Access, yes; rationing, no: Docs weigh in on reform

Access, yes; rationing, no: Docs weigh in on reform

Staff Writer, New Jersey Jewish News

Dr. Larry Weinstein, chief of plastic surgery at Morristown Memorial Hospital, complained about the ways insurance companies determine what is covered and what isn’t. “It’s appalling; there needs to be some standardization.”
Dr. Larry Weinstein, chief of plastic surgery at Morristown Memorial Hospital, complained about the ways insurance companies determine what is covered and what isn’t. “It’s appalling; there needs to be some standardization.”

Where are the Jewish doctors on health-care reform? With health-care reform at the top of the political agenda, NJJN wanted to know what stakeholders in the local Jewish community are most concerned about.

In this first article of a series, four local Jewish physicians sound off about their concerns: Do they think the system needs reform? Which areas need critical attention? And what is their particular stake in the debate?

All pointed to the need for change. With so many millions of Americans lacking access to affordable health care, everyone ends up footing the bill, they said. Most discussed the need to ensure that quality medical care is accessible and affordable. All urged tort reform and limiting malpractice insurance. Some suggested the need for a system of checks on insurance companies. Most discussed fears that a new system might negatively affect the way they practice medicine and the overall future of the American medical field.

“To me, health-care reform is about health-care industry reform,” said Dr. Cheryl Citron, a dermatologist who practices in Livingston, lives in Short Hills, and is a member of B’nai Shalom in West Orange.

The doctors discussed the need to reform insurance company practices gone awry that determine what and whom are covered and how much is paid for procedures and treatments. All offered stories of unfortunate dealings with insurance companies, including tactics they described as intentionally thwarting their ability to practice. Their complaints are legion. They talked about the insurers’ asking for separate authorization numbers for surgery and for payment, keeping staff on hold for up to two hours, denying claims as a matter of course, and forcing doctors to appeal in order to get paid.

Dr. Larry Weinstein, chief of plastic surgery at Morristown Memorial Hospital, suggested standardization of criteria as one way to manage this issue, explaining his idea through an example from his own practice. “There are 50 different ways insurance companies determine when breast surgery is reconstructive [and therefore covered] and when it isn’t,” said Weinstein, who has offices in Summit and Chester, lives in Chester, and is president of Mount Freedom Jewish Center. “It’s appalling. There needs to be some standardization.”

Citron accused insurance companies of acting on an “excessive profit motive.”

“CEOs are making millions off the backs of subscribers whose claims are denied and caregivers who are not being paid for their services,” she said. “Something is wrong.”

Her suggestion is to curtail the practices of the health-care industry. These include the setting of “preexisting exclusions,” “a total cap on coverage,” “denying care altogether,” and “not paying doctors appropriately.”

“There needs to be something done to rein in the practice of denying care and refusing to pay while they are happy to collect premiums,” said Citron, “which go up unbelievably every year — 20 percent a year. At some point how do we keep up?”

Access to care

Almost everyone interviewed agreed that access to medical care is critical, pointing to the 47 million Americans who have no insurance. All agreed that some kind of universal insurance is the way to ensure access for all.

“If you can’t get to see a doctor, then the system doesn’t work. If the doctor doesn’t take insurance or won’t see you, then you have to go to the Emergency Room,” said Dr. Paul Carniol, a plastic surgeon who practices in Summit, lives in Union County, and attends a Conservative synagogue in Union County (he requested that NJJN not reveal the details).

Dr. Greg Gallick — an orthopedic surgeon who practices in Summit, lives in Short Hills, and attends synagogue in Summit — endorsed the concept of mandating coverage for all. “It’s like car insurance. We do not care how you pay for it. Everyone has to have it,” he said.

But just mandating it is not enough. While some people who could afford it, particularly healthy people in their 20s and 30s, choose not to get insurance, others simply cannot afford it.

Gallick didn’t have any new ideas beyond having government help out and forcing all employers to offer insurance. But in order to achieve coverage for all, he said, he is “willing to pay” out of his own pocket. He acknowledged that this is an unpopular idea among his colleagues. “When I voice these opinions to surgeons and anesthesiologists, they think I’m a socialist,” he said.

Carniol suggested that savings resulting from cutting waste and abuse could be used to fund health care.

Meanwhile, Citron pointed out that affordability of coverage is not enough if the coverage itself is insufficient.

“We’re all one step away from disaster,” she said. “We could have a catastrophic illness and with a cap on what the insurance company will pay, we’d all lose everything.”

She emphasized that coverage without regulation would not work. “That just provides a windfall to insurance companies” without real reform, she said.

Quality of care

Doctors’ concerns about access and affordability extended to how quickly patients are able to see their doctors and the availability of swift treatment. “People in this country are used to certain access to care,” said Weinstein. “If you break your hip, you get it repaired within 48 hours. People are not used to waiting a week or two or maybe three years for replacement,” he said.

These kinds of concerns are at the heart of the health-care debate for Carniol, who also looks at the issue from the perspective of the patient. Rationing is at the top of his list of concerns. He opposes any reform involving rationing of care.

“Medicare is considering not paying for certain cancer treatments because only 30 percent of patients respond. That’s rationing,” he said. “If there are 10 patients, three will do fine for five years; seven won’t. What they’re saying is, ‘We’ve decided to save some money because it’s expensive, and you three don’t count.’ If I’m in that 30 percent and if I get a bad disease, I want to get that treatment. When I reach a certain age and I need a hip replacement, I want to make sure I can get it. I’m not as concerned about how it would affect my practice.”

Weinstein cited the situation of relatives of his in England who do not have the same access to care as family members here do. He could take his mother for laser eye surgery to save her sight, for example, while uncles in England with the same illness both lost their vision before they died. “I’ll never forget that. It really upset me,” he said.

Gallick said he gets calls regularly from patients in Canada trying to get an MRI for a knee or a back without having to wait for a year. “The problem with a socialized system based on those in Europe, Canada, and Israel is that you have to eliminate [certain types of] care,” he said.

But he also acknowledged that those systems do cut out a certain amount of waste. “On the other hand, people who demand to have an MRI when all they need is Motrin — that wouldn’t happen anymore. But in the United States, people aren’t used to being told no.”

Gallick suggested that taking away physicians’ autonomy could backfire. “If you say someone else will control how hard I work and who I work for and how much I can make,” he said, doctors might lose their drive and commitment and “maybe just work 9-4. And if someone calls and asks to come in, instead of saying come right over, I might say come in three weeks, or go to the ER, where you can wait for seven hours.”

Carniol insisted that any reform must ensure that the quality of care being delivered would be sustained.

“We need the best and the brightest,” he said. “If the system does not attract them, then the future of medicine does not look good.”

Citron pointed out, “Most of us went into the field really wanting to make a difference and do something satisfying and positive with our lives. We should be able to deliver care, take care of our patients, and be appropriately paid.”

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