This is a column about how a doctor would cut the cost of health insurance for the poor, i.e. the state Medicaid insurance budget. If my suggestions tick everyone off, including me, I have done my job. The line to cuss me out in response forms behind me.

By way of background, Medicaid is the health insurance for the poorest Americans, and one-third of its costs are borne by state budgets. State Medicaid programs around the country are amputating programmatic limbs in a frenzy of cuts brought on by state budget deficits. Maine’s Medicaid program, known as MaineCare, is in the process of having another $22 million cut out of it by the administration of Gov. John Baldacci, as part of an effort to balance the state’s budget.

I made the mistake of whining about this to my editor at the Bangor Daily News the other day. He challenged me to climb down off my high horse and come up with my own list of proposed cuts instead of just criticizing the hard and imperfect work of others. I hate it when he is right, so below is my list of things I would cut from Medicaid (some of which could be cut from any kind of insurance). I was guided by this thought; spending on health care for Medicaid patients (and all patients, for that matter) should be prioritized first to save lives and treat acute illness, next to treat chronic illness and extend life, and finally to improve quality of life.

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Based on that, here are my suggestions:

1. Medicaid administrators and medical experts should, where possible, rank treatments in order of effectiveness and in terms of years of life saved (such data exists for many treatments). The fewer years of lives a specific treatment saves the lower it goes on the list of things Medicaid pays for, and when the money runs out the things lowest on the list don’t get paid for. Oregon has done something similar, and Maine could make it work. The less evidence there is that a particular treatment is effective the lower it goes on the list, and if there is little evidence that some particular treatment or test is effective, Medicaid stops paying for it, now. Examples toward that end:

. if immunizing children is more effective at saving more years of life than bone marrow transplants for breast cancer patients, Medicaid should be paying for immunizations first;

. Medicaid should have a nurse triage line for patients to call and discuss acute illness symptoms, and help the patient decide if he or she needs medical care. That would cut down on unnecessary doctor and emergency department visits for Medicaid patients;

. if the doctor puts you on antibiotics for a cold/bronchitis, many ear infections, etc., without the illness meeting the criteria for antibiotic treatment, Medicaid does not pay for those antibiotics. Most doctors know when antibiotics are not indicated, yet we often prescribe antibiotics anyway because the patient/parent wants one prescribed;

. no payment to hospitals for admissions of patients with pneumonia who do not meet criteria for admission, those criteria having been established by large studies. Ditto admissions for other medical conditions that do not meet established criteria;

. Medicaid should pay well for so-called observation medicine, whereby patients are observed and treated for longer periods in hospital observation units to try to prevent more expensive admission to the hospital. Diagnoses such as dehydration, asthma, emphysema, congestive heart failure, chest pain and many others can often be treated this way as an alternative to hospital admission, but Medicaid and other insurers often pay so poorly for it that, for doctors and hospitals, observation medicine is not worth doing;

. no payment for X-rays of injured ankles, knees and other joints that do not meet proven criteria for an X-ray. Large studies have shown that many X-rays are unnecessary, and it is time doctors and patients were held accountable for wasting money doing unnecessary X-rays;

. no payment for low-yield routine tests and annual physical exams done in well populations, including mammograms for low-risk women, prostate cancer tests for men without risk factors except a prostate, etc. There is good data, for example, that some women with a history of normal Pap smears do not need Pap smears every year;

. establish strict criteria for Medicaid to pay for common surgical procedures, such as hysterectomy, so that the number of surgeries of marginal necessity are reduced;

. stop paying for expensive antibiotics for common infections unless the evidence suggests that the expensive antibiotic is the best choice. A lot of Zithromax at 10 bucks a pill is wasted on ailments that could be treated with Amoxicillin at about 30 cents a pill. Ditto Cipro, Levaquin, Ceftin, Biaxin and every other name-brand-only, broad-spectrum, money-wasting, bacterial-resistance-generating Big-Bucks-acillin on the market.

2. If we want them to practice in a cost-effective manner, health care practitioners need laws that protect health care practitioners from lawsuits if they follow established guidelines for not doing tests and procedures. Any state with enough gall to cut necessary health services for the poor ought to have enough guts to take on trial lawyers on this issue.

3. Stop paying every hospital in the state to do just about everything on Medicaid patients. Complicated treatments and surgeries should be done at a few, higher-volume hospitals so that complication rates go down and the state can get volume discounts. Then pay the remaining hospitals and their doctors more to do the procedures they can do frequently and well so they are not financially gutted by losing the other surgeries and treatments.

