Allow me to clarify the statement above. The legislation currently being hashed out by Congress, and the one discussed in the media and among the general populace is all about coverage reform. Health care reform, if we want to get into specifics, is the process of making changes to how hospitals and doctors treat and manage illness, how to preserve health through those appropriate professions (medical, dental, pharma, etc), and in the WHO's words, “preventive, curative, and palliative interventions, whether directed to individuals or populations.” Insurance certainly has to do with health care, but reforming coverage will not reform health care. The legislation in Congress will attempt to make health care accessible to everyone, but the issue that needs to be addressed is why it costs so much to provide care.
We live in a society where everyone expects the best health care because we have the technological ability to deliver the best health care. But the best is often the most expensive, and somebody has to pay for the cost. Enter the insurance company. Keep in mind that insurance companies, like all successful companies, are in the business of turning a profit. As more services, such as lab work, physical therapy, and surgery, are sought, expected, and provided, the costs of those services need to be covered.
High costs cannot be attributed to health insurance alone. Malpractice insurance is also a cause. There are currently no caps on the rewards from malpractice lawsuits, and so the insurance costs can be tremendous, though it differs from doctor to doctor depending on their practice. The cost of malpractice insurance is incorporated into fees charged by health professionals. Like health insurance companies, malpractice insurance providers need to cover their anticipated claims, plus a profit, by increasing premiums. The cost is passed from the professional to the patient.
So, the question at heart is how to reduce the cost of health care, but maintain the high standard of care. We have to realize that there are fixed costs that we can't do much about. These include equipment and staffing costs. Overall, the costs that we can reduce don't seem to fall much on the “delivery” side of health care. I say “overall” because in many cases there is an excess of supply, as far as hospitals are concerned. Often, in a town of 50,000 you can find two hospitals. Both hospitals are operating at 50 to 60% of their capacity. Generally, a ratio of 1.75 to 2 beds per 1000 people in a given population is optimal. So in a city like Madison, you want somewhere between 350 to 400 beds. There are over 1000, perhaps 1500, if you expand out just a bit beyond Meriter, St. Mary's, and the UW Hospital- and UW is expanding their hospital! This means that there are unnecessary building, equipment, and staffing costs. Of course, the question becomes, “which hospital do you close?”
Now, the advantages of universal coverage have been addressed and debated. Everyone pays in, the premiums go down, etc. etc. (Best-case scenario). So, how do we decrease the cost, if we don't want to close half-filled hospitals? Here's a couple of ideas.
1.Strong focus on preventive care. This isn't just check-ups and immunizations. Ad campaigns that seek to prevent or delay the use of alcohol, tobacco, and other drugs are a form of prevention. So are public smoking bans and worker drug testing. Pest control is prevention. Above all, public health codes should be carefully examined and followed, especially concerning areas like public pools, food preparation, and industrial hygiene inspections. Remember, the three leading causes of preventable death in the U.S. for 2008 were smoking, overweight/obesity, and alcohol consumption. We don't have to outlaw fatty foods, and we shouldn't. We just have to increase the education and awareness of the costs of overindulging in those delicious, delicious treats.
2.Following the doctor's orders. If an outpatient disobeys an order to rest after injury, and ends up requiring physical therapy, the costs go up. If a patient forgoes physical therapy, which would have provided relief, and as a result requires surgery, the costs goes up. This extends to prescriptions as well. I have heard stories where medicine has been prescribed, and the patient stops taking the drugs because the symptoms have subsided. Then the illness comes back worse than before, and drug-resistant, requiring something a little more potent, and a lot more expensive. Basically, your doctor knows medicine better than you. Do what he says.
Of course, there are plenty of other solutions to reducing overall costs out there, and I'd love to hear your ideas.
6 comments:
Paul, your points about preventative care are directly on the mark. There is no better way to reduce healthcare costs than to reduce healthcare demand. The next best way, which I'm sure you agree on, is healthcare IT. The reduction of administrative costs, both in money and time, are essential to improving affordability and will increase quality of care as well.
However, don't be so quick to completely disassociate insurance reform from health care reform. More specifically, the reformation of who can be denied coverage is essential to improving healthcare. The words "preexisting condition" have become a national embarrassment, and it's those who have come face to face with those words who are being left to die. I understand the profit motive, but what's the point of a healthcare system that denies care to those who need it most?
Even beyond that, most of the bills currently on the hill contain a lot of the reforms you and I have mentioned. What neither of us have mentioned, but what President Obama has been pressing for, is increased research into efficient care, with the hope of producing functional care guidelines, which is exactly what you would call "health care reform." Politically speaking, though, it is more publicly palatable to discuss the insurance side of it, thus the messaging tack. Don't get distracted by the pretty spin lights, and don't despair; Health care reform is coming.
I won't go completely wonky right now (here's a little tease, though).
A significant cause of high costs is the physician payment fee structure. It's much easier to reimburse procedures than it is to quantify intangibles like time. And since you can't really pay for time, physicians have less time to spend with the patient, less time to explain why that drug or procedure they're demanding (the one they saw in a TV ad...gah) is not medically indicated, and thus you get overutilization. Which also happens when we practice defensive medicine.
Simply doing more public health ads/educational programs won't boost preventive care as it doesn't target the root of the problem.
I'll get off my soapbox now. I've been wary of doing any health care reform posts of my own as they could be not only lengthy but a little too wonky and technical...
