Wednesday, July 04, 2007
Fourth of July. Birth of a nation. Childbirth. Health care. Seems a good day to step into the breech. As it were. Is our health care system salvageable? Does it have a pulse?
Several years ago, the clinic at which I worked signed an exclusive contract with a fairly large HMO; shock waved around the medical community, who felt we were trying to take over the town. A few years later, we threatened to fire the HMO, and that shock waved around the nation.
We'd come to the point at which the latest cut in reimbursement, announced via the usual one-way communique, was simply too much. Receiving the backside rather than the ear of the HMO, we sent letters to all our patients who were members (around twelve thousand, at the time) announcing the plan, along with toll-free numbers through which we'd help set them up in other plans. The HMO caved. It was, I'm told, written up in several health/finance magazines and hit the Wall Street Journal, as I recall. High fives.
For a while. Of course, it ended up only a holding action. We were able, on some occasions, to negotiate less onerous cuts; it's not as if we turned the tide. There is, however, a lesson. Our ability to get insurers to listen turned on two things: we were excellent, and we were big. Patients wanted to see us; lots of them. In that, I think, are some of the seeds of solution for the US health care crisis.
Let me say it up front: I favor some form of a single-payer system.* It's my view that the many problems with such a system can be overcome: it's not single payer per se, as I see it, to which people seem to object. It's some of the accouterments. Before getting to that, I'll state what I think is the obvious: having countless health insurance companies -- many of them for-profit -- sucks gazillions of dollars out of the health care realm, in form of profits to shareholders, salaries of executives, and tens of thousands of workers in cubicles. Both in the bowels of the insurers' buildings, and in hospitals and clinics and medical offices around the country, people input data, make calls, argue for and against payments, follow differing contractual rules within and between companies; in short, money that could be spent on care of the sick is diverted into pockets of those who provide no actual service to those in need of it. They are money handlers, nothing more. Medicare, for all its faults, has by far the lowest overhead of any payer in the country. By real far. The only way to get the most money going to actual health care is to be rid of the multiple middle men. And women. There are many other needs, as well. But to me, that's where it starts.
The biggest problems with Medicare are that it treats providers like shit, has stupid rules, and responds little, if at all, to input from those who know what's going on. It not only doesn't recognize, but actually deincentivizes excellence. No small things; but there's no reason a single payer has to be that way. What I'm saying, basically, is this: let's have a single payer, and let's make it smart and responsive. I think it's not categorically impossible. Faint hope, I realize. But if we take it out of the hands of politicians (after they approve it), eliminating the kind of politics-based governmental incompetence with which we've been regaled of late, there's at least a theoretical possibility of finding a workable approach.
Which brings us back to the preamble of this post: when the HMO relented, it was because we were big, and excellent. I'm aware it's also because they had competition, and that a monolith has none. But there's a point: when providers are able to have a say in the process, the system works. Better, anyway. The most destructive aspect of Medicare, from the point of view of a hard-working physician who has the ethic of excellence above all, there's nothing more demoralizing than being told, year after year, that that hard work doesn't matter; that there's another cut in reimbursement on the way. That the excellence of one is regarded no differently, in terms of payment, from the mediocrity of another. So: it's surpassingly important that this imaginary system has reimbursement guidelines that result from input from the people that do the work. Is there any other professional group about which it can be said that over the past twenty years the trend of reimbursement for service is steadily downward? It's really and truly perverse, and the effect is obvious.
I can hear the keyboards tapping away in fury: you doctors are a bunch of egomaniacal, money-grubbing assholes. Well, sure. Nor do I claim to know what's a fair level of pay for a doctor, compared to other occupations. But I do know that a system which generally lowers that level, and which disallows the ability to set or bargain for one's own pay, and which pays the same for a given widget whether the widget from one maker is a better product than that from another -- that system is headed for self-destruction. And it's already selecting against the sort of people we'd like to see join up.
The solution to the US health care problem, then, begins with this: a single payer system which is responsive to those who provide the care, both in terms of setting fees, and in recognizing those who do excellent work. Competition is a good thing. So is doing a good job. Let's build it in. Impossible? Maybe. Will it be imperfect? Of course. There's a need to recognize the special situation of training institutions. And there's always the doctors who (some with justification, and some not) claim their complications are higher because they get the toughest cases. Being excellent attracts challenges. But there are ways to deal with that. Make it like figure skating: toss out the high and the low scores. Borrow from the gassy world of anesthesia and the splashy world of diving: set up degrees of difficulty.
I'm no economist, so I can't say how much money will be saved by eliminating the profit-taking and the inefficiencies of the myriad insurers. But it's significant.
As hard as it would be to make it work, it's the easy part. Really to get a handle on health care cost requires a hard look at best practices, along with the staring right in the face of prioritizing care. I'll talk about it, like unto spitting into the wind, next...
* Need a definition, here. "Single-payer," to me, means something akin to Medicare, as opposed to the Canadian or British system of government-run hospitals and salaried physicians. I still believe in fee for service, because when you have doctors employed by governments on uncompetitive salaries, you have, as we see in England, to import them. And they become terrorists.