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Wednesday, October 21, 2009

unthinkable thoughts, hypothetically

Last night I participated as a member of a panel speaking to medical students about issues relating to health care reform. Next to me was a respectable Blue Cross executive from the state capital, next to him a health care economist from the university and then two of my doctor colleagues. Our first starter upper question from the gathered masses was what we thought was the major problem with health care in America. The insurance guy and the economist said that people don’t take good care of themselves and so are in lousy health, and that they ought to take more personal responsibility for being healthier. This is what I keep hearing from Washington DC folks not in medicine, and although it is a truism, is it actually true?

Clearly, from the standpoint of bang for the buck, health and happiness and overall simplicity of delivery, the prevention of illness by avoiding overeating, drinking, smoking and drug addiction is powerfully attractive. Add to that physical activity with all of the associated intrinsic benefits of getting out and about and using one’s body as it was intended, and the recipe is really hard to beat.

But what if the finding in the New England Journal of Medicine last year that cessation of smoking eventually would actually lead to higher health care costs due to the fact that people would live longer is also true for all the rest of the things we do that make us healthier?

That is to say, what if being healthier means we live longer, and use up more health care resources because in America that’s just what happens?

This is a hypothetical question, and the answer might include a suggestion that however healthy we become, it will still be necessary to reduce health care costs.

It is certainly a more attractive idea that being healthier is also less expensive, but then one gets into the question of how to make people make choices that make them healthier.

Studies throughout the last 20 years have shown absolutely pitiful results from doctors counseling patients about lifestyle changes. So, hypothetically again, is it possible that beyond giving relatively casual advice, doctors really shouldn’t be in the business of delivering messages related to lifestyle changes? Would it, perhaps, be more efficient to have public health people do this? Maybe making exercise and healthy food more attractive and available would work better than nagging?

A somewhat different subject, but also nearly unthinkable, is the concept I’ve been rolling around in my mind lately about the source of our willingness to pay excessive prices for procedures and drugs compared to their value to us and their objective value in a global market. Is it possible that the introduction of public insurance, medicare and medicaid, in the last 50 years, has resulted in acceptance of actually generally unaffordable health care costs? On public insurance, in most cases, anything ordered by the doctor is paid for, without a significant bill to the insured. So there is very little reason for these insured people to protest the cost of things. I am absolutely positive that medicare and medicaid have saved lives and livelihoods for the many years they have been in existence, and that if they simply disappeared today havoc and misery would ensue. But is it just possible that they have been a primary player in the creation of our financially extravagant medical care in the US?

A single payer system might have the motivation to act like a patient/consumer would, and have the clout to reduce prices and increase quality, but lacking that how can we get insurance companies to do this? And why do that not act this way?

Insurance companies, when they first started to pay the bills, paid "usual and customary" fees for doctors and for procedures, set by what had been the market forces acting on them. As time went on, insurance companies standardized what they would pay for things, due to a great variation in regional billing, and then billing began to match, or rather slightly exceed, what insurances paid. Billing for these things gradually went up, and insurance payments went up, slightly trailing billing, and here we are. But as technology got better, the cost of x-rays and cat scans should have been able to come down. Procedures could have become cheaper, and drugs that had been around for years could have come down in price.

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