Monday, November 24, 2008

Let's Start Thinking about Healthcare...

... but let's not make the mistake of starting where we are.

By that I mean, let's not allow our idea of what healthcare should be to be defined with where we are now--either good or bad--as the foundation for where we think we should go.

[Warning: this is not a complete, exhaustive post, but the beginning of several. Pandora, I don't have the time right now to try this in big bites.]

Stop and think for a minute about the distinctive kinds of healthcare that we have to deal with.

As far as the larger society itself, there is public health, used here in the sense to cover general population preventative measures: inoculations against major communicable diseases, assurances about food and drinking water [yes, they actually fall under public health despite the fact that there are separate agencies]; that kind of thing....

In terms of individual healthcare, we can look at multiple categories:

Routine: physicals, well-baby check-ups

Acute: non-emergency medical problems with specific onset, limited duration, and a pretty routinized treatment regime [e.g., skin rashes, minor cuts and burns, colds, etc.]

Chronic: the ongoing regular care for continuing conditions that are, again, reasonably routine in their treatment regimens [e.g., controllable asthma, allergies, mild migraines]

Diagnostic: this is not so much treatment as the procedures necessary to assist a physician in determining what category something fits into.

Emergency/trauma: Extreme, acute injury or illness requiring immediate treatment in a hospital-equivalent setting.

In-patient, routine: The kinds of basic hospital services/operations that are no longer in the realm of specialties: [Appendectomies, hysterectomies]

Catastrophic: This is the cancer, heart failure, big-ticket, long-term, high-specialization area.

Long-term supportive: Major chronic conditions, like, say, kidney failure requiring dialysis.

Obstetrics and Geriatrics: two branches of specialized combinations of care that I am listing separately because they are so common (half the population or more) and blur many of the lines listed above.

This is neither an exhaustive nor a highly technical list. I didn't go find some source to break these down for me; I just wanted a set of categories to attack the problem in a slightly different manner.

I suspect that medical care falls under the Pareto Principle, sometimes called the 80-20 rule or the vital few and the trivial many. Viewed in terms of healthcare, it would have two significant suggestions:

1. That 20% of the patients generate 80% of the expense [this being why insurance companies try to build their risk pools out of healthy people, and to exclude pre-existing conditions].

2. That 20% of the procedures/types of healthcare also generate 80% of the expense, and that 20% consists of the Catastrophic, Long-term Supportive, and Geriatric categories listed above. [Again, which categories you, or any decent researcher selects, are less important than acknowledging the general rule.]

Given that this 80-20 rule application virtually guarantees statistically that 1-5 Americans will fall into the high-cost category at some point in life, this also means that it virtually guarantees that every American family will fall into this category somewhere along the line. [Sometimes, like my family, you get really lucky and get a twofer: my wife with back problems requiring major surgery and my son with Chronic Fatigue].

Moreover, even with health insurance [the really good kind] that can be financially devastating.

These are realities. They are going to happen. So let's talk about policy.

I start with two assumptions, either of which is open for debate, and both of which probably betray my Libertarian leanings.

Assumption number one: making reasonable--even rigorous--efforts to take care of as much of my family's healthcare through our own resources is primarily our responsibility. Which means, in my own case, several things:

1. Both my wife and I have selected careers and employers based as much on the quality of health insurance as any other form of compensation. Both of us arguably make less income than we otherwise could, because we made the choice to find employment where the healthcare benefits were the best. There have been multiple occasions for both of us where we stayed in positions we didn't particularly like, specifically in order to retain the healthcare. Otherwise, my assumption is that we'd have to have been allowing about 20% of our income to go toward healthcare expenses or savings. Observation: most Americans, even if they have the means, have reached the conclusion that they should not have to save or set aside money for healthcare. When it happens, they treat it the same way they treat it when the transmission unexpectedly falls out of their car: they use general savings or pay for it on credit, while saying, "Who'd have thought that could happen?"

