For years after his retirement, Mr. Alipate had paid for his health care services with "straight" Medicare, assisted by a Cigna Medigap policy paid for by his prior employer. With the benefits provided by this combination he had essentially no out of pocket expenses for his health care and could see essentially whatever physician (in the entire country!) he chose.  (My wife's father, who recently passed away from complications of a rare bone marrow disease had a similar policy which allowed him to pursue care at Houston's MD Anderson Cancer Center despite the fact that he lived in New York City.)

Recently, however, Mr. Alipate had received in the mail a glossy booklet explaining that he now had "more choices" for his health care coverage.  He reviewed the booklet with the assistance of his American-born nephew but, confused by the options, called the "help" number for assistance.  He only had one fundamental question of the choices: Could he continue to see his personal physician and the specialists I recommended? Reassured by the agent at the other end of the line he elected an HMO Medicare Advantage Plan offered by Humana.

The problem is, the agent was wrong, or misleading.  I am not in their network.  Indeed, in our heavily populated suburban community there are only two physician practices within a five mile radius of my office which are contracted to see Humana Medicare Advantage patients.

Medicare advantage plans, a privately administered version of Medicare, were created by offering private companies an average 12% premium over the average costs of treating Medicare patients. They in turn use a portion of this premium payment to "enhance" the traditional Medicare benefit package to lure patients into their programs.

The problems with this arrangement, however, are manifold:  Although this has resulted in enhanced benefit packages, the marketing of these enhanced benefits has been focused upon the healthiest of Medicare recipients, thus "creaming" the Medicare program and contributing to its financial difficulties. Those enhancements which are offered do not in total equal in value the increased cost to Medicare; a substantial portion of the 12% premium payment is retained for corporate profits and bureaucratic infrastructure. The basic structure is unfair:  If there is to be an enhancement to Medicare, why should it accrue only to those who manage to sign up with a Medicare advantage plan?  Finally, the "enhancements" may be misleading: As in Mr. Alipate's case..... there is always a dramatic reduction in choice of physicians when one signs on to a Medicare Advantage plan.  

I am not sure what will be the final outcome for Mr. Alipate.  His nephew and I spoke about this a few days ago and he was going to see if it might be possible to revert to a traditional Medicare plan or to another version of a Medicare Advantage plan with which I am contracted.  Of course, given our longstanding relationship, I would be happy to continue to see him for essentially nothing, but this would complicate the process for referrals, labs, and other tests and procedures as the "network" restrictions of such plans are many.

For me, this is yet another of the daily reminders of how the balkanization of our health care system results in waste, inefficiency, and suffering.  In my own small private practice, I bill at least 150 different payers for the care I deliver.  When I administer many vaccines, I have to call first to see if a particular insurer covers the shot.  Patients get angry at me on occasion because I mistakenly send them to the "wrong" lab, the one their insurance doesn't cover.  Every time I need to write a prescription I have to check to see if a particular drug is covered by this patient's insurance formulary. The list truly goes on and on.

A single payer system would eliminate this headache, mine and Mr. Alipate's.  Readers with an interest in health reform should review Bill Clinton's recent interview and try to read through the lines.  Bill knows, as does Hillary, and BO, that only a true single payer reform will really reduce the nightmarish administrative waste and confusion that exists within our system.  

The debate featured on today's abbreviated pundit roundup is also fascinating.  It is easy to see that even a prominent spokesman for Obamaesque health care reform really knows that only single payer reform can solve our nations health care crisis, he just finds it politically unfeasible.

Political infeasibility is no excuse for failing to advocate for the best solution to our problems.  I am struck in my daily practice of medicine by how the overwhelming majority of my diverse patient population supports the kind of change I and untold others are advocating.

I have recently been thinking about the process of transforming this undercurrent of support (which I am sure exists) into change.  One perhaps significant venture into this area will likely be the focus of my next diary, but I thought I would put it out there in a tentative way now:

In recent days, when a patient interaction (on the phone or in person) provokes a thought about the problems with our health care system, I ask my patient if I might send an email about some of the political advocacy I have been doing on behalf of transformative health care reform. This is the letter I send, often edited to provide a more personal focus:

Dear Ms. xxxxx,

I am writing this today because our recent office visit brought to mind (for about the thousandth time today!) the injustice and waste within our current health care system.

I want you to know what I am doing to try to change things (which includes helping you understand the problems with our system and just what would work better) and what you can do to make things better, for you, me, and all Americans.

Probably the most important part of this letter is in the last paragraph where I

--refer you to the web site of the Physicians for a National Health Program which is probably the best source for honest information about what is wrong with our system and how it ought to be changed
--and where I give you the phone number of the US Capitol, where you can call and take the first step towards achieveing change.

What I believe we really need is a fundamental transformation of this system by creation of a single payer "Medicare for All", a system with central financing delivered through our existing networks of private providers.

I have been active in supporting this concept with my patients in many ways. One particularly interesting way was that I recently held a health care discussion with patients about this in our office.  I have blogged about this meeting and other related topics at http://www.dailykos.com/...  There you will find a series of articles that discuss various issues involving the health care system, largely as illustrated by "horror stories" that have arisen out of my practice.

On YouTube you can find a ten minute video which captures the essence of the important thoughts offered by the people who attended the health care discussion in this office. You can see the video at http://www.youtube.com/...

A longer essay which discusses the problems my patients (and I) face in dealing with the private health insurance system has also been published on line.  It was cited as "one of the top ten reads in health care" by  Change.org:  http://healthcare.change.org/... . The essay is available on line as the earliest of my postings on The Daily Kos.  A version of this essay can also be found at http://tpmcafe.talkingpointsmemo.com... under the title, "I'm Only a Family Doctor".

I would love to hear your comments and hope you can become part of the movement for change.  A good first step would be to follow the links, above, to review the web site of Physicians For a National Health Program ( http://pnhp.org ) and to call our Congresswoman and Senators to advocate for single payer, now embodied in a bill H.R. 676.  You can reach the US Capitol switchboard at (202) 224 3121. Then ask for your representative.

Thanks for taking the time to read this and joining the movement for real change!

Peace,

Aaron

I'd love the feedback of readers as to how I and others can practically further the campaign....