What I Want From Health Care Reform

I suspect I am one of many who are not unhappy that Congress has finally taken their August recess.  I suspect I am also one of many who are alarmed and upset by the next act in this play, which is the rancor and near-violence we are seeing on our TV sets every day at the various town hall meetings when health care reform is the topic of discussion.


 


This isn’t what health care reform—or whatever you choose to call it—is supposed to be about.  This is a serious matter for our nation and for many of our fellow citizens. It deserves thoughtful and deliberate discussion.


 


The events of the past several days have left me distressed and concerned.  The anger, the accusations, the lack of decorum and the distortions and occasional “untruths” being promoted by all sides have left me dismayed.  It is even beginning to affect relationships among friends and families.


 


All of this has led me to think about what is important to me, and for my family.  What do I really want from health care reform? 


 


1)      I want to know that I can get health insurance.


 


Sound simple?  It really isn’t. 


 


I have been in a medical practice or otherwise employed most of my adult life.  I have always had health insurance for me and my family.  I have had the opportunity to pick my plan, and pay more to my employer and a bit more in co-pays and deductibles so I could get the coverage I wanted. 


 


But I can not let go of the thought that I am one step away from disaster.


 


If I had to go out into the private market today, I would have difficulty getting insurance.  Why?  I have a couple of fairly common medical problems.  I am older.  Members of my family also have some medical problems.  I suspect we would be “rated” and pay through the nose if we had to purchase our own insurance, if I could even get it. 


 


I have “pre-existing conditions” and despite my efforts to take my medications and exercise regularly to keep those chronic conditions under control, there aren’t many companies who would welcome me with open arms.  I am a “high risk”, despite doing what I am supposed to do to avoid a more serious medical problem. 


 


But what if I had cancer?  What if I had heart disease?  What if I had type 2 insulin dependent diabetes?  Do you honestly think I could get insurance anywhere other than through my employer?  And if I was in a small business—such as a medical practice—can you imagine what my illness would do to the premiums of my company?


 


We know that these scenarios are not unusual or unique.  Listen to the stories, read the studies, talk to the people who have faced the problems.  These are real issues, and these are everyday occurrences for honest, hard working people that are right there in your community.  They are your neighbors, they may be your friends, and they may be your family.  They are not fictional, and they have a very real interest in the outcome of this debate.


 


2) I want to be able to afford insurance.  I want the system to be more effective in terms of quality and less expensive (or at least reasonable) in terms of cost.


 


We are out of control when it comes to spending on health care.  That’s it, plain and simple. 


 


People who want insurance and need care can’t get it; some people who have insurance want everything.  Doctors say that they have to do all the tests they do because of “defensive medicine,” yet we don’t talk seriously about tort reform.  And even if we had tort reform, I don’t believe that it will resolve the issue of over-ordering tests and procedures. 


 


Quality of health care is not top of mind for the medical profession in this debate.  We order too many tests and studies too often without evidence that they make much difference.  We can spend thousands of dollars on scans, but can’t afford dollars for vaccinations or “well care.”  We install imaging machines in offices to make more money, because our physician payment system distorts the incentives substantially in favor of doing more tests.


 


We talk about the “savings” that will come from the widespread use of health information technology, yet we don’t have standards that will allow computers to talk to each other.


 


We pay lots of money for doctors and hospitals to do things.  We pay a pittance for those who try to prevent disease, and we pay relatively even less to those who are charged with trying to coordinate the complex medical care of seriously ill patients. 


 


We need to promote preventive medical services, pay adequately for our necessary (and at the very least) basic medical care including primary care, obstetrics/gynecology, and general surgery.  We are losing doctors in these specialties, and it will take decades to replace them.


 


3) I want to know what I am being charged for when I receive a medical service, what my insurance covers, and what I owe in clear, understandable language. I want to know those fees are reasonable for the service provided.


 


We are charged substantial fees for some medical services, and as ordinary people we have no idea whether or not that fee is reasonable or the service is appropriate. 


