Saturday, September 28, 2013

Heathcare Debacle & Proposed Solutions

For all the violent rhetoric about the "socializing" of the US healthcare system, and the handwringing over the advent of Obamacare (which will probably just add more confusion and waste to the mix, though yours truly--a conservative Republican!--will definitely be signing up for it, because I simply cannot afford the cost of my $5000-deductible insurance, from either the investment or the payout end), I haven't heard any of the idiots here in either party or any branch of the government (which is threatened with shutdown) mention the essential problem with our system: it isn't capitalist.

A truly free-market system competes based on price transparency.  In the American system, neither the primary-care providers (the physicians, nurses, medical techs and so forth) nor the recipients (patients and their families) know what a particular procedure costs, precisely because even when done by the same person at the same facility, the amount varies based on what the billing office thinks can be squeezed from the paying party, and a host of other hidden factors.  The costs are always a surprise (and shock) to the consumer, and not known until weeks or even months after the care is delivered.  There are two-and-a-half healthcare areas in which Americans actually have cost information ahead of time, and can make choices of provider based on that information: eyes, teeth and ears.  For glasses and contacts, you can decide whether to go to a private practice which carries designer frames, or to a chain store offering buy-one-get-one-free options at various price points.  Likewise, it is possible (at least in urban areas) to find out how much a dental cleaning or filling costs before undergoing the procedure.  Auditory treatment (fitting with hearing aids) is a little more mysterious--I think some places let you know how many hundreds or thousands will be required for these tiny plastic devices, and others must wait until negotiation with the given insurance company.  Obviously, these fields of medicine usually involve just routine care, and except for the occasional broken tooth, eye injury or punctured eardrum, the urgent necessity of of treatment does not usually override what can be a economically reasonable cost-benefit comparison.

But even quickly-needed (if not acutely urgent) tests are frequently delayed in our current system--we don't have to wait for "socialized" medicine for this scenario, if my case is any example. Despite being in considerable, ongoing discomfort from the morning my three herniated disks manifested themselves (because two were pressing on my spinal cord!), between the referral I received for an MRI and the moment the local hospital was able to schedule me in was almost two weeks!  And then, my insurance was billed upwards of $6000 (and I was ultimately forced to pay more than $4800 out of pocket) for an hour's worth of scanning...which did not include the technician fee, billed separately). Had I known the cost, and had access to other scanning centers, I would surely have been able to get the MRI more quickly and less expensively--the machines are costly, but at the rate I was billed, in one calendar year the devices earn back their value a minimum of twelve times over.

Unless one is involved in an accident or borne down by a nasty virus--something to which children and the elderly (the latter frequently being the most ignored and neglected members of our society)--glasnost ought to be required in the US health system so that consumers can make informed decisions about what treatments they receive and from whom.  If Congress could legitimately legislate the requirement of caloric, vitamin and mineral content and Recommended Daily Allowances on all food in grocery stores, could not it mandate that procedural costs also be provided to the consumer?

The (unfortunately, frequently fatal) flaw in this method's being applied wholesale should be painfully clear to all of us--that even with this necessary clarification of cost at the outset, there are treatments that cannot be ethically denied or refused because of inability to pay.  When my niece had a blood clot in her brain four years ago, she needed many expensive tests and several surgeries to deal with the issue. Her hospital stay filled three nerve-wracking weeks (the good care she received was a contributing factor in my sister's decision to become a nurse)--she would have died had she not been treated as extensively, as an in-patient (she still had to put up with 6 subsequent months of twice-daily blood-thinner shots, which she bore bravely).  So, there has to be a means by which crisis care is assured, and payment for it is insured, so that medical centers do not make the economically rational decision to cease offering these vital, but costly procedures.  I am not entirely unconvinced that this cannot be dealt with in the main by private insurance companies, but there must needs be a public option for those who are incapable of purchasing private insurance (unless of course the Obamacare compromise of forcing private insurers to offer low-cost comprehensive cooperative plans proves workable, which I frankly doubt).  Incidentally, the only reason that Rita's treatment did not bankrupt her immediate family and impoverish our extended one was that she was, due to her age and developmental disability, on a government plan which subsidized her care. 

