Tuesday, April 8, 2008

my healthcare plan

OK, I'm not running for office here, I'm just ranting and putting some thoughts together formed from 20+ years in healthcare.
Why can't health insurance be like car insurance? Or homeowner's? You have to get it, by law, at the car insurance. To get a tag for your car you have to show proof of insurance. Sure, some fake it or lie about it, but most (I think) really have it.
So make it a law that people have to have some level of health insurance. If they qualify by income level like for DHS support, they can get it for free. But they still have to have it. I have told people for years that they should buy a major medical health insurance policy with a high deductible, to cover catastrophic stuff, and then use the money they save vs. a full coverage policy with prescription drug coverage, etc., to pay for their occasional doctor visits and medicines. 
You may say, "but people won't be able to get the drugs they need or the tests they need or the medical care they need...". Here is where "need" needs to be defined as true need and not "want" or "expect".
The proliferation of prescription drugs to "fix" all our social and personal ills is a good sign that there's money to be made in this business. It's like all the restaurants going up all around, people want to eat out, and they do it a lot. And people want pills, a lot of them. Driving through town today I saw evidence of so many things that are "wants" and not "needs" and they are unashamedly marketed out there on the street for people to see and "want" some more. Before I go on, I should tell you that I'm like the guy in the AA meeting standing up and saying, "hi, I'm Kelly, and I'm a 'wantaholic'". I see these things because I'm looking for them and they tempt me. Maybe if I was closer to the "need" stage, if I had little kids, especially, I'd be less likely to be going off on these things, but I don't so I am. Exotic play grounds for the backyard, all redwood and bright plastic with slides and faux rockclimbing attachments, the kind you used to only see in neighborhood playgrounds or God forbid, school playgrounds. I'm talking big monstrosities that look like they'd take a crane to get them in the backyard or several weeks of putting tab A in slot B and then screwing it all together, a nightmare in my opinion. Well, I digress. Well, except for pets. Like kids, there are things available for pets that someone visiting our country from even 20 years ago would have laughed at in amazement. Play groups for pets, dog parks, and supermarkets with only pet stuff, most of which no pet would even care about, much like much of the junk available for kids who'd rather just have a stick and some dirt and maybe a tree to climb and a bike to ride, but we "need" this stuff - because it's available and for sale.
Back to the health insurance issue, after my rabbit trail and segue back in - most of the medicines and tests like MRI and 4D ultrasound and designer blood pressure/cholesterol reducing drugs, reflux medicines, antidepressants, stimulants for ADD, etc., are really "wants" disguised as "needs". They are available, we know someone who has had one or takes one and so we think we must need one, too. And besides, they're for sale and all you have to have is a doctor's order, or at least that's what the commercials say. Commercials for medical stuff - another thing that a visitor from the not so distant past would find amusing, until he saw how well it works. Sure, the drug companies used to buy doctors by buying lunch or golf trips or whatever, and they still do, only mostly with food now, and "consulting fees" or "speaker fees" by having one of us review an article about their drug and then talk to our colleagues about them at a fancy restaurant. And this is paying off, I have no doubt. But nothing has paid off as well as "just ask your doctor about...". The 4 hour erection on the ED drug commercials is the best way I've ever seen a drug's potential side effects sold as a subliminal tease. I remember a show on "commercials you'll probably never see" and there were these 2 boys about 8 years old who are talking about what they're saving their money for and are overheard by their mother when one says "I'm saving up to buy OB tampons" and the other one says, "OB tampons, why?" and the first one says, "I saw on TV that if you buy OB tampons you can go swimming and skiing and biking and hiking..." and of course the mother cracks up quietly laughing. Commercials affect different people differently. And instead of eating right and exercising, I'd like a pill to make me get in shape and lose weight or lower my cholesterol and make me smarter without studying and a procedure to erase the wrinkles of aging and suck the cellulite out of my thighs and...
