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Is health care in crisis or in flux? It depends on whom you ask.

The Business Report asked four health care professionals to gather for an informal roundtable to discuss the seemingly endless problems plaguing the industry.

Tops on the list of dilemmas are the shrinking of Medicaid reimbursements to doctors and the general state of health care in America. Another hot topic was possible pending litigation by the Louisiana State Medical Society against the states four biggest private health insurers.

One recurring theme of the discussion was the frequent lack of communication among the disparate interests involved in health care-- be they HMOs, doctors or hospital CEOs.

Perhaps family physician Harold Ishler put it best. Medicine today, he says, is too much about money and not enough about the patient.

"I loved the old days when I didn't have to worry about what it cost to do anything, I just did what was right for my patient," Ishler said. "The golden age of medicine is over, those days are gone. They were gone 20 years ago.

Following are excerpts from the health care panel discussion. The panelists:

Glen Golemi, president and founder of a health care consulting company in Mandeville called Advanced HealthCare Solutions Inc.

Christopher Funes, a Baton Rouge pediatrician and member of the Lake Primary Care Network. He treats patients covered by both private insurance and Medicaid and recently acted as a liaison between his peers and the state Department of Health and Hospitals on Medicaid issues.

Gil Dupre, chief executive officer of the Louisiana Managed Healthcare Association.

Harold Ishler, an Ochsner family physician and president of the East Baton Rouge Parish Medical Society.

Medicare and Medicaid have cut reimbursements to doctors, hospitals and other providers. What have those cutbacks done to you? What remedies do you suggest?

Ishler: Family physicians see the bulk of Medicare patients. Unless Congress does something to change declining (Medicare) reimbursement, then we're going to hove a problem.

A lot of small businesses can't afford insurance premiums. They may have basic coverage, but a lot don't. There are estimates of 40 million to 47 million people either uninsured or underinsured.

Congress when it comes back from its recess has to address the issue of reimbursement to physicians and what they're going to do for patients Out there as far as prescription coverage.

Funes: The state mode a really good faith effort to improve reimbursements for pediatricians who see Medicaid patients. They increased codes (reimbursements for specific procedures) to 70 percent of what Medicare pays (up from as little as 30 percent.) So what that means is we're still getting 70 cents on the dollar compared to Medicare, which still isn't a great payment.

Ishler: Like it or not, medicine is still a profession but it's now become much more of a business than it was. I will never turn away an existing patient, but will not accept new Medicaid patients until the reimbursement goes higher.

Funes: I've heard from many pediatricians. Of 70 pediatricians in Baton Rouge, only 17 had any Medicaid patients whatsoever. Only seven were willing to accept new Medicaid patients other than newborns.

It's about access. Medicare is federally funded and Medicaid is state funded but federally mandated. The problem is, the state has wide latitude in how it implements it. Reimbursements are not adequate to have equal access. It's clear we don't have equal access right now.

On Medicaid, the federal government matches $3 for every state dollar, so Medicaid is a good investment for the state. We can keep costs down by having each child have a primary care provider (instead of only visiting the emergency room when a child becomes seriously ill). It's also much better because every dollar spent on preventive care is less spent later.

The Community Care program is a new managed care model for Medicaid delivery. It attempts to assure each Medicaid recipient has a medical home. The Medicaid population is typically nomadic, so this is an attempt to address that-one doctor for one patient. It ensures emergency room care is appropriately utilized. It's a good idea.

Is the local health care industry in crisis? What needs to happen to improve things?

Ishler: Crisis is not a term I would use. Health care in Baton Rouge is in a state of rapid flux, we're changing. When I came out of medical school, no one in the United States was doing open-heart surgery. Now, every community hospital has a heart-lung bypass machine and technicians, and they do several procedures per week. Surgery has changed. Now we have lapriscopic procedures done on an outpatient basis.