I confess that my position on the United States' healthcare system and our government's role in managing it has undergone a radical metamorphosis as I have gotten older and become better informed.  I still do not think that Britain or Canada has all the answers, that they offer ideal models for us to emulate.  I have read of and met with people who pointed out essential flaws in them, who experienced in them less than what your average middle-class American demands in terms of quality care.  Furthermore, I believe that most of us are fairly idiotic, and even with the great deal of information at our fingertips, we continue to make stupid decisions about our consumption of junk food and abuse of recreational chemicals (legal or not) which directly affect our health.  There is only so much hand-holding the AdCouncil can do with its inspirational (and frequently downright condescending) posters and billboards.  And how much should the Feds or the states have to provide in terms of "essential" care before we are even more bankrupt than before?  From a cruel, real-politik perspective, how much less will survival of the fittest cost than subsidizing the sick, particularly those whose behaviors may have contributed to their bad condition?

There are two essential steps that need to be taken, other than the partisan Obamacare-funding brinksmanship: 1) Congress, in its little wisdom, should require financial transparency (I think most Americans would agree that overall, it's not the physicians who are making money hand over fist, it's the insurers and the administrators who are cutting the backroom deals which end up with patients like me getting charged $20,000 for a nine-hour daylight hospital stay with no special care), and bills that are legible even for a layperson like me--they did it with nutrition labels, they can do it here.  2) Conservatives (and liberals of a social-action bent) should start practicing the compassion they preach about caring for the poor in the realm of healthcare.  Contributing money is one important thing--contributing time and attention is another.  Simply watching out for one's neighbor and washing one's hands can cut down on all sorts of nasty accidents and illnesses.  Any solution in this world will be imperfect, but just these two steps--towards free markets and care for fellow men, will go a long way towards addressing the major flaws in our healthcare structure and our frequently apathetic selves.


S Dawg said...

Interesting points. A few thoughts: Even in a setting of price-transparency, very few people know what constitutes quality care. (Or urgency--your scan wasn't urgent and I often have to explain this to my patients at my hospital--I know you hurt, but the person who is probably having a stroke is going into the machine ahead of you. That said, time to scan depends on the resources of the area and whether the radiology practice takes your insurance. Here, you'd have been scanned in a few days, if your insurance was good.) Go to your provider with a URI, most people feel they've gotten good care if they leave with a scrip, but that is actually poorer care than if their provider had educated them about the fact that they do NOT need antibiotics. However, people will choose the pills every time, because they don't know the science. It's actually insurers and federal agencies that put the pressure on providers to insist (often against great patient resistance) that their patients get quality care, by tying reimbursement to quality measures (HgB A1C control, etc) in patient populations. Unfortunately for providers, these do require some level of patient participation. Interestingly, the British healthcare system does a great job of incentivizing quality measures (vaccination, etc) in primary care.

No system is perfect; you just have to choose the sort of care rationing you're comfortable with. In our case, as you have noticed, we ration based on money. If you can afford to have your breast cancer treated, you will. If not, you're going to die. Most people have the idea that you can show up to an ER and you have to be treated, but EMTALA provides only for care if life or limb is AT THAT MOMENT in danger. In other words, if you have a deadly condition that isn't being treated because you can't afford it, you don't qualify for care under our current laws unless you're just about to die. We intervene then, at great cost, usually, but not prior. I see this frequently, and it ends up being both penny- and pound-foolish and usually not beneficial to the patient.

Lenise said...

The only disagreement I have is the implication that insurance companies are raking it in. In NC, there is a governmental agency which monitors profit margins very closely, in addition to collecting the quality measures S Dawg mentions. There is a tremendous amount of private pressure on insurance companies as well, from both sides: to hold costs down and boost reimbursements to providers. There are ever-increasing governmental demands made in the area of data as well as quality measures, health education, not to mention the increasingly comprehensive coverage being required. In response to your point about cost transparency, my former employer developed a cost tool for members to compare area hospitals on a number of procedures. Whether or not anyone really knows about it is an interesting question... Back to profit: the large profit margins are going to pharmaceutical companies. There is some logic behind that, too- pharma companies take HUGE risks with very long-term payout horizons. The high profit margins are what attract private investments, which is where a lot of the R&D funds come from. Healthcare cost comes down to a number of things: new technologies mean that we have all sorts of ways to spend money- more all the time. Providers don't have time to discuss quality of life or any other cost/benefit analysis with their patients: the bottom line is all they can usually manage, and that generally what is considered the most effective treatment, with no regard to cost. You know I am in a similar situation to yours, and I don't expect the market to perform any miracles (which is what is really being demanded here). I have to say S Dawg is absolutely correct that rationing in some form is inevitable. We are talking about the central problem of economics: Finite resources, infinite desires.