There are many conversations swirling about regarding health care reform, proposed 'public options,' and tax/penalty methodology to pay for the programs. The more that gets said the less specificity seems to be revealed. Instead I am hearing a lot of lofty and non-specific theory that the system will pay for itself by 'inherent efficiencies' which I have concern may be code for rationing. When pressed for these kinds of details all I am hearing is a full-frontal assault on 'insurance companies' but occasionally there is a jab slipped in at providers who are accused of making decisions based on reimbursement structure and not on clinical necessity.
There is no doubt that a reimbursement system obviously creates incentives and disincentives to how care is delivered - but to accuse providers of driving decisions solely on financial incentive is a little much. The added insult is to trumpet the 'endorsement' of prominent organizations - like the AMA - which informed people know does not actually represent the opinion of all or even most physicians.
All that aside, I think there are two essential reform components that our health care system needs and I don't hear a lot of conversation about them. These two missing components are education and tort reform. Anecdotes help people understand issues - so rather than list statistics that tend to make people's eyes glaze over I want to tell two very recent stories that help to illustrate these needs.
First is the need for education. This morning I had a patient call me and he was concerned about his bill. The bill was extremely straightforward. He injured his hand and required very short term therapy that included splinting and two weeks of guided exercise, control of inflammation, and a home program educating him on how to promote healing and slowly return to his normal tasks. He had five co-pays and his insurance company only reimbursed half the cost of his splint. His insurance company sets the reimbursable allowance of each therapy visit and of the splint. His cost was actually quite modest and completely consistent with the HMO model of 'cost-sharing' where the insurance company pays part of the cost and the patient pays the 'co-pay.' The patient was upset that he incurred costs at all and although he understood the explanation he stated, "Well I just guess that I didn't expect a bill, and I guess my health insurance just sucks."
Of course no one is happy when they receive a bill, and I am sure that everyone would like to have free health care - but this fellow didn't understand how health insurance really works and had no real appreciation for the concepts of 'co-payments' and cost-sharing as a model for insurance. Based on my experience his opinions are not unique: many people think that if they have insurance that they are then 'covered.' Many people can't understand how insurance works. They don't understand co-pays. They don't understand deductibles. They don't understand coverage limitations. People can consume health care more responsibly if they are educated - and this is a sorely needed component.
A second component is tort reform. Medical malpractice liability forces providers into practicing 'defensive medicine;' in other words, it causes providers to order tests and to perform procedures 'in defense of' potential lawsuits JUST IN CASE they miss something in a patient's case. Here is another recent example - this one personal.
My daughter complained of deep hip pain the other day and since she is an active risk taker my first question to her was "Is there any REASON why your hip would hurt - did you fall, or were you running or biking or ANYTHING??" Of course she said there was no reason for it so that raised my alert level a little. In drum corp she recently started hauling around the large bass drum and that was new so I started to think that her symptoms could be related to her new bass drum playing. Now I don't like overusing the medical system and I am very conservative, but this is where too much knowledge can cause difficulties. Although my daughter is not obese by any measure, she has been carrying around a bass drum for many hours and this adds to her functional weight and strain on her lower extremities. Then I started thinking that she is in the middle of adolescence and growth spurts. Being the therapist that I am I started putting two and two together and began thinking that there was a small chance that her sudden unexplained hip pain could be related to a slipped capital femoral epiphysis. I asked her again if there was ANY OTHER REASON for her pain and she said there was not. So, I broke down and decided to let the pediatrician see her.
The pediatrician, who is extraordinarily and appropriately diligent, ordered an x-ray of the hip which was negative. I am sure that several differential diagnoses were circling around in the MDs mind - although I did not ask her thought process. I am sure she was thinking, strain, hairline fracture, SCFE, hernia, and any other number of possibilities. Then the pediatrician asked again, "Is there ANY OTHER REASON why your hip would hurt?" Dutifully, my daughter then recounted a story where she and her friend were practicing yoga and her friend was stretching her leg. Oh, and this all just happened last night.
Of course I wanted to kill my daughter at this point because by now we had gone to the MD, wasted the MD's time, gotten an xray and perhaps killed off or mutated a few eggs in the process - all for the sake of a probable muscle strain caused by silly adolescent girls doing yoga at a slumber party. If I had this information I would have avoided the MD visit and xray - and just watched it a couple days with the anticipation it was a self-limiting and minor muscle strain. But here is where the doctor and I separated.
Although the MD acknowledged that it was all just likely a muscle strain - she also had to suggest that the only way to rule out everything else was with an MRI. That would mean an additional expensive test, a consultation with a radiologist to read the report, and more follow up with the pediatrician. I politely declined - and decided to just watch her at home. Turns out that it was just a muscle strain after all and she is fine now.
The point here is that you can see how engagement in the medical system leads to an upwardly increasing spiral of interventions - all in consideration of not wanting to possibly 'miss' something. If indeed my daughter had a SCFE or a hernia and that MD didn't order the MRI then they would be liable - and this is no small issue - A SCFE could lead to avascular necrosis of the hip and a hernia could lead to a strangulated intestine. No MD in their right mind would want to leave those stones unturned - especially in this litigious society. Tort reform could limit medical liability to reasonable levels and have a suppressing effect on the excessive use of expensive diagnostic tests. This would save uncounted billions in health care costs but is not a strong component in any of the health care reform proposals.
We need consumer education on how insurance plans work and how they can best function and make decisions in our current system. We also need to relieve practitioners of the pressures associated with practicing defensive medicine. These are examples of two important issues that are nowhere to be found in our current conversations about health care reform.