The nomination of Tom Price and the cost of optimal medical care
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The reaction within the medical community to the nomination of Rep. Tom Price (R-Ga.) for Health and Human Services Secretary (HHS) has ranged from grateful applause — from the American Medical Association — to severe condemnation. Price is an orthopedic surgeon who maintained a clinical practice until 2005, placing him in the position of having first-hand knowledge of the health system for many years prior to 2005.

Few, if any, dispute that there are significant problems with the U.S. healthcare system. Studies have shown that on many metrics, U.S. healthcare rates significantly below that provided in other countries. Many also dispute that Affordable Care Act is an imperfect system. Even staunch supporters of the ACA — President Obama included — recognize a need for changes and revisions, while opponents call for a total repeal.

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In addressing the significance of Price’s nomination from a clinical point of view, there are two overlapping areas to be explored: political philosophy and practical implementation of clinical care.

Philosophically, progressives, conservatives and libertarians have different points of view regarding whether availability of healthcare should be considered a human right assured by the government as opposed to being a commodity to be purchased by individuals, as they may be able to afford. Many people take positions within that spectrum, maintaining that only certain types of medical care or certain circumstances in which medical care is indicated require a fool-proof governmental safety net rather than being seen as a commodity.

Obviously, the position the government takes on the issue of commodity versus human right very significantly impacts availability and access to medical care. It is not my intent to debate that philosophical issue herein. However, I note that based upon his well-publicized statements and writings, Price holds a position far toward the “commodity” end of the spectrum, further in that direction than held by most physicians, most of the public and even the stated positions of President-elect Donald TrumpDonald TrumpSenate rejects attempt to block Biden's Saudi arms sale Crenshaw slams House Freedom Caucus members as 'grifters,' 'performance artists' Senate confirms Biden's nominee to lead Customs and Border Protection MORE.

The second issue, impacting every physician every day, involves the ability to implement clinical judgment in the provision of medical care without interference from third parties.

Notably, Price has also spoken to this issue. Dating back to Feb. 9, 2014, when he was interviewed by MedPage Today, Price was asked, “What's the biggest barrier to practicing medicine today?” to which he replied, “There is a remarkable level of non-medical people making medical decisions. That makes it more and more difficult to truly be a patient's advocate.”

The vast majority of physicians, this writer included, welcome explication of the constant frustrations and limitations that arise while trying to provide optimal medical care and the implementation of appropriate reforms.

Beyond the issue of access to care, interference with the ability to freely practice medicine in the best interest of the patient — to truly be a patient’s advocate — arises from insurance, restrictions, limitations due to cost of copayments or deductibles and out-of-pocket costs of medications, if not covered; if coverage is denied via Utilization Review (UR); or due to required co-payments.

Price’s statement, as quoted above, implies that he would be rather aggressively on the side of physicians’ independence from inappropriate UR.

This is a problem that many physicians believe has reached a level of frequent negligence and/or corruption in recent years, even more so during the time since Price left his practice. In fact, this is the reason this writer personally felt forced to withdraw from providing treatment within the very broken California Workers Compensation system, as well described in the news just today: They survived the San Bernardino terror attack. Now, they feel betrayed.

However, the information Price has posted to date is less than specific or definitive in describing how he would address the problem of inappropriate medical insurance UR especially as Price strongly promotes privatization of essentially all of the medical system into the hands of private insurance carriers with few governmental regulations. 

Similarly, I cannot find any information as to how Price might approach interference with physicians being able to provide optimal medical care in situations when patients are unable to afford copayments or deductibles.

Of concern, Price has made statements supporting personal responsibility that quite clearly imply if a person cannot afford payments necessary to obtain medical insurance or to pay for deductibles and copayments, other than in rather extreme circumstances, cost of indicated medical care would not be a predicament addressed or resolved through government action or programs.  
 
At the same time, Price has expressed support for people to be able to purchase cheaper, stripped down medical insurance policies that provide reduced benefits — limitations that might include re-institution of pre-existing clauses and arbitrary annual or lifetime limits.

I don't think Price has explained if there would be any remedy for a person who purchased a restrictive policy but found themselves in serious or even desperate need of medical interventions ordered by their physician but practically unaffordable. 

There is no easy solution to improving the U.S. healthcare system. Many different actors and agencies are very deeply entrenched. Some might say that any and all outside sources of potential contamination of the system by greed need to be removed from further restructuring, but that is probably an impossible task. Others have tried to negotiate with all involved, however, expecting the unconscionably greedy to negotiate in good faith is rather naïve.

I do not envy the challenges that Price will encounter. Perhaps the best candidate would be someone who can serve as objective arbiter who can forcefully represent the best interests of optimal medical care while addressing practical policy issues. Perhaps the worst candidate would be an ideologue of any stripe.  Thus, some of Price’s statements seem very reassuring to physicians while other positions Price has staked out are reason for significant worry and concern.

David M. Reiss, M.D. is a psychiatrist from San Diego, Calif.
The views expressed by contributors are their own and not the views of The Hill.