So we're now selling medical care as a "need" when most of it is really just a "want". That a CT or MRI is "standard" care for a painful shoulder or knee or for a headache is a recent phenomenon. To some degree driven by malpractice fears, doctors are able to justify an "overevaluation" of fairly common problems. The thought process of diagnosis is often short circuited by all the tests. That's a different topic, sorry. But the idea that our insurance should pay for whatever whenever is a fallacy that has gotten us to this point, and we're going to have a hard time getting off this high center of expectations from the public. I'm not going to argue that healthcare is a 'right' in our society. It is, because we say it is. But how much is 'right' when it comes to healthcare? Is there such a thing as too much? I think we all would like to think that at least some healthcare is a good thing, so there is such a thing as too little, but too much? The way I see it, we're well into a 'too much' phase right now. Too much medicine, too many opportunities for elective procedures, too much screening (in the name of health, but in reality a ploy, many times, to generate business for a particular segment of the healthcare industry), too many required tests, too many lawsuits for too much money. But we've come to expect this level of 'care' and it's going to be hard to cut back. I tell parents all the time to start small and work up with praise and rewards, etc., or they may get to the point where there is no reward large enough to make a child want to do something to get it, because the child already has it all. We are those children, and in fact, we have watched this thing grow right in front of our eyes since most of us were children. I can't tell you how many times a parent says something like "my mom never took us to the doctor unless we were dying". So why didn't she? Was there not a doctor around? I don't think so, because then they'd say, "we never got to go to the doctor when I was a kid because the nearest doctor was too far away". Was there not enough money? My dad was a doctor. I remember him charging $10 for an office visit and taking items for barter if the patient couldn't pay. Money for a doctor may have been somewhat of a luxury for some, but it wasn't the astronomical figure we see now, even with inflation. What is responsible for this rise in cost? You don't have to pay for it anymore. You pay for insurance and your insurance pays the doctor. It's like going out to dinner and not having to pay. Or, more realistically, you don't have to pay while you're there, you may get a bill for part of the meal later, but it's distant from the actual meal so it seems separate. Which gives rise to people forgetting how good the meal was and how they ordered dessert and an extra drink at the time because they wanted it and it didn't cost them anything anyway, so when the bill comes, they argue about paying it. I could run this analogy's legs off if I desired, like how you could go to certain restaurants and have dinner and have it paid for, but for others you had to pay, or at least pay more of the bill. And you could only order certain things unless you had prior approval. But I won't.
Automobile insurance is different. The expectations are different from the outset. If you want, you can only pay for liability insurance that covers any damage to others but doesn't fix your car. You don't expect insurance to pay for filling up with gas or getting an oil change or a brake job or even a new transmission. You have insurance to pay for damage done in accidents. And you don't even want to turn in many claims for that unless you want your premiums to go up. So you pay for the repairs out of pocket. How would this look in health insurance? 
Maybe we could buy an insurance policy that would cover big stuff, like accidents or severe illnesses. Then we could pay for the incidental stuff out of our own pockets. I'm cutting my own throat here, so be nice. If you had to pay for your baby's checkups and shots, you'd be looking for the best deal you could get. Sure, you want the best for your child, but if Dr. X charges 25% less for his checkups than Dr. Y, you're at least going to go see for yourself. This is the WalMart mentality. The best for less, or something like that. So, Dr. Y either has to convince you that his fees are reasonable due to better service or something else he provides that Dr. X doesn't, or you're going to change doctors. The same thing goes for procedures, and medicine, and vaccinations, and on and on. Capitalism at its finest. Ouch! No longer would there be this built in fee schedule based on what the government will pay for things. This is a pretty easy thing to see, I think. Competition is good for a business. It makes the consumer the driver of cost more than the government or big business. There is a place for the profession to police itself and the consumer needs to know that he doesn't know as much as the professional in some instances. In the same way that I take my car in to be fixed and I don't know what's wrong or I don't know how to fix it or have the equipment to diagnose and repair it, I have to rely on the expertise of the expert in this area. To some degree, I am at his mercy. But one develops relationships which are built on the assumption that the mechanic can do the job I'm paying him to do.  If he does it well and charges a reasonable price, I'm usually happy to pay it. Sure, I could go to a different mechanic for every problem, but having one who knows my car, and knows me and the way I drive and what I use a car for, that's important. In healthcare, as I'm sure in car care, there are many opinions out there that the 'experts' are ripping you off, making you sick, not doing you right. This lack of trust is natural when one is spending money on something that isn't always tangible. Like the story of the electrician who comes to a house to fix some appliance and all he has to do is push some button or tighten a screw, and when he gives the homeowner the bill, the homeowner gripes that "all you had to do was..." and the electrician responds by saying that the homeowner is paying him for the knowledge of which button to push or which screw to tighten, not the actual work. 
