Sunday, April 12, 2009
I'm borrowing a line from the Happy Hospitalist because I really appreciated one of his posts today. Go check it out here: http://thehappyhospitalist.blogspot.com/2009/04/land-of-screwed.html. I know not everyone is a huge fan of Dr. Happy, and I don't always agree with him myself (and sometimes when I do agree with him his tone still kind of gets to me), but still, I think the majority of this post is spot on.
We are facing a time in this country (and in some other countries as well) where we are going to face more rationing of care. I say more rationing because we already have some rationing in place. Every time an insurance company, Medicare, or Medicaid chooses not to pay for a claim, that's rationing. Currently, our system of rationing is haphazard and doesn't make much sense. 1) If you have money, you can pay for any test you want. CT scan of the heart to check for coronary artery disease? Sure! That'll be $500 up front. 2) Some insurance plans pay for tests that others don't, and it may have more to do with the negotiations between the insurance company and the hospital than whether the test is necessary or how much it costs. 3) Medicare benefits are not even across the country; recipients in one state may be able to get a test that those in the next state over can't. 4) Medicaid benefits are even more uneven, negotiated by each state. 5) The uninsured receive wildly variable care. If they have cash (the self-employed uninsured) they may receive care. If they go to the county hospital, they may receive care. It varies widely, and they may not be paying anything for it.
I think many people are afraid that "rationed care" is going to apply to them, personally.
Many people with insurance are afraid their care is going to be different, and that they will get less. We expect our MRI's and our expensive back surgeries and our brand name drugs. We expect these things because they're flashy and we're taught they're the best. We resist when we hear they're not the best. PSA testing may not be effective, but by gum I want to know! I think we're basically a nation of hypochondriacs, using our healthcare system to ease our anxieties.
And then some of the medical interventions that really make a long-standing difference--for example, vaccinations, exercise, psychotherapy--get ignored, downplayed, vilified, or are not covered by insurance. We want the quick fix. I was asked by a highly intelligent patient (in seriousness) whether I had a pill that would make him happy. He didn't want the medicine "that didn't make me unhappy but didn't make me happy".
Everyone is afraid of the long lines we hear about in Europe and Canada. Many of the situations I've heard about, though, requiring months of waiting, are for elective procedures. We want our knee replacements NOW. My back hurts NOW. Never mind that herniated disks may or may not be the cause of that pain, it was on my MRI and I want my picture to be prettier NOW.
I don't think there's a single best answer out there; I think all the sides have some truth to them. Patients demand certain things that they shouldn't; doctors prescribe and order willy-nilly because someone else is paying; insurance companies deny legitimate claims to pad their bottom line; government care is fraught with its own perils and problems.
I have to agree with Dr. Happy, though, on one thing: when we removed the payment from the doctor-patient relationship, we added a whole new world of problems. "Insurance" should mean a policy to save for a rainy day. I don't call my car's insurer when I need an oil change or routine maintenance; I don't call my homeowner's company when my house needs to be vacuumed or the lawn mowed; so why do we expect our health insurer to pay for our checkups? We really shouldn't call it "insurance". After all, there's no guarantee you'll get care just because you have insurance. Your claim could be denied for any number of small errors, and then you'll get the whole inflated, padded bill all to yourself.
A healthcare policy for a group of employees, for example, tries to float the costs of the few unhealthy patients on the premiums of the rest of the healthy; the problem is that the healthy think "$10 copay? I have the sniffles, I should go to the doctor." Or they think "My knee hurts; I could take Advil, or I could get the MRI because the insurance is paying for it." The costs go up and up as people utilize more care (and more expensive care).
I guess one of the biggest problems is that so much of the care is unecessary. Back surgeries don't necessarily reduce pain or return you to work. Penicillin for strep may not actually prevent rheumatic fever like we once thought. Cardiac stents don't necessarily work better than taking your aspirin and blood pressure medication, and we don't really have fewer bypass surgeries even though we're doing more stents. PSA testing doesn't save lives; ovarian cancer screening doesn't save lives; and even mammograms are suspect. Giving proton-pump inhibitors in the hospital to prevent rare occurrences of GI bleed may interfere with your Plavix and give you a heart attack. Getting the glucose down to normal in the ICU can kill you. If we truly analyze our diagnostic tests and our medical and surgical treatments according to strict evidence-based criteria, how many would stand up and how many would be no better than "Take two aspirin and call me in the morning"? How much of what we're spending our healthcare billions on is junk?
I also think doctors share a large amount of this blame. If the public expects the MRI, it's probably because a doctor ordered it for their sister, or a doctor went on the local news station to advertise, etc. While I think public expectations need to be better managed, I also think our continuing medical education needs to be revamped. How easy would it be, out in private practice, to pick "fluffy" CME courses paid for by drug companies that come with a free steak, instead of intensive and expensive courses that require real learning? I also think we are not good stewards of the healthcare dollars we help manage. Every time I order a full CBC with differential, I could have saved a significant amount of money. Any time I might think "I'll order this possibly useful test, they have insurance", I need to be swatted.
Doctors and patients are more money-conscious than ever. Both groups are worried about money constantly. But we're not supposed to talk about it with each other. We placed the insurance companies in between us and then were surprised when our discourse became complicated because someone else was taking and making money off our interaction. Seemingly, the insurance companies are the only ones truly benefiting off this interaction, because certainly the doctors and the patients aren't.
Perhaps we could go to some kind of "basic care" model, where our basic checkups and very basic labs are covered by a yearly fee (provided by the healthcare provider themselves), then we have a high deductible policy for true medical emergencies. Patients with long-standing chronic conditions that require the most medications, the most admissions, and the most cost, could be covered by the government; others could be allowed to purchase more care depending on what they think they'd need. Have a kid with asthma? Get a plan with certain types of coverage or a lower deductible. Allow for interstate insurance policies, so that I can shop for insurance in Oregon if they have a better plan than that available to me. Allow for transparency in healthcare interactions: doctors should be able to publish the cost of their office visit on their website (and it should be roughly the same for all comers, whether insured or not; the doctor can then decide to discount if need be) as well as the price of the most commonly used tests. Let patients decide how much elective care they want to pay for, and require emergency coverage (or make it very affordable).
Or do something else entirely, but (in the words of Kenan Thompson from SNL) FIX IT!