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Dr. Bill Dienst: Dysfunctional aspects of the U.S. health care ‘system,’ and possible solutions

Medicine in the United States is a bureaucratic minefield. Those of us on the front lines providing direct patient care are plagued with conflicting interests and mixed messages. Practicing physicians and nurses try their best to provide direct patient care. But now they are practicing more out of fear than reason or compassion. And with electronic health records, there is much less time for the latter. As a family physician practicing over 29 years in rural areas, I love the 20 percent of my job that involves helping people, and hate the 80 percent of the job that involves dodging bureaucratic bullets.

This “system” of different insurance companies constantly changing their rules and little standardization scrambles the egg. Large health care organizations have now evolved, with large administrative and office staff to match those of the insurance companies to take on the complex task of billing for services. They try to do their best to unscramble the egg, but they can’t unscramble the egg completely.

Traditional private practices are drying up, becoming almost a thing of the past. Many of the few private practices left are now gravitating into concierge or “boutique” practices where they can avoid the insurance bureaucracy altogether; but now their practices only serve the well-to-do, i.e. those who can afford to pay directly for their care. They can no longer serve the greater population at large, because taking care of the privileged few is the only way these boutique practices can avoid third-party payers and still thrive financially.

It would be much better if we didn’t scramble the egg in the first place. This can only be accomplished by a national health insurance program like Medicare for All: the only mechanism which can standardize and reduce insurance chaos.

If I were the health-care czar in America, tell you what I’d do … I would have a Medicare for All system that provides basic services for all citizens and noncitizens alike. We would provide better care, and save more money that way. This would level the playing field by making health care more equitable. It would also eliminate considerable stress that many of us face when life circumstances change – when we lose or change jobs, go through divorce, etc.

This system would not be completely free. Everyone would have to pay a “tithing” based on a certain percentage of their overall cost. If you use more resources, you pay more. The difference compared to today’s chaotic non-system is that the expectations of all patients, providers and payers would become more aligned, equitable and understandable.

We would also be less prone to the smoke and mirrors of wasteful marketing-hype, and subsequent unrealistic expectations. The amount of the tithing percentage would be tied to the income of each family, along the lines of graded income tax brackets based on the previous year’s tax returns. This would be updated annually. Rich people would pay a higher tithing, while poor people would pay less.

Choosing more expensive health care services (e.g. ER versus primary care clinic) would cost each patient more. Because this government health system would still pay for the majority of costs, health care would remain affordable. People might complain about increases in taxes to finance a government-run health care system, but this would be offset by eliminating private health insurance premiums, not to mention confusion and redundant bureaucracy unique to each insurance product. This would also free up employers, so they could pay their employees more.

As it stands now, the leading cause of bankruptcy in the U.S. is catastrophic health care costs that uninsured or underinsured patients are unable to afford. In cases of catastrophic conditions, review panels could look at individual situations and reduce prohibitive costs. Bankruptcies could be minimized in this way.

A Medicare for All system combined with a tithing would align patients, the Medicare insurance plan and health care providers toward providing good care while being more cost-conscious. It would motivate all of us to make more cost-effective decisions, and limit excessive defensive medicine practices.

This system would be standardized nationwide such that all players could finally learn the rules which would become more equitable and fair.

Dr. Bill Dienst is a family physician who has spent most of his 29 years since residency working in rural critical access communities in Washington and Montana, both in family practice and rural emergency medicine.


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