So, as a pediatrician, I would need to be competitive in my fees or provide something special that others didn't, in order to have higher fees than the guy down the street. It's the steak dinner at Denny's vs. the steak dinner at Outback vs. the steak dinner at Boulevard Steakhouse. There's a difference. Yes, it's all steak, it's all cooked and served to you, but some prefer to move up a notch or two in quality or service and are willing to pay for that difference. So there will be doctors who do the basics and ones who provide a level of care above the basics. One would hope that each would be reasonably similar in their ability to diagnose and treat common problems, and the difference might come in the amount of time one spent with the doctor or the waiting time was less or the office was nicer and cleaner and friendlier. There will be, and already are in some places, doctors who provide a 'concierge' level of service. They don't accept insurance payments and are pretty much on retainer for a certain number of patients who have access to this physician when they want it and don't have to put up with the 'regular' stuff the 'regular' patients deal with. This will become more common. 
So, we are not cars. We don't just decide not to fix someone and sell them or scrap them. That's illegal, immoral, and generally distasteful. We don't get a 'lemon protection plan' and we can't just get a new kid when the old one 'wears out'. And we're not pets. We can't just decide to put our kid to sleep if he's got some illness that's going to be difficult or painful or expensive or all of the above. But there are similarities. We can use 'premium' gas and extra long life motor oil and the best spark plugs and really pamper our kids just like our cars. We can buy the best dog or cat food and have them groomed regularly. But those are our choices and we pay for them. 
We get diseases that must be treated. We have accidents. We need doctors and nurses and hospitals for some things. We need MRI sometimes. We need medicines sometimes. But do we need them as much as we think we do? What if we paid for it? Out of pocket, prices listed on the 'menu' at the desk, optional extras like prescriptions called in or faxed vs. written, shots with clean needles (just kidding), phone calls returned the same day for one charge, within a week, different charge, sort of like shipping charges. 
This is all well and good for most of my population of patients. I think they'd find that they need me far less than they think when they had to pay out of pocket. They'd be less demanding in some ways, more in others. They probably wouldn't come in for a cold as often. They'd wait and see if a child actually got sick before they came in, and they'd have an opinion as to what drugs we used to treat the child (more than they do already). This shift of responsibility to the patient would cause many changes in my behavior and that of my patients. Do you want to see the doctor? That's this much. If you want to see the nurse practitioner, that's this much. If you want to see the NP but have her consult with the doctor, that's this much. Would you like an estimate to fix your problem or do you want us to fix it while you're here? This is already happening in consultations with some specialists. It would be a different world. I would have to earn your business because there's another doctor's office that you pass on your way to mine and she's pretty good. This already happens with urgent care centers, but when people figure out that they're paying double to have their kid checked by a doc in a box and then come see us the next day or two for followup when they could have/should have just waited until the next morning and visited us once. But this is America and I want to be seen now! Even if it's by someone I don't know and don't trust and now that I'm here I'm wondering if this is the right thing to do and I think I'll go see my doctor tomorrow anyway. Enough on that. That's not the future, that's the present.
For patients with jobs and some money, those not on welfare, it would be a requirement to have a major medical policy to cover catastrophic illnesses/accidents so you don't go bankrupt paying for this problem. This should be pretty cheap compared to what most insurers charge for 'full coverage' currently. Flexible spending accounts or health savings accounts could provide the cushion for the 'regular' stuff like checkups and ear infections and the occasional stitches, etc., and you'd still save money. I've told people this for a long time. I even said it several paragraphs ago. But to do this we would, doctors and patients alike, have to change. Quite a bit. But it's amazing how money is a catalyst for change. Many things we have now would decrease or go away. It might go back to where only the rich and famous could have cosmetic surgery. Where only professional athletes had their knees MRI'd 'just in case'. Psychotherapy would be the domain of the rich and famous (maybe the ones who didn't get their cosmetic surgeries, or maybe the ones that did). We would observe mild viral infections and see how our child fared, seeking care only if things were not progressing normally. We wouldn't screen our 2 year old boy for autism because he isn't talking yet even though the reason he won't talk is that he doesn't have to because you do everything for him and talking would just complicate life. We might go back to the 'old days' where an illness was allowed to 'run its course' and we'd all seen one do it and the kid survived even an ear infection without an antibiotic and an antihistamine/decongestant and alternating tylenol and motrin every 3 hours to make sure he doesn't have a fever even though the fever is what God gave us to help fight the stinking infection to start with...I digress. Again.
