The Problem with Being Told what to do
In 1961 local hospitals and community based doctors were saving lives, taking care of patients with heart attacks and appendicitis, casting fractures and sewing lacerations and doing it all for about 1/100th of what it costs today, not perfectly but not so bad.
In 1981, fresh out of residency, I was able to make a living and start paying down my loans charging $10-$20/visit to tell you whether or not your child had an ear infection or pneumonia or leukemia. These visits now cost $200 and up which is almost entirely because I have to work through for profit third party insurance. If you come into my office and I don’t do much, I have to charge you the same $200 I would have had to charge someone with BCBS, because of a contact I had to sign to be able to stay in business.
The stories currently being pushed are that medical care costs so much because of all the scientific and technical advances we’ve made, or because of the fee for service model, which encourages quantity of care rather than quality of care, or because the profession hasn’t fully adopted electronic medical records, or because patients are too fat and the baby boomers are getting old and patients are demanding too much. The truth is that medical care, the patients, the providers, Medicare, Medicaid, the VA and the economy as a whole are all dying the death of Ten Thousand Cuts, nine thousand nine hundred and ninety nine of which have come in the form of someone somewhere telling me or local hospitals or other providers how to do a job we were doing perfectly well. Healthcare providers are rarely in it for the money. Anyone who goes into pediatrics for the money probably isn’t smart enough to do the job.
The usual justification for HMO’s, Managed Care, DRG, LOS regulations, Copayments, Deductibles, HSA’s, QI initiatives, PFP’s, Patient Safety initiatives, Medical Home initiatives, and now ACO’s, is that they will save money. They never have and they never will because:
1. These programs cost money, usually many millions to develop and implement.
2. When they save money, which they often do, the money saved comes from money the insurers would have otherwise had to pay to providers. These savings never have been and never will be passed onto consumers in the form of decreased premiums because that’s not what for-profit corporations do. It’s their money and they are not going to give it back without a reasonable expectation of a ~10% return.
3. Hospitals and other providers have for sometime now been operating pretty close to the bone in a financial environment created by and run by insurers. If they are forced to decrease the LOS for healthy newborns or utilization of CT scans and that effectively decreases revenues, they will have to do something to increase revenues or be that much closer to going out of business. When a hospital or other care provider goes out of business, it works out well for the payer. No care, no pay.
4. Having the cost of medical care rise 16000% over the past 50 years has worked out very well for the insurance industry because we now need insurance to protect us from the cost of what we used to be able to pay for out of pocket. Health care costs are now the leading cause of bankruptcy. The allowable administration and overhead costs an insurer is allowed under the pathetic few regulatory guidelines are calculated as a percentage of total costs.
5. For the past 50 years and for the next 50 years, the only way to make money in health care insurance is over insure people who don’t need care and to under insure those who do need care. Putting lots of lipstick and mascara on this simple truth costs millions and millions of dollars and will ultimately bankrupt our economy and destroy medical care. HMO’s, Managed Care, Copayments, high deductibles, and QI initiatives, when they work do so by roping in as much money as they can from young healthy people who will cost nothing or close to because they don’t need care and by denying or making care unavailable to those who do need it. Whether or not a child and their parents are malingering or really need a wheelchair, it’s in the insurers best interest to make paying for it as complicated as possible and to make sure this child is insured by someone else next year.
The problem is not going to be fixed by the government or insurers or the JOHA, or the Academy of Zippy d’ DoDah dictating the content of care to me or Newton Wellesley Hospital or any other provider who isn’t feeling the need for their advice. Whether or not I ask about guns in the home or smoke detectors or sexual orientation should be up to me. My patients and I were doing fine before all these other players got into the act. We didn’t have trouble thinking up things to do or talk about. I wasn’t missing or mishandling behavioral issues.
The problem with adding a lot more boilerplate to any given clinical encounter is that by the time I see them they’ve had to verify insurance, check balances, pay copayments, check deductibles, sign HIPAA releases, financial policy information sheets and do behavioral health inventories and people have sometimes forgotten what it was they wanted to ask me about and if I hit them with a bunch of questions that are at best irrelevant to their situation and sometimes intrusive or insulting, (like they don’t know about seat belts and car seats and brushing their teeth), they might reasonably decide they don’t want to talk to me after all.
The ostensible reason I’m given so much guidance about the content of care is that there are very real problems with gun safety and domestic violence but what all this guidance and hospital regulations really do is increase the cost of care that the well don’t need and the unwell do. Any hospital or practice that is taking care mostly of well, well-insured patients will negotiate any series of hoops better than one burdened by taking care of people who are sick and not so well insured. Failure to score as well on Patient Safety or Medical Home initiatives then justifies putting a hospital or provider in a higher Tier with higher copayments forcing them either out of business or to find ways to make a living that doesn’t cost insurers any of the $16K per family they’ve come to depend on.
It’s not obesity, it’s not greedy unethical providers, it’s not illegal immigrants. It’s us and our pathetic attempts to get a few bucks ahead by paying insurers too well to shift costs and protect us from ourselves. I have very little hope we’re smart enough to find a way out of the trap we’ve made for ourselves especially if we have as a precondition to any change that the Insurance and the Pharmaceutical industries not take a hit. But what if we had a way to evaluate the net effects of the many programs and features we adopted in part or whole because they were supposed to control costs. What if copayments and managed care and HMO’s could be shown to have increased costs and decreased access to care? Maybe a plan to undo some of what we did in the past would be a reasonable way to decrease overall costs for everyone.
There should be a firewall between payers and the content of care. We can’t afford for there not to be.
We are about to spend millions on ACO’s which will fail to contain overall costs for exactly the same reasons Managed Care and HMO’s failed. They assume there’s money to be saved by having payers dictate the content of care but there isn’t unless you allow some combination of a terrific hit born by patients and providers and an increase in the overall cost of medical care because there’s one thing for sure which is that insurers can’t and won’t get by with less than 10% more than whatever it was they made last year.