t really know, and the data isn’t really out.  Yet they jump all over it, making it appear very prejudicial right from the get-go.  That needs to stop.  Those things get into the paper, but you don’t see the huge amount of, “Dr. So-and-so stayed up 24 hours making sure that this patient did well and they had a good outcome.”  You never see things like that in the paper.  You see, “Dr. So-and-so didn’t do such and such and the patient lost their foot,” or died or something like that.

Those kinds of things would be nice to see too, that if you’re going to ask people to provide this kind of service, you need to be supportive.  You don’t need to be constantly looking to sue them, and you don’t need to be constantly looking to tear them down off a pedestal or something like that.  Rather, you need to be supportive and say, “We really appreciate the fact that there are people out there willing to do this.”  Those are some things I would like to see along with the public option.

F:  But can I interject something, because I don’t think what we’re talking about is just the public option.  If healthcare reform doesn’t include the public option but does include other things that require that everybody have some kind of health coverage some way or the other, then a lot of these problems still have to be addressed.  The personnel numbers, things like that, still have to be addressed.

QT:  So you’ve seen the Wendell Potter interview.  You sent us the link.

F:  We’ve seen it twice.

QT:  Mr. Potter’s story really clearly illustrates how a for-profit insurance company and industry can cause problems for a patient.

QT:  As far as patients paying the premiums, but because it’s for-profit, there’s incentive for the insurance company not to pay.

QT:  To deny coverage, yes.

F:  Follow the money.

QT:  So then how does that same industry affect a physician’s ability to provide patients with care?

M:  A good example: very good OBGYN surgeon in Butte was talking with me the other day about a patient that needed a particular procedure.  In his point of view, this patient needed a particular procedure.  The insurance company denied it, saying, “You haven’t tried this, this, and this, and you have to do this, this, and this before we’ll authorize this procedure.”  Well, there were various reasons why the surgeon knew “this, this, and this” were not going to work, which of course, he corresponded back to them.  They would not change their position.  Basically what happens is that insurance companies begin to practice medicine, for which they are not qualified.

QT:  Do you think that they’re practicing medicine…?  Clearly it sounds like this person needed a particular procedure to be done.

M:  Yes.

QT:  Were the three procedures that the insurance company outlined less expensive?

M:  I can’t answer that.  I don’t know the relative costs.

F:  Were they invasive?

M:  Two were medication-based and one was…  I don’t think any of them were invasive.

F:  The reason I ask is because they’re not considering risks at each step along the way, or they need to.  It’s kind of the same situation as with Jane and her drugs.

M:  I think they’re playing the odds game.  If they think the patient’s going to respond to something short of having to have the procedure, they’re going to end up paying less money.  Now, there is the flip-side to that, which is that if they don’t respond to the three things and they end up having the procedure, they’re going to end up spending more over the long-haul.

F:  Or there’s another alternative, which is what you see so many people with any money doing nowadays, which is that the insurance company comes back denying something and so the patient just gets fed up and says, “All right, let’s just do this.  I’ll pay it out of my own pocket.”

F:  So why have insurance to begin with?

QT:  And yet they’re still paying their insurance company in the meanwhile.

F:  Absolutely.

QT:  To put forward a situation that is not completely untenable, but is untenable enough to where the patient loses the battle of attrition and just decides to put up with whatever condition they have.

F:  I was thinking that we need to talk a little bit about how decisions are made in medicine.  We’ve talked about insurance companies making these decisions and setting these hurdles for patients and physicians to get over with–either the patient or the physician’s just going to get frustrated and do something else and pay for it out of their own pocket.  What is being pushed in the medical profession is evidence-based medicine, which basically is that decisions are made based on the evidence in support of taking a certain course of action in a certain situation.

What we’re hearing about some of these bad examples from the insurance companies is at odds with practicing evidence-based medicine.  So I’m always thinking about the question which is: can we base at least non-emergency care – drug choices, things like that – on the evidence that is out there in the medical and scientific literature rather than on some sort of other paradigm that is thought up within an insurance company?