OK, enough about how wonderful life would be if people had to pay for their own oil changes and fillups. How only major crashes would involve insurance companies and capitalism would reshape the healthcare industry. What about the poor? Those zillions of uninsured or underinsured? 
Well, for starters, in today's world, if we adopted my 'car insurance' plan above, we'd all be considered underinsured. 
But for the truly poor, one of a couple of things would happen. What would likely happen is that the state would pay the premium for this 'major medical' policy and there would be state clinics and hospitals contracted to care for the incidentals like checkups and earaches and stitches and those contracted providers would be paid a lump sum by the state to care for those for whom they are responsible. This payment would likely not be very much. It isn't now. That's why it's hard to find doctors willing to care for patients on state insurance. There's no good answer here, and the idea of healthcare as a 'right' has to be defined. How much? How soon? How good? Depending on the income qualification for the state insurance, one could envision a plan where the only difference one would experience would be at the hospital level, where a state hospital would go back to the status of a teaching hospital maybe with either altruistic doctors who love to teach and care for people regardless of their ability to pay or doctors willing to work for less because they can't make it in the 'real world', or they're honing their skills to make it 'out'. At the outpatient level, this population could pick their healthcare provider like everyone else and use a health savings plan or plain old cash and shop for 'the best for less'. 
The other scenario would be that doctors would care for the people unable to pay along with those who are able to pay, and either charge them reduced fees on a sliding scale, or be really Christian and just see them for free. If everybody (docs, I mean) had a few of these patients, it wouldn't be so burdensome. 
But none of this is going to happen, because of American politics and expectations. We're all going to be forced to pay more for healthcare, whether we need it or not, and the government is going to dictate the prices and who gets what tests and really it's not going to be a whole lot different from the sorry state it's in now where people want prime beef steaks for Denny's prices and are upset when they get a bill for the difference. I don't see it going to a Canadian system or a British system where if they run out of money before they run out of year, all the surgeries and tests scheduled get put off until the new year begins, unless you die before that in which case, they're sorry but someone gets moved up on the list. We have too much invested in our healthcare economy to dismantle it completely to go to the Canadian system, where I've heard there's maybe one or two MRI machines in the country and there's not a 'heart hospital' where you just check in and get your stents placed because of your 'cardiac screening' results the day before. There will be a 'concierge' level of healthcare pretty much regardless of how the elections go and what he or she does to Medicare and Medicaid and what the FDA does to streamline drugs into the system and whether third party payors will continue being more and more restrictive on where they'll spend your money. They may try to put everyone on a 'diet' of less fancy stuff, but I bet, given the lobby power of the pharmaceutical companies and big business medicine, they will continue to treat healthcare as an inalienable right whether you need it or not, but they'll try to ratchet down the cost by just paying less for it, and the doctor is supposed to sit still and be happy he still has a job. That's when the quality will go down, even further than it has, and medicine will be a job and not a calling for most people, and docs will just leave at 4:30 because their shift is over and they don't feel any accountability to the patient because they're just a government employee in a white coat. And then, like some who choose to pay for private education for their children even though they still have to pay their 'fair' share of the tax for the public school, people will be willing to pay for a level of care that stands out from the government clinic or hospital and is not as accountable to the government but is instead accountable to the patient. It's a slippery slope, and it's been slipping since the concept of HMO was born. Can you imagine a CMO - car maintenance organization? Where you are told where to take your car for gas and oil changes and who can work on it and how often it can be worked on and you get in line for a transmission overhaul or a new set of spark plugs because there's a waiting list and the mechanics get paid by the number of cars under their contract and not by the number of cars they actually work on? And we ate it up when Hillary made it the topic of her first 'presidency'.
OK, I'm through, sorry for the rambling. 

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