Watching the state of medicine, it's inevitable that hospitals will close probably in all metropolitan areas. I'm a little surprised it didn't happen in the last two to three years.

Funes: I think hospitals contract because there aren't enough patients to fill beds. Medicine doesn't change, don't take into account when I'm going to stick a patient in the hospital whether there's a bed shortage.

Dupre: This community is over-bedded, but do we see the hospitals contracting? No, we see more facilities being built.

Funes: As a physician, I feel my role is to take care of patients in the best way possible. I don't consider at all whether there are empty beds.

I think pediatrics is a great microcosm of the health care industry.

Our Lady of the Lake is the only legitimate inpatient service for pediatrics in Baton Rouge. Like it or not, that's how it is. So there are a limited number of beds. In the dead of winter when you have a sick child, if there are no beds available, that child will still be admitted. He won't be sent home. The problem is not that we overbuilt and now we are over-admitting. The problem is there's a limited size pie and a lot more people want a slice than can afford to have one. It's no one person's fault.

There are only three things in health care: cost, quality and access. If you limit any of those three, something has to give. You can give great access, but something will suffer--either quality or cost. You have to deal with all three of those, but the No. 1 thing is, no one wants to give up quality. So it comes down to access and cost.

Dupre: It all comes down to cost. No one wants to use the word crisis, that's probably not appropriate. But the system is very dysfunctional because costs have gone so high. It's spiraling so fast that it's creating problems throughout the system. Most significant is, people now cannot afford the care they need. Unless we can solve that, we'll never get the system where it needs to be.

Golemi: Cost is the crisis. We have more medicines, more tests and diagnostics than ever. Can the country deliver great care? Absolutely. The crisis is how we're going to pay for it; who is going to pay for it. Government has been able to cut its costs by reducing reimbursements. Next to government, employers and industry pay the health care dollars.

Funes: What's the No. 1 way we've chosen to limit costs? It's access, right? We've said we re going to give you a co-pay as a disincentive to use our facilities, emergency rooms and doctors. We're going to create a formulary so you use a specific drug that we have a deal with the pharmaceutical company to deliver at a lower price. Everything to rein in cost involves access. You limit access in ways that are fair. And you hear about the lawsuits when people feel like you've limited access in ways that are unfair.

In the charity hospital system, people eventually pay, maybe not up front, but through prices they pay everywhere else because employers aren't swallowing that cost; they pass it on to consumers. Health care increases costs across the board. Where the indigent population gets its health care really controls the costs of health care for everyone.

Dupre: What's the proper level of co-pay?

What level of medical management makes the right formula to control casts but provide quality care to people who really need it? No one knows that magic formula--it's different for every patient. And that's the role of the managed care organization, to try to juggle all that on a daily basis, to deliver on what's been promised, which is quality core, efficiently delivered.

What about access to and the cost of medical malpractice insurance?

Funes: Louisiana has a good system to prevent malpractice. Mississippi is struggling with doctors leaving because they can't get insurance, not because they can't afford it but because there are no underwriters willing to give them insurance at any cost. We are fortunately not in that crisis, but there's always that risk.

As a doctor, you wont to do what's best for the patient. But it's always a fly around your ear--should I do what's best or do what's safe for me as a business person? As long as you have that climate, you're going to probably order a few tests unnecessarily, probably do a little defensive medicine, no matter how much you feel your decisions are justified based on the patient's condition.

The biggest barrier now in Baton Rouge is, there are two entirely different hospital systems--private and charity. By law, charity gets the disproportionate share funds, but maybe a majority of these patients are taken care of in other hospitals in the state. There's a sense out there we're taking care of those patients for nothing. The patients are getting more savvy, and they know they can't be turned away (from private hospitals). Maybe it's time to talk about integrating the indigent care in this state into the private hospital system.

The Louisiana State Medical Society has announced it plans to file a lawsuit against the four largest health insurance plans in the state. The physicians claim the plans unfairly cut and delay reimbursements. Where do you stand on the issues?

