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Tuesday, August 25, 2009

How to fix it

The problem:
Health care costs too much, insurance costs too much, and people are suffering because of money spent directly in bills or indirectly through taxes. Because of the cost of insurance and health care, too few people have access to it.
Scope of the problem:
Huge. Because of the lack of access, America’s indicators of overall health, including infant mortality and average age at death aren’t as good as most countries we consider our peers. Because of the cost, average Americans’ take-home salaries are significantly lower than they would be and federal and state governments are unable to afford other basic services such as education and other social services.
Causes of the problem:
1. Doctors practice medicine that is not cost effective because of worry about malpractice, and perceived patient expectation that costs are not a consideration where health is concerned.
2. The number of primary care physicians is shrinking because primary care physicians are not paid as well as medical specialists who do procedures. Doctors who do primary care try to do as many procedures as possible because they are paid better for them. Because they are paid poorly, primary care doctors have to see more patients, and so they spend less time with each patient. It takes more time in an appointment to discuss with the patient whether they actually need an expensive procedure or medicine than to simply order the procedure or medicine (examples: MRI or CT scans, x-rays, and antibiotics.) One MRI scan costs about as much as 50 office visits.
3. Even though insurance companies make it difficult for doctors to order tests or expensive medicines, the threat of malpractice is so great that we spend the time it takes to get authorization to do these things, and subsequently have even less time to spend with patients.
4. Almost no stakeholder, not patients or doctors, knows how much anything in medicine costs. The insurance rules and coverage are so complex that costs of procedures, medications, office visits or referrals are not known at the time they are prescribed so cost cannot even enter the equation.
5. Because billing is so complex, and insurance rules are so complex, certainly a huge amount of billing mistakes and fraud happen on a regular basis.
6. The staffs and administrations of insurance companies are very large and expensive and the billing departments of doctors’ offices have to be large and expensive to deal with them. The system is adversarial rather than cooperative and wastes a great deal of money.
7. Medical devices, procedures and medicines are too expensive because the risk of liability reduces competition. iPods have gotten cheaper and better in the last 5 years and MRIs and appendectomies have gotten more expensive.
8. Uninsured and low income patients don’t come in to see a primary care doctor because they can’t afford it. Instead, they get the most expensive kind of care, which is hospital based, when their preventable problems become emergencies.
1. Cost transparency: patients and doctors need to know what everything they do will cost ahead of time. Patients should know the cost of an office visit when they see the doctor and know what their portion of that cost would be. Doctors should know that as well. The same is true for surgeries, scans, lab tests, medications. This will not be practical in every situation. There will be emergencies and unexpected costs, but these things should be the exception not the rule. Doctors will find it much easier to practice cost effective medicine when they actually know what the costs are. This will require a significant change in the way insurance companies operate.
2. Tort reform: doctors practicing cost effective medicine need to be protected from being sued for being responsible about expenditures. Some level of tort reform on a federal level to prevent lawyers from benefiting from huge settlements will help get doctors to do what they already know how to do: take care of patients.
3. Pay adequately for primary care: it takes time and intelligence to counsel patients in such a way that they feel satisfied without unnecessary tests or medications. Surgical specialists will also be more likely to counsel patients rather that doing procedures if they are compensated adequately for the time spent counseling.
4. To alleviate the primary care shortage, consider a program to subsidize medical education for primary care doctors. High educational debt drives graduates into high compensation practices including specialty medicine and primary care in big cities.
5. Educate doctors in cost effective medicine. We are required by our malpractice carriers to take continuing education in risk reduction, and it would be simple to require a certain amount of time for learning about cost effective practice in order to qualify for updating our licenses. A large amount of research has already been done in the field of effective medicine and evidence based practice, such that there are clinical practice guidelines for many common diagnoses. Doctors know these exist, but are usually not familiar with them.
6. Provide adequate insurance to those who can’t afford it, based on the most effective and efficient models available. (Consider Medicare, Group Health, and other countries with good health indicators.)

Bad Ideas:
I have read many proposed solutions to the healthcare crisis, and a few have seemed particularly poorly conceived.
1. Across the board cuts in payments to doctors: if we make less money for each patient we see, we will have to see more patients in a day, and do more procedures in a day to pay off our educational debt, which will make health care less effective and more expensive. Costs for procedures and medical equipment may need to be cut, but that needs to be combined with some significant changes that allow it to be easier for us to do business. Doctors in the US do not make significantly more money, corrected for cost of living and average salary, than doctors in countries whose health care systems are more cost effective. In Moscow, Idaho, primary care physicians make about the same salary as a good accountant does. Medical education takes a minimum of 7 years postgraduate education and is very expensive and competitive. If the practice of medicine doesn’t offer a decent competitive salary, the people who are qualified to go into medicine will do something else, and physicians will leave their practices.
2. Requiring low income patients to shoulder more of their insurance and healthcare costs: In my experience, low income patients have no extra money to spend on insurance or co-pays and simply will not pay these bills. If there is a “public option” insurance offered by the government and patients on minimum wage are told they need to shoulder 15% of the costs and pay 20% of their medical bills, they will either remain uninsured or will fail to pay their portion of bills, and lose their access to their doctors for bad debt.

1 comment:

HMS said...

Janice, we'd like to invite you to become one of our Authors along with Lynn and DADvocate in Alexandria. You may mirror your existing posts from here or elsewhere or produce original posts there, as you desire. For your contributions and participation we will blogroll you with no reciprocation required. Come contribute your perspectives and opinions to the ongoing conversations there. Contact us through the site for full invitations and instructions.