November 27, 2007

To the editor:

This SCHIP is off course

I congratulate Mr. Honeycutt for his concern for children.  Yet “insuring the health care of our children” by expanding SCHIP is not the same thing as actually providing health care for them.   

Canada provides health insurance for all of its 33 million citizens.  Yet a Canadian woman had to travel across the border to a Montana town of 57,000 to deliver quadruplets because no neo-natal ICU in her entire country had the capacity to care for her four babies. 

Given that Montana was a red state in the last election, I think it’s a safe bet that there were nurses and doctors among Bush’s “Right Wing forces” (as Mr. Honeycutt called them) showing “love, concern, and support” for these little Canadians once they arrived safely from their mother’s womb in the good ol’ USA.

From my perspective as a physician with roughly 5000 uninsured patients, it seems that the people who clamor most loudly to expand public health insurance – both “Left Wing” and “Right Wing” – are the least likely to be found providing medical care to the uninsured personally.  Perhaps, as Mr. Honeycutt noted, they are too busy “gaining economic success.” 

Despite universal health insurance, little children in Canada suffer long because it takes on average 10 weeks to get an MRI, 5 weeks for a CT scan, and 38 weeks between GP referral and orthopedic surgery.  Even Canada’s Supreme Court in a 2005 landmark case had to admit that “access to a waiting list is not access to health care” and that “patients die as a result of waiting lists for public health care.”

Here in the States, insurance is not always what it’s cracked up to be.  One of my patients canceled her family’s CoverTN policy after she realized that it would not pay for large claims, the very thing insurance is supposed to cover.  “We can afford the everyday stuff,” she said.  It’s the big bills we need insurance for.”

Some people cannot afford “the everyday stuff,” and for those the government should provide a safety net.  Yet, the vast majority of Americans can and should pay for their everyday primary medical care.  Casting a wider safety net than is necessary only makes health insurance more expensive for everyone and spreads government resources so thin that the poor do not receive the care they need. 

This is because it costs a lot more for primary care doctors to file small medical claims than most people think.  Insurance-free practices like mine save doctors about $200,000 per year in overhead, which works out to be about $40 per patient visit, the amount my patients pay to be treated for an ear infection or sore throat.  Can you imagine paying an extra $40 just to settle a $40 subscription invoice from The Greeneville Sun?  There is something terribly wrong with a system where it costs as much to pay for the transaction as it does to pay for the good or service itself.

Settling small medical claims directly could save the country over $100 billion a year.  That would be healthier for everyone, including our children. 


Robert S. Berry, M.D.
Remington Court


November 13, 2007

The Greeneville Sun
121 West Summer St.
Greeneville, TN  37743

To the editor:

Mr. Whitfield & Healthcare Reform – For Such a Time as This

Mr. Chuck Whitfield, president and CEO of Laughlin Memorial Hospital, deserves to be congratulated for recently being installed as chairman of the Tennessee Hospital Association’s board of directors.  Greeneville is fortunate to have someone in such a key position leading THA’s effort to, as Mr. Whitfield said, “develop a healthcare reform plan for Tennessee that can serve as a national model.” 

His selection could not have come at a more critical time.  According to a recent Harris poll, a majority of Americans consider healthcare to be the most important domestic issue for the 2008 election.

I hope as Laughlin’s president and CEO makes plans to reform health care statewide and nationally that his efforts will begin here locally.  As THA’s task force, the Rolling Hills Group (RHG), starts to “examine the uninsured … the cost of health care … consumerism and transparency,” I hope that Mr. Whitfield will take the lead and provide a price list of his hospital’s routine outpatient services, such as labs and X-rays. That way the uninsured and consumers with high deductibles can make more informed decisions about how best to spend their health care dollars. 

Currently, these consumers have to obtain a quote from the hospital before deciding whether they should purchase its services.  Recently, one consumer paid Laughlin $163 for a lipid test and a liver panel to assess the treatment of her cholesterol medication (and this was after a 28% discount for payment at the time of service).  Had she been able to review these prices on Laughlin’s website before traveling to the hospital, she might have compared them with the prices at the PATMOS website where she would have found them to be $40 plus a $5 phlebotomy fee. 

One uninsured patient recently obtained a quote from Laughlin for a CT scan of the abdomen and pelvis for $2,200 (the discounted price for up front payment).  A tax-paying facility in Johnson City has been doing this test for $650.   It appears that Mr. Whitfield might not have to travel to “various countries” to discover why health care in Tennessee and America costs so much. 

Of course, the question that naturally arises is why does Laughlin Memorial Hospital, an organization that (as I understand it) does not pay taxes on income, property, or purchases, charge patients so much more – in many cases several times more – than do medical facilities that pay taxes?  After all, Laughlin is doing very well financially.  According to a recent 990 tax return (a document that is “open to public inspection”), the hospital had $115 million in cash reserves as of June 30, 2005 – or roughly $1,800 for each person in Greene County.  Perhaps this is one of the places our health care dollars are going.

