My libertarian leanings would support free market solutions to health care. I would love to see patients have a better understanding of costs. Physicians should all consider costs as part of the diagnostic and treatment equation.

But alas, we already live in a socialistic medical system. We physicians can charge what we like, but we get paid exactly what the insurance companies and Medicare decide to pay us. We do not receive more if we are more experienced or more in demand. Patients cannot pay extra money to have longer visits. Patients cannot pay money for improved email access or telephone access.

Now admittedly there are a few exceptions. Retainer practices and cash only practices do work on free market principles. One can pay separately for primary care, and then have a high deductible policy for “catastrophic” insurance. I have written about several such situations in the recent past.

The free market does work for procedures that insurance does not cover – lasik surgery, cosmetic dermatology, much plastic surgery. Costs do decrease as more physicians compete for business.

But for most medical situations and most patients we do not have a free market. We have an irrational insurance system. We have an irrational payment system. And we are reaping the outcomes of that irrationality – decreased interest in primary care, increased use of expensive imaging studies, shorter visits and less access for patients.

While I do not agree with the entirety of any of the health care reform packages, I do believe that they have the opportunity to improve the status quo. While they do not yet do enough, they do increase the emphasis on primary care. I believe that they will improve the competition for health insurance and increase health insurance transparency.

I still hope (and doubt that my hope will be rewarded) that we will see malpractice reform. We clearly need a malpractice that protects both patients and physicians.

We do need a standard way to care for the uninsured. Some would argue that in a free market system, those without means most rely on charity. However, we do provide significant care for the uninsured. We have laws that require us to provide emergency care and hospitalization for these patients. So we spend money on these patients. Your insurance premiums include an indirect tax that helps pay for this care. Medicare costs are greater because we indirectly subsidize this care.

So I favor making care for the currently uninsured explicit. I have no objection to a two (or even multi) tiered system.

What would I most prefer? I would like to see most outpatient routine care (either with primary care physicians or subspecialists) removed from the insurance system. I would revert back direct payment for outpatient care. I would allow physicians to set their own fees. I would let the marketplace work. But we will not see that system. Direct primary care like Qliance may succeed if such primary care arrangements are allowed. Cash only primary care may succeed if such practices are allowed. Our current system wastes too much money in overhead and administrative costs. We need to remove insurance companies from outpatient practice.

But my dreams are unrealistic given the current situation. So I do favor health care reform as the best solution for an untenable situation. Do I love it? Obviously I do not love every part of health care reform. But I do think it necessary.

Regardless, I will continue to love practicing medicine. Those physicians who threaten to quit practicing if reform passes must have lost the reason they became physicians. The money is nice, but the profession has much greater rewards than money. We physicians should always remember that we serve our patients. They benefit from our efforts, and we benefit because we can help them.

Related posts:

1. In which Evan Falchuk explores health care reform
2. Some thoughts on health care reform
3. The complexity of health care reform
4. A few more thoughts
5. What is wrong with health care

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