Ishler: I don't think it was just timeliness of payment. I think there were a lot of other issues out there. This is not unique to Louisiana. There's a growing frustration across America by all physicians that managed care is deliberately using our money that's owed to us as a float to gain extra interest for insurance companies.

Dupre: That's an impression, and I think a lot of that perception--rather than factual information--is what we see in the lawsuit, which to our knowledge the medical society has not actually filed as far as we know. There's a very specific issue that's stated there in the medical society's release, that health plans are not meeting the standards that are set by law. And we just do not believe that that's true.

Golemi: On the issue of whether there is a systematic method by which health plans are narrowing the pipeline? As a practical matter that would be very difficult.

Dupre: How much sense would it make for health plans to systematically delay and try to the use the providers' money, when they have to a pay 12 percent adjustment on claims that they pay past 45 days? And yet we could only earn a few percentage points on that same money. It's just not a good business model.

Funes: You'd like to believe that it not being a good business model would be enough to keep people from doing it, but the fact is that the American Academy of Pediatrics talked to several large insurers recently and they found that, for certain codes, they systematically were not paying what was negotiated, or ignoring certain codes. Even if it's not practical to run a business that way, there are examples where it's been done.

Golemi: Is there miscommunication? Is there better administration and poorer administration in some areas? Absolutely, but the fact that there may be some inferior systems doesn't indicate that there's a premeditated method of delaying the claims.

Funes: Would it be a fair comment to say that there have been insurers--even if you want to say it's been in the past--who systematically made denials on a claim they knew absolutely had merit? I think the answer is, yes. There have been insurers who systematically deny certain claims. It's been shown to happen. If you ask people on the receiving end of payment and people who are writing the checks, you're going to get a huge disagreement.

Dupre: (Health plans) have a lot of provisions in their processes to help them manage costs. It's only natural that there's going to be a conflict at that point between those two parties. They almost have two different objectives. But I think the disappointing thing about this litigation is the fact that while there probably were some discussions between physicians and health plans, it really wasn't high-level discussion to get down to what the real problems are. This was sort of a bold surprising move to immediately go to litigation.

Funes: That's what drives discussion.

Dupre: I'll give you a good example of how it doesn't drive discussion. How can you expect to get health plan representatives to a forum like this? Even though the litigation hasn't been filed, the only responsible thing for them to do is act as if they're in litigation right now.

Funes: It would be great if everybody could sit down and come to some conclusion. But any chemist will tell you, you involve pressure in the equation, all of a sudden you get a little more bubbling and a little more results.

Ishler: I've tried after hours to call some health plans and it's amazing. You don't get a human being. You write a letter, you get no response. There are some you can call and you get through right away to the medical director. But there are some companies that are viewed in the provider community as being anti-physician. That's not necessarily a deserved reputation, but it's a perceived reputation. Somebody needed to get the attention of the managed care industry.

Dupre: There may be parts of (the law-suit) that have some basis, but we all know that one of the results of this is going to be one of cost. Everybody is going to incur cost--the providers who are involved are going to incur costs. At a time when everybody's struggling with costs that are creating havoc, we're going to just add another layer of cost on top of that. That's the disappointing thing, that we didn't take the time to try to discuss these issues and try to find out what are the real problems and can we address these problems outside the legal system?

Do you feel anything is gained by roundtable discussions like this, bringing various parties together?

Dupre: These types of discussions can be constructive. We should be doing more of this. We should be getting together and finding where is the common ground.

Golemi: It took half an hour before we began to disagree on some of this. There is some common ground on a number of things. We're certainly not going to resolve all the dysfunction that exists on all the different fronts today, but discussions in the right environment will help.

Ishler: I think there has to be a marching in parallel between providers and managed core to do what's right for the patient. I think the best possible scenario to come out of this would be for all parties to sit down and talk just like we have this morning.

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