 


I recently got a bill for the treatment of a member of my family.  Two 1 centimeter superficial lacerations resulted in a $1700 bill, including a remarkable physician charge which was in fact “upcoded” (that means the doctor “coded” for a service that was a higher level code than appropriate for the service that was performed.  I assume it was an “honest” mistake, because if it wasn’t it would be fraudulent).  The skin glue was charged out at about 9 times the purchase cost available to me on the internet.


 


I get hospital bills that simply say “pay us money”.  No itemized bill. No insurance bill or statement, just pay us the money. 


 


Patients go to doctors, who look at you sideways if you ask in advance what their charges are for their services.  Keeping their fees secret has been a long tradition among my colleagues, and in private conversations they tell me they should be able to charge whatever they want to.


 


Some physicians say that we should individually contract or negotiate the costs of our medical care. The man I cared for a couple of weeks ago on an airplane was in no position to negotiate the costs of his care as the emergency medical technicians wheeled him off the plane on his way to the hospital.


 


Hey, folks, here’s a bulletin: there IS no private market in health care, except for cosmetic and concierge services.  Patients are at an incredible disadvantage in understanding the costs of their services. There is no transparency regarding the costs of medical care and services. The prices are jacked up for those who pay because others can’t—or don’t—pay their bills. 


 


My personal experience confirms that you have to go to incredible lengths to get answers to even simple questions, and I am considered an expert in this stuff.  If you are an “ordinary patient,” I can’t even begin to imagine how you would understand the charges and the payments.


 


4) I want to know what treatments and medicines work, what doesn’t work, and if we know whether or not it works.  I want to know that I am getting appropriate, quality care for my medical problem


 


That is NOT rationing.  It is information.  We need more of it.  We are doing too much of what doesn’t work, too little of what does work, and who knows how much of what may or may not work.


 


It may be a surprise to some of you, but there are many thoughtful physicians and top-tier medical professional organizations who have been clamoring for this type of research.  I have said this publicly and will say it here: It is time to understand that just because a doctor recommends something, doesn’t mean it works or is the right treatment for you.  But you (and too frequently even your doctor) don’t know that, because the research hasn’t been done. Think about hormone replacement therapy, and you will understand what I am saying.


 


Here’s another bulletin: In too many circumstances, you have no way of knowing whether or not you are getting quality medical care. 


 


Too often you as a patient have no way of knowing if you are receiving the right recommendations for your health, whether or not there is a less invasive or less expensive treatment option, or whether the treatment has been shown to effectively treat the condition you have.


 


The medical profession should embrace quality, quality improvement, transparency, and accountability to demonstrate they are providing the best medical service.  Unfortunately, this has not been exactly at the forefront of the discussion about health system reform.  If it was, I would venture that patients and those who foot the bills for these services would greet the effort enthusiastically and reward health care professionals appropriately.


 


5) I want confidence that my insurance will be there when I need it for a serious medical illness.


 


We have too many instances—and too many bankruptcies—where “satisfied” people suddenly found themselves not so “satisfied.”  I am willing to bet that you (and me) have no idea whether or not your insurance will be a facilitator or a barrier to your care if you or someone you love becomes seriously ill with a disease like cancer.  You just don’t know. 


 


So don’t stand there and rail against your Congressman or Senator because you are “happy” with your health insurance.  I wonder how many of you have had a serious, prolonged illness in your family.  If your experiences have been positive, terrific.  But don’t discount that many others have not been so fortunate.


  


I am looking for someone who is a “trusted voice” or “honest broker” who can bring this discussion and debate about health care reform back to the center, who can tell us what is in the bills and what is not.  Too many lies, too many untruths and too many distortions have me feeling there is no such voice being heard in the land today.


 


Then there is the question of what we are really talking about anyway.  There isn’t one bill about health care reform; there are several.  And there is one that hasn’t even made it to the public.  (I find myself hoping against hope that those six senators will have the wisdom to get this close to “right” so we can have something that will ignite the passion of those of us who want something done, yet want it done with balance and the participation of both sides of the aisle.)


