More Thoughts on Healthcare

The current state of healthcare isn’t literally about healthcare at all. It is about the enormous and continuing rise in the cost of healthcare due to the separation of healthcare consumer/patient and the entity that pays for the care, typically an HMO or the government. To give an example of “HMO-driven inflation,” before transferring my care to the Veterans Health Administration (VA), more than one of my providers had a “standard” rate at which they billed HMOs and presumably Medicare, and a second, significantly lower rate that they charged to individuals without health insurance or other third-party payer. I was shocked to find an example even within the VA. Under certain circumstances, such as lack of available bed or inability to provide a service in within a mandated time limit, the VA contracts with private healthcare providers to handle their overflow (at no cost to the veteran – the cost is billed directly to the VA). I had occasion to be treated by a private provider on behalf of the VA, and I came to learn that my care was billed to the VA at a rate that was TWENTY-FIVE PERCENT above the standard rate that was billed to HMOs or other payers. As shocking as that is, I suspect it’s more of an example of the government ironically being price-gouged because its needs are frequently immutable, rather than being a major contributor to “HMO inflation.”

The problem and its causes are no great mysteries. More important are solutions that avoid a massive new Federal government entitlement (when some major current programs are of questionable sustainability) and pricing healthcare out of reach of more Americans, straining non-profit hospitals by further turning the ER into a primary care clinic. I don’t advocate the abolition of HMOs, but I do propose doing away with absurdities like the “sky’s the limit” surgery in exchange for a $20 copay. ¬†We need to look at reviving features of “traditional” 80/20 insurance (which has never gone away for small businesses or the self-employed), such as DEDUCTIBLES and a reasonable, realistic (for patient and provider) percentage match. Nothing onerous that would prevent a person from obtaining needed care, an amount sufficient, if only symbolically, to restore the patient/consumer’s awareness that increased consumption of medical resources costs proportionately more, a basic lesson of economics that seems to function normally until someone with a lab coat and stethoscope enters the picture.

Published in: on 2009 08 16 at 01:25:12  Leave a Comment  
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Some Thoughts on Healthcare

As a brief preface, this post was precipitated by the current disagreement within the United States about President Obama’s healthcare proposal. As with any writing on a political “current events” subject, it is doomed to eventual irrelevance. I must confess at the outset that I have not read President Obama’s proposed bill, in part for reasons based on MY source of healthcare.

I am a disabled Navy veteran. For two years now, I have received all of my medical care from the Veterans Administration (VA) at a VA Medical Center in a major city. I interact with my healthcare providers far more than the average person (merely intuitive assumption) and have for over a decade, and I feel as though my more frequent interactions with a broad spectrum of providers gives me a bit more insight than the average bear on at least a comparison between HMO care and VA care. There are a few things that are the same: one will not always agree with one’s doctor, specialist appointments take longer to get than primary care appointments, and PCPs are the gatekeepers for specialists. There are also some differences: though both can change doctors, the VA has a smaller pool than an HMO in all but the most rural areas, specialist appointments are generally much faster in the VA, all of my VA providers, as well as the pharmacy, work from and contribute back to a master electronic medical record, which contains documents as well as all labs and diagnostic imagery I have ever had, the VA is quicker to adopt evidence-based procedures and standards of care, and if I am dissatisfied with a situation and cannot resolve it with my doctor or his/her clinical supervisor, I can go beyond them to a patient advocate who can navigate the bureaucracy much better than an outsider such as a patient.

In general, I am more satisfied with VA care, though I miss several of my former providers personally. I have heard it suggested that a solution for Medicare might be to give Medicare patients access to VA facilities. I don’t support that particular idea, though some of my reasons are purely personal, such as the sense of cameraderie with other patients, and some VA staff, as fellow veterans.

I think that requiring those hospitals that are significantly subsidized by federal funds be brought to VA standards would vastly improve the care experience, and outcomes, for patients who, perhaps due to “falling through the cracks” between heath insurance and Medicare eligibility, use the county hospital-of-last-resort as their primary source of care. Mandating that hospitals use VA-style electronic medical record and prescription system would improve care/outcomes and reduce errors.

Having said all that, I DO NOT support required government healthcare (or being able to decline it only at your disadvantage or peril). My VA care is a benefit of a specific contract between me and the federal government, basically “Workers’ Compensation” for the Armed Forces. It is a valuable benefit to me, but I am still free to seek care anywhere, from anyone. If the government required me to surrender that liberty in order to avail myself of VA care, the VA wouldn’t know I exist.

If one wants to improve healthcare, don’t start by thinking about what liberties you must take away from the American people. I do not believe, however, that the free market will fix this as long as the current HMO system exists, where people pay their premium, then feel entitled to consume all the medical resources they want for a $20 copay. The economics of paying, say, a $40 copay for a medication that costs $900 just don’t work. There is no free lunch. So the choices appear to be status quo, government regulation, or quite a bit of temporary pain if we want the free market to shift the system of medical payment to something closer to reality. Even the status quo is, I think, merely delaying deciding between the other two.

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