03/28/2017
Since the early 1990s, Americans have been witness to much debate re the cost of health care in the United States. There have been unfavorable comparisons between the American system, and those of other Western, industrialized nations. We’ve been subjected to a dizzying array of statistics, including cost projections, coverage rates, and the impact of health care outlays on the budgets of state and federal governments. The debate seemed to culminate with passage of the Affordable Care Act (ACA) in 2010. Unfortunately, flaws in the ACA dashed its sponsors’ hopes that the issue was finally settled. Now, in 2017, a new president, and Republican Congress, are scrambling to replace former president Barack Obama’s singular domestic achievement. Debate is back, and with a vengeance. While politicians, pundits, and policy wonks battle it out, however, important questions about what type of care actually reaches patients doesn’t seem to be high on the agenda. Somehow, the debate has revolved around health insurance, as if the actual delivery of care is of only secondary importance.
Expanding eligibility for Medicaid, and the associated Childen’s Health Insurance Program (CHIPs), provided most of the newly insured under the ACA. Still, with limited choice in doctors who accept the program, and low reimbursement rates to providers, what ensures the poor get access to quality care, especially if a patient requires the expertise of a specialist? Will a young asthma sufferer be able to find a pediatric pulmonologist who accepts the program? If a Medicaid patient is released from the hospital after suffering a heart attack, will they be able to access a participating cardiologist, or even a family practice physician, when facing significant travel time, or an extensive wait for an appointment? In spite of coverage, will these patients see the best option for obtaining timely care as a trip to the ER? Will these patients see the expanded program as truly meeting their needs?
For those purchasing insurance on the healthcare.gov website, getting it through their employer, or even buying a plan on the open market, how much actual say do they have in the care they receive? Can they choose any doctor, or is the available pool restricted to a certain medical group or hospital? If they become seriously ill, will they be covered for first-rate care, or will they be settling for something less than the best? Will they have access to the best treatments, or simply be dismissed with the assurance that a cheaper, older medication is good enough? Will anyone even be able to tell them the true cost of their care relative to the premiums they pay? In effect, does the level of care they receive represent good value for the money they’ve invested in an insurance policy?
In the nation’s only true single-payer entity, the Veteran’s Administration health system, scandals involving everything from long waits for care to improperly sterilized equpment, have been reported with sickening regularity. Many VA system hospitals lack stable leadership, and politicians’ promises to correct deficiencies have proven hollow. Many veterans suffering from PTSD, or other mental health issues, face long waits for help in dealing with their service-related disabilities. The Congressional Budget Office estimates that in 2013, the Veteran’s Administration spent $54 billion on care for 9 million veterans. Does anyone have confidence that veterans received good, timely care?
For seniors, will the proposal to move Medicare from fee-for-service, where doctors/hospitals charge for each individual service delivered, to bundled payments, where a single group payment is made to cover all services, really improve care while holding down costs? If you require surgery, will hospitals and outpatient clinics be tempted to choose a relatively inexperienced, less-highly compensated surgeon in order to increase their share of the bundled payment? Will rehab centers employ less skilled therapists? And if reimbursements drop too low, will out-of-pocket costs push some procedures/treatments out of the average patient’s ability to pay? Since Medicare recipients currently only pay about 13 cents in premiums for every dollar of care delivered, does the average enrollee fully appreciate the true cost of their care?
Considering the number of years the health care argument has raged, the issue of the value of care has rarely been addressed. Mostly, the discussion concerns cost. We hear that insurance costs are too high, that drugs cost too much, or that a hospital stay can be the gateway to bankruptcy. Those are, of course, legitimate concerns, but any price is too high if the patient feels shortchanged, or worse, ignored. Massive bureaucracies have been created, ostensibly to ensure appropriate care is provided, and that doctors and hospitals are reimbursed fairly. Unfortunately, the accompanying regulatory environment imposes huge administrative burdens on health care providers, often turning doctors into little more than data entry clerks. Treatment decisions are often contingent upon insurance company guidelines that tie physicians’ hands. Patients become bystanders as decisions are made without their input. They sit in exam rooms, talking to the back of their doctor’s head as he/she fills in screen after screen of the individual’s electronic health record. Eye-to-eye contact becomes a rarity, as do real discussions. There have been some half-hearted reforms, aimed mostly at shifting responsibility for making the bloated system work onto doctors and hospitals. Can anything be done to get the patient back into the game as a participant?
If we can put the power of the health care purse back in the hands of patients, at least whenever possible, the issue of who the system actually serves would be weighted in favor of the patient. Whether the path to empowerment comes in the form of direct care, a willingness of employers to allow their employees greater voice in choosing coverage, allowing participants in government programs to direct at least some of their benefits, or a mix of all options, the patient wins. When patients are in control, the system will finally have to respond to the needs of the person whose life and health is being directly impacted. The real value of care will be determined by the quality of the doctor-patient interaction, not insurance companies’ balance sheets, employers’ HR departments, or politicians. Every attempt at reforming the muddled mess that is today’s American health care system should be geared toward that goal. It’s the only real solution.
Raymond T Kyle
Copyright 2017 Kyle Policy Partners