Tuesday, December 1, 2009

Sustainable Healthcare

In the early 1990s, while we were traveling back to the family farm in southern Illinois, our middle son got an ear infection. I took him to see the local doctor, an elderly Marcus Welby MD-type who had treated my husband when he was a boy and had treated his father before him. He was kind and unhurried. His office was decorated in a retro-50s motif, complete with hospital green cabinets and vintage medical devices.

It wasn’t until the doctor picked up one of the otoscopes and began looking into my son’s ear that I realized these were not part of a period office decor but were, in fact, what he used on a daily basis. They were probably the same medical devices he had bought when he started his practice.
Long story short, the doctor was quickly able to confirm that my son had an ear infection and then to prescribe a standard dose of penicillin, which his nurse gave us at the front desk when we checked out. The final bill for both the visit and the meds: $20. Not a $20 co-pay. Just $20.

Fast forward ten years. We returned to the same country community in the early 2000s. The old doctor had retired, and there weren’t too many new physicians to take his place. Word was that most of the doctors had fled after a spate of malpractice suits had made the cost of insurance for medical practitioners all but impossible to afford. We spent two months looking for a doctor who would take new patients in Madison County, IL, a place that had earned the dubious title of “judicial hellhole” for the sheer number of lawsuits that had been filed within its borders.

When we did finally find a family doctor, he used the most modern equipment and ran every test necessary to confirm his diagnoses. We paid accordingly. So much for Marcus Welby. Medicine had become progressive and defensive…and expensive.

Virtually everyone agrees that our current healthcare system is not sustainable. The U.S. spends over 15 percent of its GDP on healthcare, far more than other developed countries.
Blue Cross Blue Shield of Texas estimates that the national average emergency room visit costs about $400 while the national average doctor’s visit costs $60. Medications can also be cost prohibitive. One name brand prescription drug cost $71 for a 30-day supply ($22 for the generic equivalent). Others can cost hundreds or even thousands of dollars, making health insurance a necessity not a luxury.

However, good insurance coverage doesn’t come cheap.
American Medical News , an online publication of the American Medical Association, recently estimated the average cost for family coverage to be $13,375, up 5 percent from last year. Even those whose employers pay part of their healthcare premiums are finding they must pay higher deductibles and higher co-pays for doctors’ visits and prescriptions.

To complicate matters even more, insurance companies can deny coverage to individuals with pre-existing conditions , which means that if you are self-employed or get laid off from your company and you have a pre-existing health condition such as diabetes, hypertension, or cancer then you could be forced to pay for your medical costs out of pocket or just go without. COBRA coverage may help, but not everyone is eligible and many of those who are can’t afford the premiums.

So how can we make our healthcare more affordable…and more sustainable? Obviously, there are many possible solutions or combination of solutions. In a system where the end consumer (the patient) is not necessarily the purchaser of the services being performed (insurance companies pay for those services), there is bound to be confusion.
But there are, I think, a few basics that might be helpful:

(1) Reduce waste.

In July 2009, the Healthcare Administrative Simplification Coalition (HASC) came out with a report identifying billions of dollars in healthcare waste and recommending changes to reduce that waste and the costs associated with it. HASC found that executing streamlined procedures such as utilizing standardized, machine-readable health identification cards and implementing standardized prior-authorization processes as well as reducing other unnecessary administrative practices by just 10 percent could save as much as $500 billion over 10 years.

(2) Increase the size of the risk pool.

Currently, residents in each state can only purchase insurance from carriers within their state, who are regulated by that state’s insurance commission. In other words, if I live in California, I can only buy insurance from a California insurance company. This limits the size of the risk pool—that group of individuals who are purchasing health insurance—which in turn drives costs up.

Insurance companies are for profit. It’s not in their best interest to insure someone with heart problems who might end up costing them hundreds of thousands of dollars. However, if the risk pool is large enough, insurance companies can afford to cover everyone because they have enough people paying in to cover their losses on any one individual.

One of the provisions being discussed is that of a public health insurance option, offered by the federal government, which would be open to anyone, living anywhere in the United States. But is there any reason why such plan would have to be run by our government? Why not simply allow consumers to buy from privately run insurance carriers across state lines?

(3) Practice medicine…not defensive medicine.

PricewaterhouseCoopers has estimated that liability concerns in the medical sector increase annual health care spending by $124 million (2006 dollars). American Medical Association President J. James Rohack reportedly told a group of Harvard business school alumni that trial lawyers are one reason health-care costs are up. His assertion was that doctors are more inclined to order tests, even unnecessary tests, for their patients in order to avoid lawsuits. An AP poll conducted this year found that 54 percent of Americans favor making it harder to sue doctors and hospitals for mistakes while taking care of patients.

However, not everyone thinks that tort reform would lower costs. Tom Baker , a professor of law and health sciences at the University of Pennsylvania School of Law and author of “The Medical Malpractice Myth,” reportedly remarked that litigation costs and malpractice insurance only account for an insignificant 1 to 1.5 percent of total medical costs. Baker attributed the trend in defensive medicine less to frivolous lawsuits and more to the human tendency for doctors to “go along with the prevailing standard of care in their region.”

Regardless, the medical malpractice tort costs have risen dramatically over a 30 year period, causing many to hold tort reform as a key component to healthcare reform.

This week, the Senate will begin debate on what is arguably one of the most far-reaching bills in the history of this country: Healthcare reform.

In listening to the various arguments for and against this legislation, I am reminded of a phrase in the Hippocratic Oath : “I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.” In other words, in curing what is wrong with a patient, a physician must avoid both extremes; s/he must avoid drastic measures as well as doing nothing.

If only our Congress could keep that in mind.

There is little doubt that we need some type of reform, but I think we would do well to first do no harm when restructuring a system that has such a universal impact on our day-to-day lives.

In evaluating the sustainability of any organization, it is important to implement those strategies that most reasonably and thoroughly address all three aspects of the triple bottom line—profits, people, and planet. Given this scenario, healthcare reform is one of the most important sustainability issues of our time since it affects virtually every person in our country.

Access to reasonable healthcare may be a right, but that doesn’t mean everyone is going to get every treatment they want or even need. It is simply not possible given the finite nature of our circumstances, both in terms of medical know-how and in terms of society’s ability to pay for increasingly more complex and involved medical procedures.

To be truly sustainable, our healthcare system is going to have to reasonably address the healthcare needs of the majority of people in a fundamental way. Physicians, hospitals, pharmaceutical companies, insurance carriers, and attorneys are going to have to come up with a course of action that is both affordable and sustainable. But, at the end of the day, it is us (the patients) who have to make the final decision…or allow someone else to make it for us.