| I talked to a French Canadian woman, who had managed her brother's pediatric practice both in Canada and in the United States.
She said that a pure socialized medicine model (Canadian Medicare, a social insurance approach) was unworkable. There were simply too many constraints because of inelastic demand for a "free" service and wait times for services vastly lengthened as a result. However, after people were allowed to buy private insurance and "jump the queue," things were much better.
On the other hand, many people were not able to even afford the nominal co-pays for State Child Health Plus ("SCHIP") in the US today and her office often had to waive co-pays. (CAUTION: Co-pays should only be waived after ascertaining that a patient has genuine financial need, especially where the payor is a Federal Health Care Programs.) She felt that a better public payor option for those with real financial need and a system of private insurance were the optimal approaches.
I talked to a woman who was self-employed and who had lacked adequate health insurance for years: she had either lacked insurance or had high-deductible insurance that created a financial hardship if used.
During that period, she developed cancer. However, the American Cancer Society had helped her to apply for Medicaid and she was about to have surgery.
I talked to two Primary Care Physicians ("PCPs"), who felt that the Preferred Provider Organization ("PPO") model had turned Medicine into a volume business, where PCPs were more concerned with generating 6-10 patient encounters per hour at an intensity of at least a Level 3 on the Resource Based Relative Value Scale ("RBRVS"), and with trying to justify billing the encounter at a Level 3 or higher, than with actually treating the patient.
They felt that PCPs (e.g., Internists, Family Practice) were more receptive to reform than Specialists (e.g., Radiologists, Surgeons).
They were also concerned with tort reform, which they thought was essential to securing physician support of reform.
I talked to a former school superintendent and his girlfriend, a commercial artist. They had very interesting insights.
The former school superintendent had been involved in a negotiation with the local teachers' union, some years ago, where continuing with a certain not-for-profit health insurer had been an issue. The teachers' union had been very happy with that insurer's panel of physicians. On the other hand, an Independent Practice Association ("IPA")-based HMO, which had a different physician panel, was offering to provide equivalent coverage for $1.2 million dollars less per annum, which the district strongly supported. Finally, the district allowed the union to negotiate with the insurer and the union was able to get the insurer to agree to the same price the IPA-model HMO had quoted.
His girlfriend, a free-lance commercial artist, was uninsurable as an individual, because of a minor, congenital cardiac problem, a "pre-existing condition." The local Chamber of Commerce (the "Chamber") offered health care plans for the self-employed but that Federal and State laws precluded the from treating people with pre-existing conditions as employee sponsored plans would and kept them from negotiating coverage terms with payors.
The former school superintendent's father had become ill when he was in his early 80s, after having been very healthy all his life. About $300,000 worth of (painful and invasive) tests were performed over a five month period, at which point the attending physician said there was nothing that could be done. His father died a few days later.
The former school superintendent felt that this had happened because doctors do not feel comfortable with situations where nothing can be done, so there is a tendency to perform tests instead of referring someone for hospice care. Additionally, he felt that reimbursement models that rewarded procedures were a perverse incentive toward over-treatment, even when such over-treatment was medically futile.
Reflections
1. Not-for-profit entities (The American Cancer Society and the teachers union in the examples above) already help patients navigate the often rocky shores of the health care system and to allow groups to negotiate for lower costs.
2. Pure single-payor systems are less effective than many believe.
3. The uninsured (the free lance commercial artist, the self-employed woman with cancer) are a civic problem, but the under-insured are an issue as well. The woman with cancer had had some sort of high deductible insurance that discouraged its use. Even the nominal co-pays on SCHIP may be a barrier to people seeking treatment for their children.
4. A great deal can be done on health care reform that does not involve creating new programs. For example, changing onerous reporting requirements under Federal Department of Labor Multiple Employer Welfare Arrangement ("MEWA") rules would allow organizations, like the Chamber, to offer group plans that would allow many people to be insured who are self-employed or who own small businesses, especially where these individuals may have pre-existing conditions.
5. The culture of Medicine has to change, on both the provider and the patient side, to one of prevention and wellness rather than rescue care. This is especially true with end-of-life treatment decisions. This change has to come from the society in general, and not from government mandate. The issue of legitimacy is critical here, but not often discussed. |