A friend of mine had a similar situation to what Jack’s talking about with drugs.  I won’t go into all of it, but basically the insurance company denied the drug that the physician wanted to put this woman on.  She was supposed to go for 30 days on one drug, 30 days on another drug, 30 days on another drug, and then she could have the drug he wanted to prescribe her.

M:  If she didn’t respond to the others.

F:  Yeah.  She had a problem with the first drug, a side effect, so he wanted to jump her to this one drug.  The insurance company said, “No.  You didn’t even finish 30 days on the first drug, so you have to go back and do that, and 30 days on each of these other drugs.”  I said to her because she was really upset, “You know, the question I have for them is, ‘What is the evidence?  What do the clinical trials say about what they’re proposing that you have to do?  What is the evidence for their approach?’”  I don’t know that that’s going to solve all of the problems, but I think we have a real dichotomy between the business of insurance and the practice of medicine and what physicians are being encouraged to do within their profession.

QT:  My thought on the whole thing is that right now we have a middle man, which is the insurance company, which as Mr. Potter’s interview illustrates, there is a problem having a for-profit middleman in between the patient and the doctor.  My inclination is to say that insurance should act as insurance, and we take that cost out of the everyday lives of everyday people.

F:  How?

QT:  By having only catastrophic insurance, for example, and really pushing health saving accounts instead of paying an insurance premium that’s so high.  Pay for a catastrophic plan, and put the rest of that in a health savings account that is your money to use on your health care.  My thought is that if you’re not paying the fat middleman for every transaction that you do, that should bring down the costs overall in the system.

F:  But the problem with that is that people who are just starting out, maybe just starting a family, can’t do that.  I don’t know what the costs of having a baby today are, but I’m guessing we’re in the tens of thousands of dollars.

QT:  Six grand?

F:  Not just the delivery.  I talking all the care.  Somebody told me a knee arthroscopy is $30,000.  I can’t believe that, but…

M:  I find that hard to believe.

F:  Anyway, we’re talking about 10,000, 15,000 if things go well.  That’s just too big a gamble.

QT:  Part of that cost is you’ve got this bureaucracy, this insurance company that’s leeching money off of every transaction.

F:  I’m not arguing about that.  But I think you need to look back at how health insurance worked at the time that we had you, at the time that we were just starting out.  I think it was Mr. Potter who made the comment that greed wasn’t such a big factor.  The insurance companies weren’t pushing their profits to the limit, and were working so hard to make a profit that they forgot their customers in the process.  When we had you, I paid $9 and that was for a prescription I knew I didn’t need.  That was it.  Insurance paid for everything.

Insurance had been that way.  There was no argument.  There was no second-guessing.  The physicians weren’t wasting their time with insurance at that time.  I don’t know if we can ever go back to that scenario, but I think a lot of what’s driving the problem right now with insurance is the need for companies to make money for their shareholders.

QT:  So then can the system survive with a for-profit insurance industry?

M:  I frankly don’t see how.

QT:  How do you fix it?

M:  But there is one thing that I would be willing to have people explore, which is an option that a Princeton professor who studied this for a number of years said we really need to do, which is that everybody needs to be given access to a basic health plan, and that all the insurers involved in health care need to offer the same basic health plan.  I think what he would be saying then is that it’s got to be cheap, it’s got to be affordable, etc.  Basically what it would provide is prenatal care, immunizations, wellness care, preventative medicine kinds of things – just a basic package, and everybody who buys it knows exactly what they’re getting.  There’s no question about what’s going to be excluded, what’s not.  No question about preexisting conditions; nothing like that.  Just basic health care.

F:  But it would have to include some surgeries, some procedures, cancer treatments, stuff like that.  We have managed our health care over the years – I know you’re going to ask about this in a bit – a lot of how we’ve managed our health care over the last couple of decades is that we’ve paid for all the little stuff, and we’ve had insurance in case the big stuff happened.  So what he’s saying sounds to me like paying for the little stuff, but the thing about health care is that you’ve got to address the big stuff that bankrupts people or that causes such terrible problems in terms of them being able to get the care that they need.  It’s just a travesty.

M:  It strikes me that that’s the kind of safety net that ought to be there is for the catastrophic situations.  Somebody ought to step in and say, “You shouldn’t have to pay for all of this.  It’s just too much.”

