Saturday, September 05, 2009

Personal Perspectives on Health Care Reform

There are two crises commonly acknowledged in the health care debate. The first is that the cost of providing health care to the growing pool of senior citizens from the baby boom generation (as well as to those who meet low-income guidelines) will spiral out of control in coming years. The U.S. spends more on health care than other countries, with some regions charging far more than others (yet not producing better outcomes). With the cost of premiums far outstripping wage increases and inflation, there is a need for cost containment.

The second crisis is the large and growing number of uninsured people in the U.S.; as premium costs burgeon and unemployment strips workers of benefits, fewer people can afford health coverage. Indeed, the Gallup Poll finds more than 20% of Americans in a number of states are without health insurance entirely. By the time they seek help, uninsured Americans require costly specialty care and hospitalization that could have been prevented by timely visits to primary care providers.

Much of the challenge that the current administration has faced with respect to health care reform can be traced to the tension between these two crises: reining in costs and expanding coverage are not easily compatible goals.

Lost in the din of recent debate is the simple fact that the current system for insured individuals rations care in ways that produce suboptimal health outcomes. It does this by restricting access to (relatively low cost) primary care, while covering (relatively high cost) specialty, subspecialty, and hospital care. Stated in other terms, the system rewards the treatment of illness, rather than the promotion of health.

A personal experience drove that home for me yesterday. I had my annual checkup with my family physician. He spent over 90 minutes with me. He did not have other rooms booked with patients; I was his sole focus for those 90 minutes. We ran an extensive battery of blood and physical tests to detect early heart and lung problems, as well as cancer. He briefed me on the latest research studies that had come out for each of the medications I take. He examined me from head to toe, explaining each of his findings as he proceeded.

During the visit, we detected two blood anomalies that showed up only because of the laboratory he used and its updated reference ranges. Both were contributory to recent fatigue I had noticed, and both were addressed by the end of the visit. One potentially precancerous skin growth was detected and removed. We set goals for fitness measures: body mass, fat, etc.

My physician found that, in his hospital-affiliated practice, he simply did not have time to perform the kind of care that he had learned about and valued in medical school. With some soul searching, he developed a practice where he sees a limited number of families, each of whom pays an annual fee for his coverage.

We can raise our noses at such "concierge care", but the reality is that several of my problems would probably not have been detected in the traditional brief primary care visit. How many early signs of cancer and heart disease go undetected, simply because the insurance system (modestly) reimburses physicians for appointments in units of 15 or 30 minutes? How can you make such a system work as a physician paying off six-figure student loans, unless you run four rooms at the same time, shuttling among the rooms while nursing staff rush through questions and tests?

Is that quality healthcare?

When I was in Syracuse and ran a private practice in psychology, one of my most important practices was to give all clients my home phone number and make myself available 24/7. Why? I knew that psychological crises are also times of opportunity: if I could get to a person soon enough, we could turn the crisis around and avoid an expensive and disruptive psychiatric hospitalization. As a result, it was very, very rare that I ever needed to hospitalize anyone.

Those phone consultations and emergency visits were rarely reimbursed by the insurance system. The system reimbursed weekly therapy, and the system reimbursed psychiatric hospitalization. Insurers rarely compensated me to see someone three times a week or talk to them in the middle of the night by phone to prevent a problem from becoming so severe that it would lead to the loss of a job or hospitalization.

By expanding the number of primary care providers and changing the incentives so that positive health outcomes and preventive healthcare are rewarded, we might make changes that expand care *and* contain costs. Simply making our broken public *and* private systems universal is not the answer to genuine and effective reform.