Would physicians be constitutionally opposed to a single payer, or to some mix of approaches, if government at all levels, consumers (which includes those who pay – insurers – and those who have disease – patients), attorneys, academic physicians, community representatives, and the Doc’s themselves, actually discussed what was at stake and how the future might look? If they learned from each other about fears and agendas? If they developed faith in the commitment of each to an honorable conclusion that provided safety to each and every stakeholder? If stakeholders were made shareholders?

Doctors are people who went to medical school; they are not doctors who went to people school – and skipped classes. Let theorists in “health care access” and operations research and decision theory and financing and law come to central Georgia, of Tennessee, or New York. Tell us how our communities and our epidemiology are the same as “everybody else’s” (whence one system for all might work), because we’ll tell you how we’re different – and how we need a unique structure. Tell us how we’ll be able to send our kids to Vanderbilt or Northwestern and how we’ll be able to retire when we want. Ask us how we would enlist the Crips and Bloods, legal and illegal aliens, those of us who deny the dying their death and those who find a way when the family knows it’s time. Have CMS come to the KFC on a Thursday night – Wednesday night, the Baptists can’t come – and then to the Doctors’ Lounge at 6AM on Friday, and talk to us about what they want, and how we may – or may not – reach a negotiated reality. We are tired of being told THAT: this hasn’t worked with us since junior high and daddy’s car. I daresay there are folks in Cullman, AL, as well as at UAB, who would like to participate in deciding their fate.

We have all known lots of doc’s. I’ve consulted around this country in health care for years, and I’ve talked to thousands. And you who read this, in your way, to your thousands as well. Have you met a doctor yet who denies the moral obligation that, as physicians, we owe to other people? Are there hundreds of doctors at UAB who would turn away from the ED when their names are called and the chart says “self pay”? Let each of us take a stand in his community and accept that moral burden. All together. In the town square. Moral right to access solved. Don’t insult us with legalisms.

But let the social contract be restored. Let the community tell us how it intends to reward our commitment, and what sacrifices it will make, and how we shall be cherished for what we do. Each of us cherished that first patient – remember?, and each of us now feels betrayed for that investment of Caritas and Spirit. “I’m gonna be a Doctor,” we said the Day Before the First Day of Medical School, “and we will care for each other.” Fata Morgana.

It is time now for leaders and mediators and teachers – which, after all, is the root of “doctor.” One more position piece from Stanford or Princeton? One more ’study’ out of Harvard Med or the Mayo by salaried worker-doc’s who daily prove They Ain’t Us – even when we ARE on salary – by showing scant notion of what drives us and what charms us and what scares the crap out of us? Oh, please: skip the methodology section; Lord, skip the abstract and just give us the last line of the conclusion. We’re all getting out anyway STAT. And some of us have to wake up early in the morning.

David Block MD, PhD

The current system is somewhat socialized. Medicare is the baseline for most payers. The current payment system from most “private” HMOs/PPOs plans is based on Medicare fees with a take it or leave it attitude. Most plans pay within $5 of the going CPT code fee at Medicare fees. Patients without insurance are seen in the ER for “free care,” as the ER is about the only place patient cannot be turned away for not paying. Patients with expensive insurance premiums only pay 10-20% of the true premium cost and expect top care for every $20 copay. Preauthorizations must be done for brand name meds, MRIs/CTs, and specialists. The insurance companies currently set fees and try to dictate to physicians how to practice medicine. Most insurance companies redundantly duplicate the same services for close to the same costs of coverage. Outside of boutique practices, private practice is a misnomer in the US. About half the population is covered by Medicaid, Medicare, and Tricare, which are government backed plans. Even a physician who opts out of Medicare or Tricare has a maximum allowed fee by law for out of network care, which is socialism and not free market medicine.

I recently came accross your blog and have been reading along. I thought I would leave my first comment. I dont know what to say except that I have enjoyed reading. Nice blog. I will keep visiting this blog very often.

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I’m always interested in comparisons of health care systems. I live in Canada, and I know that many people compare Canadian health care to American health care. The problem is that there is no such thing as “Canadian health care.” For some reason, each province is responsible for its own health care and the result of that is that care varies very widely. The province of Newfoundland has no 911 service outside of the capital city and I have spoken to some Newfoundland physicians who find that medical facilities in remote areas are “much worse” than those found in third world countries. In the capital of New Brunswick (pop. 50 000) more than 3000 are without a family doctor and the walk-in clinics are embarrassingly bad. There are no private care options. I would gladly pay to visit a doctor rather than risk complications, but that is not an option. It seems to me that if we made “adequate access to health care” a right (protected by the constitution) patients would have better access to care because legally going after negligent provinces would be much easier.

DB… always love your blog and appreciate your insights on the improving primary care.

but let’s think about this.
i’m kind of tired of hearing how good Frances medical system is.

ALL four of the countries mentioned (France, Japan, Germany, and Sweden) can thank US (the USA AND ALL THE OTHER NATO allies) for their “wonderful” healthcare system.

All four of these countries have little to no military, and they depend on us for their own national security.

I would be interested to see how well their healthcare system would hold up if we stopped wasting so much money defending them.