QT:  Should that be a public thing through the state, or should that be an insurance thing?

M:  I don’t know.  I do agree with some of the groups today that say we’re moving awfully fast on this and we don’t know how the law of unintended consequences is going to play out.  I kind of agree with that.  I think if we could get a reasoned debate where people aren’t yelling at each other, but where people are saying, “Okay, I’ve thought your proposals through.  These are some of the problems I see with it.  How do we address those?”  That kind of back and forth would go on for a while.  It seems to me that we could come up with an answer to a lot of these problems.  I think if we just jump feet-first into something, we are going to be subject to the law of unintended consequences, and I’m not sure what that’s going to look like.

F:  The thing that really makes me angry on a personal level, and I’m a little torn now because I’m signing up for MSU insurance which isn’t going to have this problem, so I’m going to be part of the huge group that’s got really good insurance, instead of someone who’s buying it on my own, worried at every turn that if I do get sick, the insurance policy is going to be pulled.  If I ever have an insurance policy dropped, which has happened to us before, I could have a preexisting condition that would prevent me from getting insurance in the future.

So the real thing that I think we have to start with is some consumer protections, setting aside the non-insured for a moment, but anybody who has an insurance policy should not be able to be pulled if they’re sick.  It should not be able to be pulled if they’ve lost their job.  It’s got to be kept on a better basis than COBRA.  Anyway, what I’m really getting at is some consumer protections so you get into an insurance policy knowing that it’s going to treat you fairly.  It might not always say you can have everything you want for no extra cost, but it’s going to treat you fairly and you know it’s not going to be pulled the day that you get your cancer diagnosis because you’ve gotten your cancer diagnosis, that kind of thing.  You just hear those horror stories all the time, and the people who are buying insurance on their own like we have, you don’t feel secure at all.

QT:  Well, let’s go on to that question here, because I know Jill was in a similar situation.  Is she working now?  She had not been working in quite a while.

F:  Maybe part-time.  I’m not sure.

QT:  She was talking about getting insurance and how expensive it was.

F:  And she has a pretty significant preexisting condition, too.

QT:  That may have been part of it.  The question I have written here is that Jack is an M.D., you have a Ph.D., you’re both intelligent, well-educated people, you’ve worked–

QT:  You’re both healthy people.

F:  Yeah, we’ve been lucky.

QT:  But you’re both educated, you’ve both put in time in the work force, you’ve both been in comparatively excellent health, you don’t smoke, you don’t have alcohol problems, but you’ve had a really hard time finding insurance that was reasonable for you.

F:  Yeah.  The cost isn’t the only issue, but it does start to get expensive if you want anything but a high-deductible policy, so we’ve always gone for some version of high-deductible, at least in the last few years anyway.  When we were with that catastrophic policy, it was about a $30,000 deductible.  Now we’re on something with a $6,000 deductible, which is still pretty high, but it sends the premiums down.

M:  And interestingly, a little known fact about high-deductible policies is if they’re high enough, they preclude your ability to have health savings plans.  It’s a window that if you have a deductible between one number and another number, and I think the upper limit is about $6,000, you can get a health savings plan.  If you have a deductible that’s higher than $6,000, you’re not eligible for a health savings plan.

QT:  So there’s no way to win?

F:  There is no way to win.  The other thing that happened to us is that we’d gone through AMA for insurance for a good part of the last 15 years, and that’s always had a $20,000 or $30,000 deductible.  So you keep the premiums low and you try to save the deductible if something big happens.  Makes sense.

We have had that policy pulled or discontinued so that we were left having to get something else.  We actually went back later to get another AMA policy; that went along fine for years.  Meanwhile, we’ve not been sick.  We’ve never used the policy for anything.  That went on for a while, then they decided that, “Well, we don’t want people using this as their primary insurance policy.  To heck with these people who are able to save $30,000 against their medical costs,” so they started charging us one and a half times because we didn’t have another policy.  And then of course AIG fell apart last fall, and our premiums went up one and a half times in January, and that’s what precipitated me trying to get another policy.

