There are a few pieces of the puzzle strangely absent from the Obamacare debate… well, if you can call the buzz around Obamacare debate. But let’s just pretend for a second that you could have a conversation about the detriments of Obamacare without being labeled a heartless greedy murderer. In that instance, I would bring up a couple of points about Obamacare. 1) We should stop assuming that affordable insurance automatically equals better and more affordable healthcare. 2) We should listen to doctors’ concerns about where healthcare is heading instead of insinuating that they are greedy or thinking of them as servants to the rest of us. Two such doctors have written articles posted on kevinmd.com which highlight the misconceptions of insurance, and misunderstanding of doctor reimbursement.

Luis Collar writes in The Affordable Care Act perpetuates a myth of health insurance that we need to view health insurance the same as other insurance in order to properly use it. Car insurance doesn’t cover oil changes or inspections, home insurance doesn’t cover painting and routine repairs, and health insurance shouldn’t cover the costs of routine checkups, or contraceptives. My parents always said that insurance is for things which you can’t afford to replace. Catastrophic coverage for healthcare therefore makes sense, since we only get one body. But to funnel money through an insurance company in order to pay for health needs that are foreseeable and can be budgeted wastes money. Insurance companies must make a profit in order to exist, so if we have x amount of money to spend on healthcare, as big a percentage as possible should be going towards actual care, instead of administrative costs involved on a number of levels through interactions with your insurance company, and their interactions with the hospital or doctor.

But the truth is insurance increases the cost of routine care. It raises physician and hospital administrative costs and artificially inflates prices in several other ways, not to mention the aforementioned profit reality.

Improving access to education, reducing unemployment and increasing household income by stimulating small business and innovation, limiting environmental hazards, reducing poor health behaviors, and increasing the number of primary care physicians available would have a greater impact on health than more coverage. These are some of the confounding variables that lead us to believe insurance is always the answer. And focusing directly on these true determinants of health status does not force patients to relinquish control or artificially drive up the price of health care services; insurance paradoxically does both.

Part of the solution is essentially being more mature with our money and personal choices. We have no problem paying $400 plus for a smartphone and $100/month for the plan, we know we can’t even talk to an attorney for less than 100 bucks, somehow we manage to budget for monthly electric, cable, internet, and gas bills, but god forbid a routine checkup at the doctor’s costs more than $20. Even with a medical condition for which the medication or a procedure costs $200 a month, funneling that money first through an insurance company only raises those costs, and means less money for actual care, and more for the middleman. Insurance is for unforeseen or catastrophic costs, not to evaporate the need for budgeting. Collar sums up his point with 3 principles of affordable care:

• No one knows how to spend an individual’s money more wisely than the individual does, not the government, not insurance companies, no one.
• No one is more qualified to determine the appropriate medical care for a given patient than a well-trained, independent physician.
• The introduction of any intermediary between a patient and his or her physician will, by definition, always decrease the amount of money available for medical care without adding anything of comparable value to the process.

But insurance is not the only thing that makes care unaffordable for many. Misunderstandings about how and how much doctors are paid, and misunderstanding of true costs to doctors in practicing medicine put the focus on reducing costs in the wrong place. Obamacare will raise costs to doctors, with many retiring early and others choosing another profession; Matthew Moeller covers all this and more in his article Dear lawmakers: Why aren’t doctors involved in health care reform? I mostly want to address what makes healthcare cost so much above and beyond the actual medical procedures.

First off, doctors face an average of $250,000 worth of student loan debt after medical school, not to mention the cost of forgoing 14 years of employment and income in order to train as a medical professional. Since many doctors could face a 26% reduction in reimbursement under Obamacare, this decreases incentives to become a doctor, or remain a doctor. In the whole media cheerleading of Obamacare, a lot of false numbers were thrown around about what doctors get paid.

Leaders need to stop attacking doctors for how much they earn because they do not really know how it works.  In all other professions, one gets paid what the bill says.  If a handyman comes in to fix your sink and charges $80, you pay him $80.  If you seek a lawyer, and he says he charges $250/hour and he works 4 hours for you, you owe him $1000.

Unfortunately, the medical billing is unique, confusing, and wrong.  The charges (bills) that patients see in the mail are not what doctors get paid.  These are inflated numbers derived from contracts between hospitals or groups and insurance companies.  A recent New York Times article headlines read “As Hospital Prices Soar, a Stitch Costs $500.”  Sadly, these inflated numbers have nothing to do with what the doctor gets paid. In fact, those bills do not go to the doctor at all, but rather to the hospital.

For instance, many medical bills have two charges, one called the “Professional Charge” the other called the “Facility or Hospital Charge”. The doctor never sees a dime of the facility charge, and only sees a percentage of the professional charge because of the overhead costs of running the practice which can range from 30% to 60%. President Obama either does not understand this, or intentionally mislead the public when he claimed that when performing a foot amputation, surgeons get paid 30 to 50 thousand dollars.

Looking at the Medicare Fee schedule, CPT code 28805 states that the surgeon would get paid $738.90, which is the fee before his expenses are considered.  This $738.90 needs to cover his office space, staffing, medical liability, and years of training to have the privilege of performing this life saving operation.  Thus, the doctor actually gets paid 1.4% ($738.90/$50,000) of what President Obama claimed he got paid. Our leaders are clearly confused and have no right attacking physicians’ reimbursement.

Dr. Moeller discusses multiple ways that most people do not understand how much doctors get paid, and offers a solution to make the costs more transparant: a health savings account where patients control their own expenditures to decide the best course of action with the help of their doctor. Of course this won’t help as much if doctors still get sued every time they miss something. Doctors will order every costly test in the book to make sure they “did what they could”. Insurance helps hide these costs, and lawsuits make it easier for the doctor to push the cost of tests off onto a patient, rather than suffer the costs of a lawsuit. (Insurance against legal action, by the way, significantly contribute to doctors’ costs). This is called defensive medicine and can cost about Americans $200 billion a year. Those costs could be dramatically reduced if there were particular standards for malpractice lawsuits, instead of the current “ad hoc jury by jury” proceedings.

Go ahead and read both those articles for yourself if you have the time. You can learn even more about health savings plans which are a viable alternative to a government takeover of the healthcare industry. The doctors also get into some discussion about end of life care, when “during the last six months of our lives, we spend up to 50% of our own total lifetime health care dollars.” Again, control should not be taken away from the patient and their family in these scenarios, but absent the shadow of lawsuits, many different paths would be chosen for how a 92 year old with a chronic disease should go out.

Gathering the lessons of the two doctors who wrote the articles to which I refer, the main cost increases in healthcare appear to stem mostly from control of healthcare being taken away from the individual, and given to insurance companies, lawyers, and the government. Health savings accounts and legal medical reform would therefore lead to the biggest reduction in costs for healthcare by returning control over health expenditures to the patient, and eliminating excess costs that surround the health industry, but have nothing to do with actual healthcare.