 


When this discussion started several years ago, the American Cancer Society had four principles that were core to the Society’s efforts surrounding health care reform.  On reflection, those four principles articulated at that time are consistent with what many of us want today: 



  • Adequate—Timely access to the full range of evidence-based health care, including prevention and early detection.
  • Affordable—Costs are based on the person’s ability to pay.
  • Available—Coverage is available regardless of health status or prior claims.
  • Administratively simple—Processes are easy to understand and navigate.

Aren’t those principles what this is all about?  Can’t we focus on those principles and move this process forward?  Is it really that difficult to get this done?


 


We need some sanity in this discussion.  We need to think as individuals, communities and as a nation about what is important to us when it comes to health care reform and our health care in general.


 


I suspect there is a sense in the country that many of us are willing to “pitch in” if everyone pitches in.  This shouldn’t be about us against them.  This shouldn’t be about “I’ve got mine and you can go to h—.”  We are better than that as people and as a nation.


 


It’s time our public discourse and our political/legislative process should reflect the best of what we are as a nation.  We need to get this done.


 


 


 

5 thoughts on “What I Want From Health Care Reform

  1. A significant number of Americans believe that the answer to our health care problems is to rely on the free market. Health care can’t be marketed like bread or TVs. An explanation was eloquently brought out by Princeton economist Paul Krugman.

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    There are two strongly distinctive aspects of health care. One is that you don’t know when or whether you’ll need care, but if you do, the care can be extremely expensive.

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    It must be largely paid for by some kind of insurance. And this in turn means that someone other than the patient ends up making decisions about what to buy. Consumer choice is nonsense when it comes to health care. And you can’t just trust insurance companies either, they’re not in business for their health, or yours.

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    This problem is made worse by the fact that actually paying for your health care is a loss from an insurers’ point of view, they actually refer to it as “medical costs.” This means both that insurers try to deny as many claims as possible, and that they try to avoid covering people who are actually likely to need care.

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    Both of these strategies use a lot of resources, which is why private insurance has much higher administrative costs than single-payer systems.

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    The second thing about health care is that it’s complicated, and you can’t rely on experience or comparison shopping. That’s why doctors are supposed to follow an ethical code, why we expect more from them than from bakers or grocery store owners.

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    You could rely on a health maintenance organization to make the hard choices and do the cost management, and to some extent we do. But HMOs have been highly limited in their ability to achieve cost-effectiveness because people don’t trust them, they’re profit-making institutions, and your treatment is their cost.

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    Between those two factors, health care just doesn’t work as a standard market story.

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    There are a number of successful health-care systems, at least as measured by pretty good care much cheaper than here, and they are quite different from each other. There are, however, no examples of successful health care based on the principles of the free market, for one simple reason: in health care, the free market just doesn’t work. And people who say that the market is the answer are flying in the face of both theory and overwhelming evidence.

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    And what Krugman says about “medical costs” is explained by former Cigna Insurance Company executive Wendell Potter. The industry is driven by two key figures: earnings per share and the medical-loss ratio, or medical-benefit ratio. That is the ratio between what the company actually pays out in claims and what it has left over to cover sales, marketing, underwriting and other administrative expenses and, of course, profits.

  2. Think about that term for a moment: The industry literally has a term for how much money it “loses” paying for health care.

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    The best way to drive down “medical-loss,” is to stop insuring unhealthy people. You won’t, after all, have to spend very much of a healthy person’s dollar on medical care because he or she won’t need much medical care. And the insurance industry accomplishes this through two main policies. One is policy “rescission.” They look carefully to see if a sick policyholder may have omitted a minor illness, a pre-existing condition, when applying for coverage, and then they use that as justification to cancel the policy, even if the enrollee has never missed a premium payment.

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    Rescission is important to the business model. At a recent House Subcommittee on Oversight and Investigation meeting, Rep. Bart Stupak, the committee chairman, asked three insurance industry executives if they would commit to ending rescission except in cases of intentional fraud. “No,” they each said.