When Mr. Whitfield and RHG “review the major drivers of cost” in healthcare, maybe they will find out why taxpayer-subsidized, non-profit hospitals within the THA charge the uninsured and other cash paying patients so much more than do organizations that are paying taxes to subsidize these hospitals. 

When they do, I hope they will reveal it to the rest of us, because the conclusive proof that the people have been duped (to paraphrase a French political economist) is that their non-profit hospitals are rich and powerful.


Robert S. Berry, MD
Remington Court


October 23, 2007

Mr. John Jones
Editor – The Greeneville Sun
121 West Summer St.
Greeneville, TN  37743

Dear John,

Please find enclosed an op-ed piece entitled, “In healthcare, freedom to choose trumps government-run” that is a response to Lisa Warren’s article concerning ABC’s healthcare special last month on 20/20.  It includes information Mr. Stossel decided not to include in his show, constrained as he was by time and Nielsen ratings.

It is a long piece for a newspaper – over 1400 words.  It represents the first two sections of four that I plan to submit to the Greeneville Sun.  The first two are about the failings of government-run health care systems and how giving people the freedom to choose their own healthcare through medical practices such as PATMOS might be part of the solution.  The third section will show why Americans do not have that freedom right now. The last will discuss possible policy solutions as I see them as an independent, frontline physician. 

According to a recent poll, healthcare is the most pressing domestic problem right now for Americans.  It could be that a medical practice in The Greeneville Sun’s hometown might be part of the solution.  Apparently, a few national news organizations think so. 

While this essay and my medical practice might be locally contentious, the questions they present cannot be avoided on a national level during the next election cycle.  That is not for me to decide.

What is for me to decide is what I will do on a daily basis to attend to the needs of persons within our community who are left out of our healthcare system – and do it apart from taxpayer expense in such a way as to give each person the dignity he or she is due.   What is for me to decide is will I stand against dehumanizing, State-controlled systems in order to protect the freedom that affords men this dignity. 

As editor of our local newspaper, I hope you will decide to print the series in its entirety. I would be happy to discuss these issues further in person if you would like. 

As Edmund Burke once wrote, “All that is needed for the triumph of evil is for good people to do nothing.” 


Robert S. Berry, MD


In healthcare, freedom to choose trumps government-run

October 23, 2007
Robert S. Berry, M.D.

I would like to thank The Greeneville Sun for running a detailed article last month by Lisa Warren summarizing ABC-TV’s 20/20 hour long special on health care. 

One of its producers, Gena Binkley, first contacted me in late May after surfing the Internet looking for “free-market” medical practices to include in a program that would refute Sicko, Michael Moore’s movie promoting a government takeover of health care.  She came across my 2004 testimony before Congress on “Consumer-Directed Doctoring” and sent me an email asking if I would be willing to participate.

Sharing John Stossel’s passion for individual freedom along with his deep-seated distrust of government power, I agreed to the interview, even though I didn’t know what part, if any, he would choose to include in the show.  I applaud him for taking on a topic as complex as health care and making it understandable – even entertaining.

I believe if nothing else he succeeded in demonstrating that a government-run system would be worse than what we have now, despite its many problems.  With unforgettable stories and images, he showed the delays in care and lack of choice in countries with universal health insurance. 

A Canadian woman bearing quadruplets had no choice but to come across the border to a Montana town of 57,000 because no neo-natal ICU in her entire country had the capacity to care for her four babies. 

Another chose to have surgery in Seattle because she could have died waiting for treatment in Canada.  The government told her the surgery was elective. “The only thing elective about [the surgery] was that I elected to live,” she quipped. 

A million Canadians cannot find a family doctor and as many Brits are awaiting elective surgery.  Footage from a British news program showed a long line of “hundreds of people queued around the block’” waiting to see a dentist.  Delays in dental care are so long that some have resorted to pulling their own teeth. 

Mrs. Clinton was shown among a cheering crowd campaigning for “Universal health care for every single man, woman, and child.”  The only thing universal about health care in countries such as Canada and Britain is that it is in short supply and requires long waits. 

Mr. Stossel did not ignore the flaws in America’s health care system – high costs, 47 million uninsured, people locked into jobs for fear of losing their health insurance.  One North Carolina woman switched careers, developed breast cancer that was treated into remission, then lost her temporary insurance.  In tears she expressed the fear of many uninsured Americans, “Who’s going to take care of me?” She wondered whether our medical system would abandon her now that she has no health insurance.   

