Sunday, July 19, 2009

Why We Need Government Involvement In Healthcare Reform

Another blog post that actually started as a reply to an e-mail. I do not want to print the initial e-mail, as it was not intended for general release and I'm going to refer to the writer as Dr. X. This e-mail was sent to a mailing list with other physicians, which explains what might seem as cryptic references to a mailing list.


I am by no means a health policy expert, but I have some concerns about Dr. X's position that patients would be better off with a high-deductible catastrophic-illness insurance policy coupled with an HSA. I think this model of providing health care threatens to leave far too many patients without adequate coverage.

I have spend my career to date (not the longest career on this mailing list, but still...) working in underserved and marginalized communities. I have seen patients defer or delay care b/c they could not afford their insurance co-pays. This includes the 20% co-pays required by some private insurance plans as well as the $40 required by a university health system's patient assistance program. How would patients in these positions realistically be able to save enough to fund their HSAs to cover the potentially thousands of dollars required by a high-deductible plan? Is there proof that a drop in medical resource utilization when patients switch to an HSA is b/c patients are being more careful w/ their care (as Dr. X contends in her e-mail)? Or are people deferring needed care b/c they cannot pay the costs?

I also question whether the increased use of medical resources when patients are enrolled in public plans is simply a matter of "if you pay for it, we will do it". I suspect that in many cases, patients have put off important care because they were uninsured (or underinsured), only to try and catch up once they can afford to thanks to some sort of coverage. How many of us have had patients ask us to try and work with them in terms of their care and try to delay optional things until they have Medicare? And then we have to decide whether our recommendations are urgent and must be addressed despite the financial burden--or maybe we can wait a little while. How many of us have had patients show up after qualifying for Medicare or some other insurance and be faced with the challenge of not only controlling out-of-control chronic illnesses but also struggle to catch up with long-neglected health maintenance?

I am not proposing that there be a government committee of some sort to dictate care and I, personally, do not feel that the programs to show relative benefits of treatment would be used to promote valuable care and not to deny care. I may be optimistic on this, but remember that many of our current meds were approved based on their benefit vs. placebo (and not vs. other active therapies) and that many of our specialty-endorsed evidence-based practice guidelines are not always followed.

I suppose that I just feel that there can be a role for the government in controlling costs. If a public health insurance plan is included in the legislation and is unsuccessful, then the private plans will prove their superiority. Considering, though, that the administrative overhead for the for-profit insurance plans can be 6-8x that of the current public plans I think the private plans will have some work to do. We also have to address the fact that the public plans disproportionately insure those patients who will have the highest utilization (such as the elderly and the disabled) while private plans do not carry this burden. This means that, currently, private plans tend to have a favorable patient mix with more relatively healthy people than the public plans. If public plans were able to enroll these healthier, lower-utilization patients, I would suggest that premiums and costs could be lowered. Using the larger purchasing power of such plans, some costs (such as medications) could be lowered drastically.

Finally, we do need to keep an eye on ourselves. I DO NOT think that doctors are the problem, and I do not want to be accused or thought of as saying that this whole messed-up system is our fault. But we can do better. In a recent New Yorker article, Atul Gawande shows how physician practice styles can impact care ( Granted--much of this is the result of the inefficient health care system we currently are discussing. But, if we cannot honestly review and address issues of our practices that will inflate costs, then any reform of ANY kind is facing a steep uphill climb from the beginning.

Finally, we need to continue to work on reform that will address the primary care workforce shortfall. Someone once compared universal health insurance (with guaranteed access for all) without increasing the primary care workforce to giving everyone in town free bus tickets--but only having one bus. The issues of medical student debt, reimbursement for primary care physicians, and changing the model of primary care to allow for the complicated care-coordination and health-promotion roles played by primary care physicians need to be addressed in any health care reform.


Thanks for reading. Let me know what thoughts or comments you might have.

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