Saturday, August 29, 2009

How do we do this?

Steve commented on my last post, suggesting that there are two sides of reform needed to fix health care. The users and the payers. He's right.

Insurance has an important place in the picture. We could have a system that each individual pays out of pocket for all their health care needs. This works for the very healthy and the very lucky. I myself was minding my own business one day in January of many years ago, standing at a streetlight, waiting to cross...and a Pontiac hit a patch of ice, popped up the kerb and took me with it. I don't remember the car accident (which was a hit and run). The first thing I remember after the 'minding-my-own-business' part is waking up while being rolled into an MRI.

In 1994, that entire mess had cost upwards of $25,000. Which is cheap by standards I know now. But when I was 25 years old, I was living hand to mouth and that 25K might as well have been $25 million. I was glad of having insurance. I was lucky. Dumb, stupid luck.

Thousands of people are not lucky, and bad things happen to good people all the time. Insurance holds a very useful place in the economy. It's a gambling business....who to whom can we provide a safety net while keeping the most in our coffers? There is absolutely nothing wrong with this. Yay, capitalism.

Logically, though, this leads to abuses. It's expensive to treat human beings who've been unlucky. With cancer, tuberculosis, name it. Obama's discussion does focus on reform on the insurance end of things.

So what DO we do about the other side of the equation?

I am not a doctor, and therefore, do not know boo about medical malpractice. I believe the many docs who say there needs to be reform here. My guys say it all the time. Others can speak to that.

What do we do about the fact that among users of health care, some people abuse the system? Read any nurse blog out there, and you'll find stories of those patients we really don't enjoy taking care of. How do you make Americans responsible, accountable, fair users of the health care system?

What if every American was required to carry health insurance, the way that you must have car insurance to drive a car....irrespective of pre-existing conditions. Obama's plan could conceivably force this in a number of ways.

Would spending less money out of pocket motivate people to improve their health? Might there be incentives in discounts on monthly rates, or in deductibles or in percentage paid for services? Incentives for:

* Having a healthy BMI or weight range or body measurements range?

* For belonging to a health club? For fitness training? For working with a physical and/or occupational therapist for some post-op surgeries?

* For safe driving records (e.g. no DUIs)?

* For proof of appropriate annual checkups that make sense? Annual physicals, or well-baby, or gyne PAPs/breast exams for women over 18, eye exams for those who need it and for people over a certain age (40? 60? I don't know). Mammograms for women, prostate exams for men...etc.

* Among diabetics, incentives for having good quarterly HB1AC values? For going to cooking classes? Among ESRD patients, incentives for going to their dialysis appointments three times a week, having good monthly KT/V and/or albumin numbers.

I don't know. I'm not sure how to encourage Americans to take care of themselves. Saying 'this is good for you' is useless. Saying 'this is less painful and difficult for you' is useless.

I'm thinking out loud, and I don't think any of these are original ideas. How else could we curtail user abuse of the health care system. Quit giving Dilaudid to people not genuinely screaming in the ERs?

I beg my docs to not order 'stat dialysis' after hours for patients who blow their dialysis appointments the same day, come into the ER feeling crappy, but their potassium levels are not yet dangerously high. I ask if they can wait 12 hours until morning. Some of my guys do this, some do not. It's a cost difference of a couple thousand dollars to the hospital/Medicare/the taxpayer. Rarely has this 'stat dialysis' been for a patient who missed an appointment in good faith. It's usually people like Zack (see below). (Zack, by the way, has been back to Hospital B this week.)

What else can we do to prevent abuses by the users of health care?


Sean said...

A couple things:

I think that changing the legal climate of healthcare would make a HUGE difference. If it were harder, and/or less lucrative to sue, it would erase defensive medicine. Less paperwork, and less unnecessary exams would occur.

Giving emergency rooms the ability to refer patients to emergency clinics if they show up for non-emergent issues. Less clogged ERs

Get rid of the sense that healthcare is a customer service business. It's not. Nurses/Doctors are not there to make you happy and serve your every whim. They are there to provide healthcare.

Fortunately, here in Canada, I can say to a patient, "I'm in the healthcare business, not the customer service business. I'm here to make you better....not to wait on you like an overly happy family restaurant waiter who's desperate for a tip and your approval."

Unfortunately, in the US, where healthcare IS a customer service business...this doesn't fly so well.

Anyway....just some thoughts.

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