4. If you are a patient with Medicaid insurance you should have to sign an agreement saying that you will always wear your seat belt and will not drive while talking on your cell phone. One violation should get you a warning, a second violation should lose you your Medicaid insurance. As a Medicaid recipient you have an obligation not to risk the public’s money doing stupid things in the car that place you at risk to be injured in a crash.

Since the rest of us should be sharing in all of this pain, the state should ban the use of cell phones while driving. Drivers who phone and drive (me included – I am a hypocrite on this issue) are a menace to our health and health care costs. While we are at it, Maine should have a primary-enforcement seat-belt law, meaning we can all be stopped and ticketed for failure to wear a seat belt. At the point we are depriving Medicaid patients of necessary care, and businesses are leaving the state because they cannot afford health insurance here, it is time to force all of us to hang up, and buckle up, in the car.

5. Co-payments for prescriptions, emergency department visits, and routine doctor visits for Medicaid patients, even if the co-payments are a couple of bucks. Ditto the rest of us, no matter what our insurance is. Co-payments should be higher if you smoke. Whenever any of us get treatment of any kind our doctor/pharmacist/hospital should tell us what the bill would have been without insurance; everyone ought to know what their treatment is costing someone.

6. No payment for Viagra for Medicaid patients. Impotence is a real disease and sexual intercourse is a wonderful and normal part of life, but if Medicaid cannot afford adequate mental health care for poor children it cannot afford pills for impotence.

7. Require all hospitals providing care for Medicaid patients to adopt a specific core set of quality practices that have been shown to improve care and reduce health care costs. The better a hospital does on these quality practices, the more it gets paid for care of Medicaid patients. The worse it does, the less it gets paid. Give hospitals a year to comply, then start cutting the checks.

8. Pay for fewer visits to all kinds of doctors, but pay better for each visit. I think the net will save money. Allowing unlimited visits but paying poorly for them is simply causing doctors and dentists to stop seeing Medicaid patients, depriving those patients of any access. Better payment will assure some access, which is better than no access.

I have no idea what all of this saves, or even if all of it is legal. Those issues are a problem for someone else. My challenge was to make a list, to play the terrible “game” of cutting Medicaid.

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There are a few rules if you try:

1. It’s an ugly, brutal, dangerous game – think health care Jumanji for real.

2. You have to cut Medicaid – raising taxes in most states at this time is not a politically viable option, the budgets must be balanced, and there is not enough money that will be cut from elsewhere to avoid cutting Medicaid.

3. There are no painless options. Even if you could save all of the necessary millions by cutting waste, errors, etc., that cannot all be cut in time to avoid the harsher cuts this year. Besides, there will probably be a need to cut again next year.

4. You are messing with important stuff, including people’s lives. It’s possible that Medicaid cuts could result in some hospitals closing, some doctors refusing to see Medicaid patients (many already are), some pharmacies closing, and some patients dying because they did not get enough care. It’s possible, but another rule of the game is that you cannot be sure of any of this until it happens, and by then it will be too late.

5. Someone will disagree vehemently with every cut you suggest, and oh, by the way, you are an uncaring jerk for suggesting whatever you suggest.

6. For every argument in favor of one particular cut there is an argument someone can make against that cut, but you still have to choose.

For those suspicious of where my self-interests lie in these issues, they lie all over the place. I am a doctor, I work for a large hospital, some of my favorite patients are Medicaid patients, I am a patient, and I am a taxpayer. I co-chair the Maine Governor’s Council on Fitness, Health and Wellness because the governor asked me to, so I guess he owns me too. I think the only interests I don’t represent are probably those of the pope and the pharmaceutical industry; other than that I am deeply conflicted. So are most of you.

For those concerned that I’m uncaring, nothing could be farther from the truth. The need for a list of what care must be cut for the poor of this country appalls me, especially when corporations such as Enron can go years without paying any corporate income tax. I am embarrassed that my America does not provide health insurance for every American, and I carry the weight of that embarrassment around my neck with my stethoscope.

Finally, this is a game we are all playing already, because it is on our behalf that our government is cutting Medicaid. There is a little blood on all of our hands.

Erik Steele, D.O. is a physician in Bangor, an administrator at Eastern Maine Medical Center, and is on the staff of several hospital emergency rooms in the region.