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    Cost, not access, is underlying problem facing American healthcare

    Editor’s Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Anish Koka, a cardiologist in private practice in Philadelphia. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.


    The House of Representatives vote to pass the American Health Care Act—the Republican attempt to replace the Affordable Care Act--has received much attention.  The coverage has focused on technical details of projections from healthcare analysts regarding the number of people that would lose insurance coverage with any attempted changes to the status quo.  While I am sympathetic to the plight of those who benefited greatly from the Affordable Care Act, I remain unconvinced that the current conversation does anything to reach the goal shared by the vast majority of Americans regardless of political party affiliation: Make basic healthcare affordable to the maximum number of Americans.


    Further reading: House Obamacare bill won't fix healthcare system, doctors say


    The current conversation fails because it does not address the fundamental barrier to healthcare access - which is not insurance coverage, but rather the cost of healthcare coverage.Anish Koka, MD

    Consider the bill a friend of mine who has health insurance through her employer recently received after her daughter had an echocardiogram and an ECG done - $4800 for the echocardiogram, $1200 for the ECG.  Last I looked, Medicare pays about $12 for an ECG, and about $140 for an echocardiogram.  The facility was out of network, so the insurance company paid about 80%, leaving the remainder of approximately $1000 as the patient's balance.

    This raises the interesting question: Are insurance companies forced to pay what hospitals charge, or do hospitals charge what insurance companies will pay?


    Hot topic: Medicaid expansion must remain safe in healthcare reform


    The truth is somewhere in between: both parties are complicit.  Insurance companies turn out to be very poor stewards of your money.  Hospitals, emboldened and strengthened by consolidation that reduces competition, are more than happy to set outlandish charges that insurance companies will pay.  It is  a cruel irony lost on most that the Democrats, who were supposed to be the party of 'adults', the party of technocrats, the party that traditionally speaks for the common man has a platform built on an individual mandate to buy health insurance and support this hospital-insurance nexus.

    Next: Healthcare's access problem is its cost problem

    Anish Koka
    Anish Koka is a cardiologist in private practice in Philadelphia trying not to read the writing on the wall. Follow him on twitter ...


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    • [email protected]
      I agree with the high costs: of medication (some of which are generics), hospitalizations, and procedures are driving the cost of healthcare up. The confounding problem for the uninsured patient is they pay ten times or more what the insurances contracted rate is for labs, hospitalization, medications, and to a lesser degree physicians charges. My brothers son recently was air ambulanced for 90 miles with a charge of $35,000(charged by the state of Pennsylvania). He stayed for half of a day in a nuero intensive care unit where they didn't even do nuero checks every four hours and was discharged to home; and the charge $20,000. How about a 5 g tube of Denavir cream for herpes cold sores,from Mylan, the people who made the Epi Pen famous, would you believe over $800. When does this insanity stop? Another problem is that those who have pre-existing conditions are now grouped in with a small group of mostly small business people in the ACA plans. This has caused the insurance rates for these small businesses to skyrocket. To make any plan work that covers high cost, previously uninsurable patients, there must be enough healthy patients to offset there costs. This is the major problem with the current affordable care act. I suggest we open the Federal Employees Health Benefits Plan to anyone who wants to join. This will increase the cost of healthcare to federal employees but not to the degree the current ACA plans have increased the cost to small businesses and should make insurance more affordable to those currently in the ACA plans
    • [email protected]
      Inflated medical costs, caused by our reliance on third party payment, is absolutely the big problem. We are not underinsured, we are overinsured. Dr Koka's recognition of this situation is a welcome addition to the public's understanding.
    • [email protected]
      Dr. Koka is correct that the healthcare crisis is driven by the excessive and unfair prices charged for medical services. If a hospital is happy to perform an ECG for the $12 paid by Medicare, then it is unfair for a patient to be charged $1200 for that same ECG. It is tempting to address this inequity by government edict; price controls to force hospitals to charge every patient the same reasonable fee for the same service. This is how the problem of preexisting conditions was addressed by ObamaCare, which prohibits insurance companies from considering them. The problem is that nobody, no matter how smart they are, can set prices or mandate services better than the free market, in the long run. All prior attempts throughout human history to fix prices or mandate services have failed, including ObamaCare (its collapse is imminent). India is no exception, nor is Canada, where patients suffer from excessive waiting times for needed procedures. The rich in England have the option of an "upper class" private hospital system, as an alternative to the rationed care at their National Health Service. Canada's more stringent Single Payer system enforces egalitarian care, but still allows the rich to leave the country as "medical tourists", to receive timely care on a cash basis in other countries. The answer is always to provide more freedom, more transparency, more choices, more patient empowerment and more negotiation on prices. Monopolies must be smashed. The best way to accomplish all of this is to introduce free market solutions and competition, and to allow patients to purchase their own tests without the delay and hassle of an overworked doctor in the middle. A prescription for any medical item or service should allow the patient to shop around and negotiate his best deal. In the short run, the poor must be subsidized with socialist charity. In the long run, the poor should share in the prosperity created by free minds working in free markets.
    • [email protected]
      I agree with you but part of the problem is frequently a patient doesn't know what a charge is going to be. An uninsured patient spends two days on a med surg floor in California. Four weeks later there is a $35,000 bill. Labs on an uninsured patient are done by his doctor to work up a rheumatologic problem. Three weeks later the patient receives a $2,000 charge from the lab. Unfortunately, in the current system the patient has no clue what the charge will be in advance of the bill. Its like a store sending you the television you like (without knowing the price) and after it sits in your home for three weeks the store sends out a $12,000 bill to you.

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