Oh I almost forgot to mention that we spend the most money on care during the last 6 months of life. I'll leave it at that.
Adam--
I'm not denying the importance of health care IT. In fact, it's something that I try to follow closely, since many of my friends work at Epic Systems, and that's what they do. Of course, if I mentioned it, then what would be discussed? I don't disassociate coverage reform from health care reform, but in my mind, they are two different efforts towards two different goals. One is making health care accessible, the other is reducing the cost of health care.
Suchita--
Glad to hear from you as ever. I never meant to say that ad campaigns should be the simple solution. Clearly, other methods must be followed. For example, consider this: On the south side and west side of Chicago, you often have to drive miles to find a restaurant that's not a fast food joint. That likely leads to nutrition and obesity problems. I mean to say that ad campaigns are a comparitively cheap and low impact way to affect behavior, especially from youth. But it's only one of the ways. I eagerly await your wonkish comment.
Paul,
I agree with pretty much everything you said. Two points to add to the discussion...
First off, I agree that medical malpractice payments should probably have a cap but I am always a little wary. There are some very genuine instances where malpractice payments are essential to the patient. Like most civil suits it is fairly easy to figure the solid costs as in, a botched procedure should be reimbursed by the doctor/hospital at fault. It is difficult when we start trying to pay for grief, what if a patient dies or is crippled as a result of the malpractice. How can we possibly begin to quantify suffering? One possibility would be a sort of cap but there may need to be exceptions for egregious instances. Another possibility would be having judges who are medically trained in charge of determining the damages. This may make it easier to draw a distinction between genuine malpractice and honest mistakes.
Second, prevention, this is the key, without it everything falls apart. The United States is not a particularly healthy country... We eat too much and don't exercise for starters. It is not easy for people struggling to get by to purchase healthy food. Exercise is great but when you have been working for 10 hours and come home to laundry, dishes, and who knows what else, exercise seems to be the thing that gets left aside. We can't force people to live healthy lifestyles but we can reward them for it. I would love to see some sort of healthy living incentive program attached to any healthcare reform. Not a tax as you can easily how well that would go over, a "fat tax." Tax breaks for restaurants that sell healthier food, the government subsidizing the purchases of fruits and vegetables, my point is that there are options available. The promotion of healthy living and preventative care are essential!
Healthcare reform is a BIG issue. The political stakes are high for the politicians involved. The implications are massive for the future of our country. As I said over on my blog. I would love to see all of the interested parties involved in coming up with a solution. If the current attempt fails we can only guess as to how long it will be before there is public will to try again...
I'm going to try to keep this post brief because health care professionals are busy people (why do you think you get 15 min max with your doctor? :-) )*
Here's a few more solutions beyond your first two:
3) Place a cap on medical malpractice lawsuits.
As you alluded to this in your main entry, these costs are part of the reason doctors must charge so much, and, for that matter, you don't see doctors in many parts of the country -- simply because they can't afford to work there. Did you know there isn't a single neurosurgeon in Illinois south of Peoria? Honestly, I see no logic of suing for $15 million for "pain and suffering" if a patient isn't satisfied with how her surgery turned out. True, doctors make mistakes, like all people, but lawsuits should only arise in the case of undue negligance, and be reasonable at that.
As an added bonus, passing a medical malpractice cap alone would be enough to get the AMA on board. And you need the AMA to get any healthcare bill some credibility. Unfortunately, I'm a little pessimistic on tort reform here, as 70+% of congress is (surprise!) lawyers. What a shame for everyone.
4) Give physicians and hospitals the Medicare payments they are waiting for.
In principle, I like Medicare. Ask any doctor on staff, however, and they'll tell you how much they hate it. Why? First, Medicare reimburses doctors a fraction (~ 2/3) of what private insurers do. Second, the government (and particularly the Illinois government) has a funny habit of not paying doctors and hospitals at all for Medicare. What's the result? At best, doctors can't afford to see Medicare patients as much. At worst, some hospitals don't take Medicare at all. This is unfair to medicare patients, who increasingly are being pushed into fewer and fewer places where they can get care, and it is unfair to doctors, who often have to work for free. Which brings me to #5...
5) Provide Coverage to the Uninsured.
This is Obama's baby. The logic behind it is that the uninsured, because they can't afford medical care, put it off until it is too late. As a consequence, they are taken to the ER, where doctors are professionally, legally, and most of all -- morally -- bound to help them. Problem is, the hospital doesn't get compensated, and neither does the physician. As a consequence, they must charge more to people who CAN pay simply stay afloat, which is passed on in higher insurance premiums for everybody. As bizarre as it sounds, many Americans (60% to 25%)don't get this point, citing "lowering costs" as a higher priority than "covering the uninsured". How compassionate! In effect, however, expanding coverage will bring costs down. Just look at Canada/France/UK -- they spend less on healthcare then us and they have better outcomes at that. The secret? Everyone can go to the doctor. That's not only economical -- it's ethical.
*By the way, the reason you DO only get 15 min with your doctor highlights on another issue: physician compensation. Doctors in primary care specialties (Family medicine, general internal medicine, pediatrics, etc.) make easily half as much (if not less) than specialists (surgeons, cardiologists, etc). As a consequence, fewer and fewer medical students are going into these specialties (Don't get me started on the role of medical school debt in determining the specialty of choice for some students...). Because there are fewer, poorly paid primary care doctors, they have to see a flurry of patients each day, every day. That's why you get 15 minutes.
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