Monday, October 13, 2008

A Radical Idea

I'm working on a post about the health care policies of both candidates, and a thought occurred to me. It all started while watching the second presidential debate the other night. I realized that both men were focused on access to health insurance, but neither fully realized that health insurance is not health care. Obama came near this point when referring to his mother fighting her health insurance company for a "pre-existing condition" in acknowledging that just having health insurance is only part of the battle, but did not encourage access to doctors, just to health insurance.

My thought was, why do we have health insurance?

I own a dog and a cat. I take them to a veterinary chain, where for $25-$50 per month per animal I pay for 2 full checkups per year, including blood work; annual dental work (and biannual for the kitty); required vaccines; and I get a free office visit + 10% discount on any further treatment they need. I can pay for a cheaper plan and get a little less, or a more expensive plan for a little more. I upgraded the dog a few years ago when he started needing dental cleanings, because it was cheaper and easier to pay for it over the course of a year than all up front.

Why don't we have similar plans? Why do we need large insurance companies to be our middle man? It seems like (to be overgeneralized) the insurance companies (and the drug companies, but that's a different story) are the only ones making lots of money here; they squeeze hospitals dry, they squeeze doctors dry, and they cut out coverage for patients with "pre-existing conditions" or for taking Drug X instead of Drug Y to dictate healthcare for their patients. Until insurance companies are run and staffed by doctors and other healthcare professionals, WHY do we let them dictate our care? Why do we have to argue on the phone with a glorified secretary* (who probably makes more $$ than this intern) about why we, the MD, ordered the MRI?

So why do we need health insurance? Or rather, why do we think health insurance has to pay for everything? Why don't we remember that "insurance" is something for a rainy day which we hope not to have to use, but we have it around just like the fire extinguisher under the sink? Since when have we become too cheap to take responsibility for our own bodies and our own health?

I realize that health care is expensive, and even visits to doctor's offices can be out of reach for some patients, but consider how much cheaper the system could be if we largely cut out the insurance companies. Doctors' office staffs could be smaller because they wouldn't spend all day on hold with Blue Cross Aetna UHC arguing over a $10 copay and begging them to cover a visit.

If we got rid of "managed care" entirely, and went to a system of high deductible "rainy day" policies for those people who were healthy, and got rid of the middle men so patients could negotiate care with their own doctor, health care prices would fall as competition evened out the playing field. Patients with chronic health problems or who needed more care would have to pay more under such a system (they do now, too), but even they could still negotiate with a doctor and then purchase insurance to help cover costs they couldn't afford.

Insurance companies get their $$ another way, too, by selling malpractice insurance to physicians, which may cost up to $250,000/year for some specialties. Putting caps on malpractice settlements may help, but does not solve the problem. Perhaps a solution other countries have tried may work: make the plaintiff pay for something if they lose. Or make the plaintiff pay a small court fee (a few hundred to a few thousand or so) in advance, to be refunded if they win. Or make the plaintiff's attorneys (another group making $$$ out of the healthcare pot) pay fines if they sue frivolously, or cover the defense's court costs for fighting the battle. Right now, plaintiffs and plaintiff's attorneys have nothing to lose by filing in court, where doctors have everything to lose just by getting named on the lawsuit. Oh, but what about the poor plaintiffs who can't afford to pay the court costs? Where does it say in our Bill of Rights that we are born with the right to sue?**

Obviously, this scenario leaves out a big player in this business: CMS. The rules would have to change dramatically for CMS, too, because they essentially dictate the amount physicians will be reimbursed for services, and then most insurance companies adjust their reimbursement rates based on Medicare's. I'm fresh out of ideas at the moment as to how to fix Medicare, but my main point is this: there are a lot of fingers in the healthcare pot. A lot of non-physicians are controlling healthcare dollars on behalf of patients, doctors, and hospitals, and currently very few players are winning. The ones who are winning are not the health care providers, the hospitals (at least, the non-profit ones), or the patients. So why are we letting all the wrong people benefit from our trillion dollar healthcare budget?

*I have nothing against secretaries. I am totally inept when it comes to those huge phones with the transfers and hold and multiple lines, gah!
**Lawsuits can occasionally be necessary or justified, including those against physicians and hospitals. I'm not opposed to all lawsuits, I'm opposed to irresponsible suing.
***Written when I was trying to go to sleep but couldn't. Sorry if it rambles or makes no sense.


The MSILF said...

A lot have made a similar point. How did a totally unnecessary body end up wedged into a transaction between two other parties, and now become "indispensable?"

Tiny Shrink said...

Exactly. At my clinic today, I had this exact same conversation with an attending and a former ER nurse, who had (already reached) the same conclusions. Perhaps health care is so expensive partly *because* health insurance companies say "health care is expensive, you need our product". They create the need for their product.

Dragonfly said...

Makes me glad to live in Australia. And still glad that I have private health insurance (thank you parents, for me being included until I graduate or turn 25, whichever comes first) because elective surgery waitlists are looong.
Long live America though....nothing against you guys :-) (Except Starbucks...their coffee is rubbish).

Anonymous said...

I grow weary of politicians telling the public that they need insurance and the public believing it. People need health care, not health insurance. Health insurance is simply not cost effective at all. At one time it was for catastrophic loss and hospitalization. It worked. Then unions convinced people that their employers were going to somehow magically provide for everything......and the cost of insurance has been out of control ever since. Yes, we must do away with health insurance. How do we deal with the cost of care then? Good question. I don't know. It certainly is expensive though. It costs a great deal in human time, resources, and we shouldn't be adding the huge cost of insurance to that total.

Barbie said...

I hate hearing insurance companies saying they provide choice. No, you provide a complicated beaurocracy that people get too confused over until they 'choose' an needlessly expensive plan that covers too little. When people say they want choice in there health care, they mean they want to see the doctor they want to see and get the procedures they need.

Anonymous said...

Okay, great anonymous 645. If we do away with insurance completely, how do I pay a $65,000 bill to remove DH's kidney stones? At that rate, we couldn't even afford one illness per lifetime, each. What if one of us gets cancer, and the bill runs over $1,000,000? How many people do you know who could afford that?