It’s just when you’re buying insurance by yourself, as an individual, it’s time-consuming, it’s expensive, and you had better not have anything in your health record or your spouse’s health record or your children’s health record or your parents’ even – because they ask all this stuff – that is going to worry them about every having to pay anything out.  I mean, they denied Jack at first pass because he had paid out of his own pocket the previous year for preventative laser surgery on his eyes, not for surgery to correct a problem.  It was for preventative surgery.

M:  And they didn’t have to pay a cent.  We paid that out of pocket.

F:  No.  No insurance did.

M:  And they said, “Oh, this is a preexisting condition,” as in, “Don’t you understand that the preexisting condition has been fixed?”  That’s why we did this.  It’s that kind of lunacy that is out there.  We have some neighbors up the hill from us who pay $26,000 a year for health insurance.  There’s a physician in Butte that I was just talking to who pays $4,000 a month for health insurance, and he said it’s not that good.

F:  Is he healthy?

M:  He’s a healthy guy as far as I know.  I don’t know, he may have blood pressure issues or something like that.

QT:  $4,000 a month?

M:  $4,000 for his wife and himself, and he says it’s not all that good.

F:  So we’re in an age range where, if your salary is good and you’re buying insurance on your own – and our policy right now is not that expensive, partly because of how we’ve structured it – but they’re just raking money off of people in our age group who have done okay–

M:  Who are healthy.

F:  –self-employed, or small business, or something like that, and we’re all waiting for Medicare to kick in, but it’s not kicking in yet.

M:  And it likely won’t for us.

QT:  You mean it will be gone before then?

F:  But it’s just a dicy feeling.  So as you probably know from being with a public entity, it’s very reassuring now to have a policy through a public entity.  Well, I haven’t signed papers, but I will soon.  To know that it’s going to be the blessing of the big group policy, where you get pretty good rates, good coverage and I don’t think there’s–I have not heard horror stories from my friends over the years about having cancer treatment or anything else like that be problematic.  There have been some issues, but not too bad compared to what we would face.  So the first thing I ask of health reform is to make it fair.

QT:  It almost sounds like it’s your credit report.  In order to have a good credit score, you have to have creditors.  You have to be in debt to someone to have a good credit score, in order to get somebody else to enter into a relationship with you.  But if you were really taking care of stuff, you wouldn’t have the kind of debt they want.

F:  Keep it as good as you can, but don’t go borrowing money just for your credit report.

QT:  But it seems like that.  “If you want to play ball with us, you’ve got to buy into this policy, even though you don’t need it because you’ve been taking care of things elsewhere, because if you don’t, we’re not going to play ball with you.”

F:  So the dilemma I’m in is that I’ve got this mandatory coverage from my employer.  I’m on a one-year contract, which is probably at least verbally going to make a three-year relationship with my employer, so do I count on that?  Do I count even on that year and drop my other policy, or do I have to pay for two policies now just in case I lose my position at MSU or in case something happens?  How much can I count on that?  It’s expensive to have more than one health insurance policy, but I feel like maybe I should keep that going, just because I don’t know what the future’s going to bring with my job.  There aren’t too many 58-year-olds who’ve had as little medical treatment as we’ve had.  Jackie is really healthy, but she’s had a lot of procedures done, a lot of health worries.  I think she’s probably more typical that we are.

QT:  You and I were talking yesterday, down by the market, about the questions that would go into providing the public option, or a public mandate for health care.  I expressed to you that my chief concern is how an option like that will be paid for.  Your response to me was something along the lines of, “Right now we’re facing down a moral question.”  Would you care to repeat that?

M:  I do feel that’s what we’re facing.  As far as I’m concerned, this does come down to a moral question of “what kind of a people are we?”  You know the Potter interviews.  You saw the health fair that he took cameras to and all.  That’s going on in this country, people who will consent to having health care in an animal stall at a fairgrounds because they can’t afford insurance, they can’t get it any other way.

We have doctors who go on junkets to Mexico and India and Tibet to go and do this outreach medical care when we have people in the United States who cannot get that level of medical care.  Why isn’t it just as attractive to go to West Virginia or Montana or North Dakota or someplace to give free medical care as it is to go to India or Africa to give free medical care?