2. Which means: most of us here in America who have the means are pretty damn irresponsible about realistic planning for healthcare. I discussed this with my HR benefits person about two years ago, when she was complaining about lack of attendance at a long-term care briefing. They'd brought in an attorney to tell people how, starting at about age 45, you should start shielding your assets against nursing homes, and two consumer advocates to talk about how to shop for long-term geriatric care policies. Out of nearly 400 employees, only three showed up. She told me that she was getting increasingly frustrated in trying to get people information about planning ahead for health-related issues, because nobody ever showed up. I have to ask myself: if making long-term plans about your own healthcare isn't a priority for you as an individual [until you come down with cancer or need a kidney transplant], then why should it be a priority for me as a taxpayer?

[Again: please note that I am excepting people who do not have the means at all from that last observation.

My point is that planning ahead for healthcare related issues--both in terms of treatment and costs--should begin as a personal responsibility.

Assumption Number Two: Health insurance shouldn't pay for everything. Most health insurance--even the really shitty kind--makes it way too easy and way too cheap to go see your Primary Care Physician for just about anything. I can remember, growing up, that my parents used to call the doctor's office when we got sick, and the doctor or his nurse would listen and make a decision about whether or not we should come into the office. At least half the time they told us to do X or Y, and call back in 24-48 hours. Sometimes they called meds into the pharmacy without having to have an office visit. But the combination of medical malpractice, licensing, and low office visit costs have combined to eliminate market pressures that might have created alternatives. What alternatives? Consider just a few:

1. So-called Wal-Mart docs: small offices run by Physician's Assistants or Nurse Practitioners in small offices in shopping centers or storefronts that can see and treat a limited number of minor ailments on a cash and carry basis.

2. Cyber consultation with a medical professional. I'm not talking about googling "find me a doc" or anything like that. I'm talking about two or three doctor's offices joining together and placing one or more of their professionals online 24/7 for cyber consults at a fixed fee. Of course, this would require changes in malpractice and liability laws, but imagine if for ten bucks from the comfort of home or office I could get a quick consult with a doctor/nurse--even get a script called in? Yes, for some people this would not be good, but I can take my kids' vitals and give detailed symptoms--why shouldn't I be able to avoid the travel costs, time off, and germs of the doctor's office?

Unfortunately, both options are, right now, actually illegal in most places in this country.

But they wouldn't be, if patients actually had to pay the real cost of office visits to the doctor.

I happen to agree with Dr. Michael Munger on this issue. I don't have automobile insurance to pay for oil changes or tune-ups. I budget for those things when I purchase the car. If we expected people to actually set aside their own money in advance to plan for routine, predictable medical expenses; and if we changes licensing and malpractice rules to allow for innovation in the treatment of minor acute and chronic conditions, then we can look at health insurance for catastrophic and other big-ticket issues [as well as how to pay for these services for the truly indigent) from a slightly different perspective....


Anonymous said...

Regarding your comment on budgeting for health care maintenance --- you obviously don't live near the poverty line. How do you expect the poor to budget for health care when they have difficulty budgeting for shelter, food, and their children.

Steven H. Newton said...

Read slower, damnit. Did you miss this line (which, in different forms, was in there three times)

[Again: please note that I am excepting people who do not have the means at all from that last observation.]

Give me shit if you want, but at least actually read the goddamn text.

Anonymous said...

Interesting take, Steve. The only concern I have is the number of people who would put off seeing a doctor on a regular basis because it wasn't paid for, thus allowing small illness to turn into big ones.

Okay, okay, I know that that's irresponsible, but people are irresponsible. And if they skipped the wellness visits could that raise the 20% mark? Couldn't this possibly lead to a "sicker" population?

BTW, I'm not dismissing your suggestions. Just trying to flesh them out a bit.

Anonymous said...

I'm following along. This crowd WILL NEVER accept anything less then "everything for everybody". And that is a philosophical reality and adjustment that will need to be made.
80% of your healthcare dollars are spent in the last 30 days of your end of life care. I want to see a "pro-rated" expense option incurred. You undergo chemo beginning at 81--let's get out the acturial charts, and see life expectancy post age 81, and then pony up the difference. A pacemaker at 106? Sure. Is that VISA or a reverse mortgage you are doing? People need to get real. We die and are really dead. Comfort, compassion, and care should and can be an option, with all costs covered. But NO, Americans have to do it all, then get pissed if asked to pay for any of it.

Anonymous said...

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