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    Potter also emphasized the practice known as “purging.” This is where insurers rid themselves of unprofitable accounts by slapping them with “intentionally unrealistic rate increases.”

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    The issue isn’t that insurance companies are evil. It’s that they need to be profitable. They have a fiduciary responsibility to maximize profit for shareholders. Potter explained, he’s watched an insurer’s stock price fall by more than 20 percent in a single day because the first-quarter medical-loss ratio had increased from 77.9 percent to 79.4 percent.

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    The reason we generally like markets is that the profit incentive spurs useful innovations. But in some markets, that’s not the case. We don’t allow a bustling market in heroin, for instance, because we don’t want a lot of innovation in heroin creation, packaging and advertising. Are we really sure we want a bustling market in how to cleverly revoke the insurance of people who prove to be sickly?

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    Most Americans are aware that what is good for the health care system as a whole often looks very different when it’s their own health at stake or the health of someone in their family. Do we Americans view health care as a communal resource that should benefit everyone or do we view it mainly from the standpoint of “what’s in it for me”? Do they view themselves as citizens working together for a “greater good,” or as patients and consumers of health care, worried about retaining access to all that medicine has to offer? The longer we delay, the higher health care costs rise, while more and more Americans lose their health insurance. In the meantime, you’ll continue to have a corporate bureaucrat between you and your doctor.

  3. Thank you.

    Part of the problem is that a good number of Americans may not believe the system is not working well … and will only learn that it’s badly in need of repair when they get sick, therefore it’s vital that physisians also weigh in on this issue.

    I’d like to add that a health care system that excludes sick people (preexisting conditions), or those who have less income, puts everyone at greater risk of infectious disease as described in a recent NEJM piece:

    “Early detection of a new infectious disease — and potentially the survival of those who are infected — requires that sick people have access to the health care system and receive early treatment. Delays in seeking care can lead to delays in the recognition and control of an epidemic and in the treatment of patients.”

    Further, if we ration care to those who can afford it, we will be less able to deal with medical emergencies of any type, such as from natural or man-induced disasters.

    Finally it is very sad that our representatives cannot work together constructively on reform efforts. Misinformation about reform efforts should be repudiated vigorously by leaders in both parties … and failing to do so diminishes their credibility.

  4. Congress doesn’t even know what’s in it, how can you? The final bill hasn’t even been voted on (it keeps changing)! First there was the ‘Smoking CONTROL act’, NOW mammagrams and in-line is ‘body fat’! Hummmmmmmmm???? BUT I am nearing the age of ‘the back door’ part of this ‘great health bill’! I recently got back into the VA Health Care after being told there was a 18-24 mo. waiting list for the eighth time since serving during the VietNam era. AFTER the Walter Reed incident the waiting time came down to on average 90 days???? Hummmmm NOW I get to see a primary care DR. for 15 min every 6 mos. I was inlisted in medical treatment at VA clinic during 2003. After recently receiving a copy of my medical records from that facility, none of my diagnosis is what I was told affected me back in 2003. I quit smoking July 6, 2009 (cold turkey) after smoking 48 yrs. Reason taxes not by choice. A week later I had my first VA Clinic appointment since 2003. They had me go to VA Hopsital to take a breathing test. A month later and the findings showed a ‘normal breathing capacity’. WOWWWWWWWWWWW ….. maybe someone’s lying about the harm smoking causes! YET I have chronic fatigue daily? YOU who think this OBAMACARE health bill is so good, go visit VA hospitals, see the line, hear the stories from real veterans and patients to government health care! AND while your at it, ask them how a 48 year, 1 1/2-2 pack a day smoker has no lung or breathing problems? Since I cant pay rent the next 4 mos. to get me to the date I can collect my regular SS at age 62, maybe the cig manufacturers would be interested in paying me to do commericals contradicting the governments (false) campaign against smoking???? Guess like alot of VETS, I’ll end up homeless along the road without cigarettes?

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