It’s a moral question, as far as I understand.  Are we a country that is going to demand that young women who find themselves pregnant, cannot have the option of abortion, and yet as those kids grow up we’re not going to allow them to have tubes put in their ears so they can hear and keep up in school and have a chance for a normal life, and we call ourselves moral.  I do not understand how you can have the one without the other.  I think this whole idea of insurance is just something that negates the whole concept of morality, that if we are going to structure people’s ability to be healthy based on their ability to pay to be healthy, what are we as a people?

F:  I see it a little different than that.

QT:  Do you think, though, that really kills the question of how are we going to pay for it?  For me, the question of how we’re going to pay for it is somewhat ameliorated by the fact that we’ve already bailed out investment banks.  Even though it’s a tangential issue, it’s still a lot of money being thrown around for something that’s not necessarily going to make a lot of people healthier.

M:  I share your concerns about how do we pay for something like this because our country isn’t structured to pay for it, however when I think it was Johnson signed the Medicare Act, there was a hew and cry about how it was going to bankrupt the country.  Medicare has not bankrupted the country, in fact, it’s one of the most successful programs we’ve ever launched.

QT:  Aside from the fact that it’s not paying doctors.

M:  There are some problems with Medicare, yes.  But it didn’t bankrupt the country.  We found a way to pay for the healthcare of seniors with this program.

F:  Until we baby boomers get to be seniors.

M:  But I don’t think that it is unreasonable to say that we could structure a similar kind of program to pay for the healthcare of everybody.  Now my point of view is if we have this program, taxes are going to go up.  I don’t see any other way to do it.  Taxes are going to go up, but if you’re not having to pay insurance premiums and you’re having to pay taxes, is there really any difference?  You’re either paying your money to the insurance company or you’re paying your money in taxes.  Which do you want to do?

F:  Just a second.  May I interject something?

M:  Sure.

F:  We can’t forget the fact that those of us who have any money are already paying for people who get care who do not have money.  That’s not to say that those people who are uninsured have enough appropriate care, but their not being able to pay for it doesn’t mean that the cost of it goes away.  It’s put on the backs of other people, so we are already carrying that burden, why not just make it more sensible?

M:  Except as we saw on that program on Bill Moyer’s Journal, some people who get into that are just driven into devastating poverty because they’re honorable.

QT:  What do you mean?  Into what?

M:  People who do not have the resources to pay, and yet are encouraged to get medical care…  Yeah, you make a very good argument that they need it, but they don’t have the resources to pay, so by accepting that they’re going to get medical care, they are driven into absolute poverty, despair, sometimes suicide or early death because of this.  I just don’t see that as justifiable, because yes, we pay for those people’s care but those people continue to get bills because they owe money, even though what they actually have done is paid for it.  We found the money to do it somehow.  It’s just a system that comes back to cause no end of problems, where we don’t have a mechanism of covering these people effectively.  What we do is we punish them for getting medical care.

F:  That’s why you need catastrophic coverage for people.

QT:  And you were saying you had a slightly contrasting viewpoint?

F:  Yes, because I tend to see some things from an infectious disease or other kind of biological perspective.  It is potentially harmful to my granddaughter to have some of her classmates or kids she may run into someplace or another not be able to be immunized.  It is potentially dangerous to people I care about to not have people who maybe get the swine flu, if that becomes a big problem here, to get appropriate medical care, appropriate medical advise to restrict how much they spread the virus, that kind of thing.

And it goes beyond just influenza and basic immunization.  There are lots of examples of that kind of thing with HIV infection and other infections.  It’s not just infectious diseases but we’re a big complicated society with a lot of people traveling a lot.  We have got to think about, if we want to take care of society, and especially if we want to take care of the people closest to us, then we’ve got to be able to manage some big programs from time to time to keep us fed well, to keep us from getting serious infections or else it’s going to catch up with us.

It’s amazing how many immunizations kids have.  I don’t know how many kids are falling between the cracks between their parents’ insurance and CHIP, but I suspect there are quite a few, and that’s a problem.  That’s a problem for everybody.

M:  Malthus still rules.  No matter how much you want to think he doesn’t, he does.

