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Thursday, September 17, 2009

Senator Baucus' proposal--are health care co ops a bad thing?

I just skimmed the 223 pages of the health care proposal by Senator Baucus, with a focus on the health care cooperative suggestion and the mention of medical malpractice reform.

There are lots of sections in this proposal, and most of them contain good ideas. Achieving all that is in it would be a humongous and monumental amount of work. It also nearly completely misses the boat in terms of cost savings.


The proposal suggests that we establish health care cooperatives as an alternative to presently available insurance plans, that work about like Group Health does now. Group Health is a cooperative based in the northwest which provides full health care services to members for what looks like a reasonable price compared to what most health insurance costs. It provides basic services easily, emergency services competently, and focuses on prevention. It provides good care for serious illnesses of all kinds, and skimps a bit on cutting edge technology and medications. Sometimes members have to wait for services if the providers get busy. The basic idea behind cooperatives from a doctor's point of view is that we get paid a salary to take care of a certain number of patients, and provide those patients all the health care we are qualified to do, and refer out to other providers or services as necessary.

I worked for Group Health from 1989 to 1993 or so, and had a baby while insured with them. The total cost for prenatal care and delivery was $5, which I paid for use of the TV in the delivery room (which I didn't actually watch). As a provider, I was occasionally quite annoyed when I wanted to prescribe a new medication for a patient, and they wouldn't pay for it until I had tried 3 or more ineffective medications with tons of side effects, but no one ever died because of that.

It will be difficult to establish functional health care cooperatives on a large federal scale in time for them to absorb all of the people who need insurance now, but it would be well worth the effort. A cooperative such as Group Health has the ability to mandate cost effective strategies for taking care of patients, and if that began to be part of the way medicine was practiced in the US, it might spread to the fee for service arena, as the overall culture of care changed.

The problem is that it would be slow, but then the strength of it would be that it would be slow.

The changes that need to happen in health care are so large that going too quickly might entirely bust something that is only mostly busted right now.

Still, to get a health care cooperative up and running well will take years, and will be a bumpy road for each individual cooperative, which gives little relief to people who need medical care now.

A public option, if it were identical to medicare, would have the difficulties of medicare, with a set of rules that don't make good sense, and reimbursement that is low enough that many providers opt out of caring for patients insured with it. If we could make a public option plan available and also improve medicare at the same time, with a medical home model, this would be better than cooperatives, but if that can't happen, all would not be lost if we were able to get in motion good, solid, viable health care cooperatives.

There was exactly one paragraph in the bill about malpractice, saying the the "sense of the senate" was that states should take this change in health care delivery as an opportunity to change the liability system so that it actually works. I can see that perhaps the inclusion of broad and powerful malpractice reform in a health care bill might kill it, but I am disappointed nevertheless. Tackling malpractice is vital to reducing costs and there is actual energy and motivation to do it now.

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