Mr. Stossel could have boosted his argument for consumer choice in healthcare if he had driven home the following point - had the woman with breast cancer owned her insurance policy, as do the employees of Whole Foods, she would not have lost it after switching jobs. 

Mr. Stossel should be given credit for interviewing her.  Michael Moore was not so fair or honest in Sicko.  The truth, however, is that neither he nor Mr. Moore has the answer for people confronting tragedies like hers.  With a history of breast cancer, the “free market” quoted her premiums of $27,000 per year, which she could not afford with an annual income of $60,000.  In countries with universal health insurance, her cancer most likely would have spread beyond cure while she waited in line for treatment.  She would not have been able to obtain the timely medical care she needed at any price. 

Mr. Stossel believes more capitalism will solve our health care problems, while Mr. Moore puts his faith in socialism.  However, when it comes to health care, they both suffer from the same “mere observer” bias.  Far removed from the difficult realities of providing medical care to the ill, the injured, and the dying, they can afford the luxury of indulging in ideologies – “dreaming of systems so perfect that no one will need to be good” as Gandhi once described mere observers.  Political theories are a poor substitute for hands-on care.  In the real world, real persons fall through the cracks of every health care system. 
It was because many persons in our community were falling through the cracks of our broken system that we started PATMOS EmergiClinic almost seven years ago.  Without presuming upon other taxpayers through non-profit incorporation or direct government grants, the practice has grown to nearly 8000 patients with about 60% uninsured, despite the presence of three State-subsidized clinics in Greene County.  It would seem that voluntary exchange, or the “free market” as Mr. Stossel calls it, cannot be suppressed.  
But how can health care consumers exchange their money for medical services when they don’t know the prices of those services?  Since day one, PATMOS has posted its prices – at the clinic, on our website, and at one time on billboards on the 11E bypass.  To my knowledge no other practice in this area makes its prices public.  Nor do our hospitals, even though as non-profits they are exempt from paying taxes on income, property, and purchases. 
Even though on multiple occasions I have requested a price list for routine outpatient services from Laughlin Hospital, it has refused to provide one.  Patients are forced to obtain quotes even for simple services like labs and X-rays. For a cholesterol profile and liver panel, one woman recently paid $163, its “discounted” price for immediate payment.  At PATMOS, she would have paid $45. 
Takoma Hospital has furnished PATMOS with prices for services such as X-rays and labs.  For about five years, the hospital and its radiologists used to charge little more than what Medicare paid for them.  However, since being purchased by Wellmont, its prices have increased several-fold.  Two months ago, I requested that Takoma re-evaluate its new pricing structure for cash payers, which it has been doing.  Nevertheless, one of my patients recently was quoted $268 for rib X-rays by Takoma (without the radiologist’s fee).  We were able to locate a facility in Johnson City to do them for $47, radiologist’s fee included. 
When prices are publicly available and people are free to choose without government coercion or privilege, competition forces producers to be accountable for the prices they charge and the quality they provide.  This – the free market – insures value for the consumer and fairness and honesty in the exchange. 
The reason PATMOS is able to offer services at relatively low prices is that it does not accept insurance and thus avoids the cost of settling thousands of small medical claims each year. Most other health care providers in this country don’t make their prices available to the public because the vast majority of Americans don’t pay directly for medical care – even everyday care.  Their insurance does. 
Insurance payment not only obscures prices, but it also increases cost.  The annual overhead at PATMOS is about $200,000 less than that of family physicians who accept insurance (according to data compiled by the Medical Group Management Association).  Given that PATMOS has about 5000 patient visits per year, the cost savings runs about $40 per visit – nearly the price of a PATMOS visit.  PATMOS has saved the uninsured and patients with high deductibles over $5 million when compared with what they would have paid at local ER’s for similar services.  The free market saves consumers money.
If all 300,000 or so primary care physicians in this country settled accounts directly with their patients, there would be an annual savings of about $60 billion.  To put this in perspective, approximately $350 billion are paid to physicians and their medical practices each year. 

Other costs must be added as well, including the additional administrative costs incurred by insurers, employers, and government.  All of these deadweight costs are included in the costs of every good and service this country produces, which is partly why many American jobs are being exported to other countries.   Reintroducing the free market back into everyday health care would reduce labor costs and save American jobs. 

PATMOS requires 3 fewer employees per physician.  This means that about one million persons throughout the country are doing little more than settling small claims for routine medical care.  This is not a trivial issue considering that as a country we will need 1.2 million new and replacement nurses by 2014.  Eliminating insurance payment for small medical claims would make more people available for direct patient care.  The free market insures that scarce financial and human resources are deployed efficiently on the consumer’s behalf.

Given PATMOS prices and the increasing cost of insurance, I believe that reasonable people should conclude that Americans don’t need and can’t afford insurance for every day health care.