F:  Restate it.

M:  Malthusian restraints on populations, which are famine, war, and pestilence, and he still rules.

QT:  Don’t know that you can ever get around that.

M:  No, but I think people–

F:  And the cynic would say, “Why even try?”

M:  Yeah, and I think people need to be aware that those are the constraints on populations.  If you value your population, if you think it’s important that your community survive, then you’ve got to pay attention to some of those details like public health.

QT:  What is your reply to the cries of socialism and fascism?

M:  As we discussed yesterday, I’m not sure I understand exactly what fascism is.  I know what your explanation of it was, and it sounds reasonable to me.  I think more of the concern I hear is that people talk about this being socialism.  As we talk about yesterday, you can’t have an effective society without components of both.  There’s no way to have a for-profit police force, or you’re going to end up with something like Blackwater.  There’s no way to have a for-profit fire department.  There are lots of things that cannot be done in a for-profit model and be effective.  I think actually health care may fall into that.

F:  In my view, at least the public health portion of health care has to be part of that.

M:  It has to be public.  It has to be socialism.

F:  It doesn’t do any good to have public health measures apply to half the population and not the other half.  Why do it at all?

M:  And in any dynamic society, there’s this constant tension between how do you manage certain things?  Do you manage them in a socialistic fashion, or do you manage them in a capitalistic fashion?  That’s a lot of what our society is about, is making those decisions.  I think we’re coming up to having to confront that maybe medical care should be managed in a socialistic fashion, because we’re having a tough time doing it in a capitalistic way.

F:  But you know, if you start thinking about what this is going to mean if we give access to health care to people who haven’t had access to health care, I would predict that the waiting lines in Canada are probably going to look good to us.  Personally, my experience listening to family members who live in Canada and have had serious diseases in Canada, I have not heard any horror stories with any of the people in our family, in our extended family.

QT:  Have you in yours?

QT:  Nope.

F:  But there is a perception that people have to wait for some things, and I think some have had to wait three weeks for a particular operation that didn’t cause any problems.  Frankly, in this country, you probably have to wait a week or two, always–

M:  To get an appointment.

F:  Well, there you go.

QT:  That’s best case, a week or two.

F:  But I would say the situation that some of us are pretty comfortable with right now, that usually in any kind of a relatively urgent situation, that you can get in to see a problem looked at within a couple of weeks.  That could be made a little bit worse.

QT:  Ever try to get in to Dr. Doe on short notice?

F:  No.  I call months ahead.

QT:  You could never get in there in less than a month.

M:  But we have a little bit of an advantage compared to a lot of people.  For instance, you had that abscessed tooth.

F:  Yeah.  We should have been able to figure that out.

M:  Well, we did.  And I got you started on antibiotics, then you went in to see the oral surgeon–or no, it was our dentist.  I can’t remember who it was, actually.

F:  You tell the story, then I’ll tell you what really happened.

M:  They said, “Yeah, she should be on antibiotics, and probably the one I would put you on is this,” so they didn’t quite agree with the one I started her on, but because I have the ability to prescribe, I could get you started on antibiotics pretty quickly, which is something another family can’t do.  They have to wait until they get seen.  If you have an abscessed tooth, that can be a pretty miserable wait.

F:  So there is some unfairness already built into the system, not that there are that many physicians and that many physicians’ families, but there have been times over the years, including recently with my ear, where Jack’s made a call and gotten something seen and taken care of a lot faster than Joe Blow is going to be able to do.  So having grown up in this family, there might be a skewed view of what other people have to go through.

QT:  I remember when we were young, there was professional courtesy, which is no longer legal.

F:  Yeah.  That’s long gone.  I don’t think the insurance companies allow that anymore.  I don’t know quite why that went by the wayside–

QT:  Which, if you consider how much it costs for a physician to get health insurance, it seems kind of odd.

F:  I was never comfortable with it because my perception always was that I made enough money that I could pay my way as well as anybody else.  So when we first started getting it when we were a lot younger, I just felt very uncomfortable with it, and now I kind of would be more comfortable with it for some unknown reason.  Don’t quote me on that…  But it’s gone away and I don’t know what the reason is for that, except to say that that coincided with the fact that a lot of medical practices were being bought up, consolidated, and unifying rules were set up for all of those.  I don’t think it’s a bad thing that that has gone away, frankly, but I think it’s just part and parcel of cost-cutting or profit-making entering the medical practice.

M:  To get back to your question of how do we pay for it, I also kind of look at it like public schools.  Everybody chips in out of their tax money to pay for public schools, and people who don’t have any kids don’t think that’s fair.  They say, “We get no benefit out of this.”  Well, yeah, you don’t get immediate benefit as far as your family, but if you have an educated population supposedly everybody benefits from that.  I think that’s a valid argument, that an educated population is probably better than an unintelligent population that can’t do stuff.

I think the health care situation is the same way.  I think if everybody chips in to pay for this, everybody benefits from it even if they – perhaps the individual -  doesn’t partake of it for whatever reason, maybe they’re just really, really, really healthy and they never get sick and they never get any benefit out of the tax dollars that go to fund this.  Society as a whole benefits from it.

F:  There are a lot of things like that, too.  There are a lot of people who don’t fly, but they chip in for the FAA and other costs.

M:  Through our tax dollars, we support the FAA that makes flying safer.

F:  Up until a couple years ago, I hardly ever took medication, but I’m still pitching in to the FDA, that kind of thing.  Also, people who don’t drive, or maybe they live out on a farm and go into some dinky little town once in a while and that’s it and don’t take advantage of the federal highway system, but you’re still paying for that stuff.  There are a lot of people who don’t agree that we should have gone to the war in Iraq, but that’s not my first complaint about the war in Iraq.

M:  You mean paying for it?

F:  Paying for it.  As a nation, we do a lot of things together.  Frankly, I think a lot of people’s objections about taking care of the health care issue is uncertainty about how that’s going to affect their own personal situation and their ability to see the doctor they want to see, and also just greed.  “I don’t want the next person pushing into my spot in the healthcare system, so I don’t get the care I think I need.”

M:  Are you paraphrasing or are you saying that’s how you feel?

F:  I’m paraphrasing what I’m seeing other people maybe saying.

QT:  My understanding from the Canadian system, and I don’t know if this is true of the British and other more socialized systems, but my understanding of the Canadian system is that if you want to go to the public health doctor, you want to stay in the public option, then yes, you may have to wait in line.  But if you don’t want to wait, or if you want to see a specialist of your choosing, my understanding is if you’ve got the dough, you go see them and there is no prohibition.

F:  Are the doctors different?

QT:  There are private practices in Canada.

M:  There are.  That’s correct.

QT:  So it’s not a closed system.  There’s a public network, but my understanding is anybody can go to a private doctor as long as they can afford to pay for it.

F:  So who are the private doctors?  They’re not anesthesiologists.  We know that.

M:  Yeah.  They’re just physicians.  I think a lot of them participate in the national healthcare system, but they also have slots available for paying patients who can get in on short notice and stuff like that because they can afford to pay.

F:  That’s what I was thinking, so people have combination practices.  It was interesting because when Jack was in training, people were moving down to the States from Canada – physicians were – because they didn’t want to have to work in the public health system in Canada.  Now there’s no place for physicians to hide.  For one things, I don’t think it’s that much better down here for most of them, but if we have some sort of public healthcare system, there’s going to be that constraint.  You’re not going to be able to go to some other country and have it be more lucrative because we’re one of the last countries to do anything to reign in healthcare policy.

But to me, the big overriding issue is completely a moral one.  To circle back on what Jack was saying, it upsets me a lot to hear the situations that other people are in when they get sick, that they might lose their insurance, that they may have so much in debt that they lose their homes, that people my age would have to move in with their kids because they had to income.  That injures me to have people who are just trying their darnedest to get by treated that way.

I also very much object to the fact that you guys are very constrained in the kinds of jobs at least one of you has to have in order to not have to worry about healthcare all the time.  One of you has to have a half-decent insurance policy, or you as a family are taking huge risks nowadays.  No one ever even thought about it when we were graduating from college or medical school or graduate school or anything.  It just wasn’t anything you thought about.

–END RECORDING