The Summer of Healthcare

Most of you know that healthcare and the cost of healthcare are very near and dear to my heart. It's something we as a nation will be discussing this summer as the President has laid down the law saying that if we are to get health care reform done, it needs to be done this year. After that, the pressure to change may lessen, slightly. The cost of healthcare is a lion clinging to the hindquarters of the cape buffalo of the bull-market economy. It may not necessarily be the lion that ends up bitting the neck, suffocating the beast, but it is the one that makes it possible for a weaker, slower lion to do the job. Sure, we might shake off this first "Troubled-Asset" lion that's been squeezing our economic windpipe, but unless we get that other lion off our ass, something else is going to kill us off, like the "Energy Cost" or the "Trade Deficit" lion.

Here's a New Yorker article on "The Cost Conundrum" (groked from Jay Lake's link salad). The money shot?

"Providing health care is like building a house... Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected... Getting the country’s best electrician on the job... isn’t going to solve this problem. Nor will changing the person who writes him the check."

As you read the article, pay close attention to the "for profit" and "not-for-profit" tags. Also, near the end there's a conversation with Dr. Dyke about changing the payor of health care that you should read. It may seem that what he's advocating is an HMO, but it really isn't. What he's advocating is a business practice and professional organization. That's a fancy way of saying "Professional Union," but that last word gives many people too high a squick response to work well. In Ohio, as we limited healthcare malpractice awards in an attempt to lower the increases in malpractice insurance (because "allz our doctors is gonna leave us", which didn't work because that wasn't really the cause of high insurance rates, and the doctors haven't increased their retirement rates), we also discussed opening up a database that patients could search to see if their doctors had malpractice claims or professional black marks on their records. That part of the bill died pretty quick.

For our village, as well as many of the local businesses, we've been discussing healthcare programs. The most prominent idea that's being pushed is the healthcare savings program. This is where you set up a savings plan, have automatic payroll deductions to match up to a specific plan deductible (a very high deductible, normally on the order of $5000 and above). The individual is then responsible to spend the money out of the savings plan wisely. The actual insurance part of the plan is essentially a catastrophic plan (something that used to be the norm before we did the surveys that preventative care was more cost effective).

I can't tell you how much I hate these plans. Not so much for the patient (except that it's a way to shift more costs onto the individual from the company benefit side), but for what it will need do to the rest of the industry. I'll say this here, if you want the consumer to make decisions based on cost for health care, the providers will need to provide price sheets for common procedures and provide estimates for the rest. The system based on consumer choice cannot work any other way. And yes, I'm talking about a McDonalds' menu board style price list out front, before I see the doctor and start incurring costs.

Right now all the arguments I keep hearing are about how to control costs and who pays for what and to whom. As the article explains, no matter what we do on that side of the argument will have any real impact. What will have an impact is taking the profit incentive out of healthcare. I'll probably write a whole other post on why that's going to face a tough battle, but it's been done. Germany, Sweden, and Switzerland all have private health insurance, private doctor systems, and controllable costs systems (that all sides feel are too tough), and they've done it by removing profit from the game plan. Insurance companies are by law non-profts. They must insure any applicant, doctors must accept the insurance, and everybody (as much as possible) needs to be insured. These countries also have structures that remove much of the profit incentive (or outside plausible reasoning for high costs, like providing free medical schooling). Our system costs more per patient, and provides less care (by outcomes such as infection rates, hospital stay lengths, mortality and morbidity rates).

When I was in the ER on Monday, they started to wheel me out to do a CT scan. At the time, the logic part of my brain was saying, "Wait, shouldn't we test the urine first to see if there's blood before we use the machine that goes 'Bing!'?" But at that moment I wasn't in a position to argue, and I doubt that my wife wasn't going to stop treatment for something that she knew was exceedingly painful to me. Now, in the end, they would probably have done the scan anyway to see how large the stone was, and if there were any others waiting in the wings (4mm, and no, it was a single). But if I had a health savings plan, I might have argued. Because I'm a cheap bastard. I might have also said, "I'll only take the second shot of morphine if you discount it, because I shouldn't need a second dose only 25 minutes after the first one" (they believe the stone moved to a more painful spot, which made me glad for the first dose because it got just as painful again).

The time to worry about costs is not when you're in the middle of treatment. Unless you think blackmail is an acceptable business model. As a consumer, I'm buying the insurance. Part of that payment, part of the insurer's job, is to control costs. Or, as I've told my fire chief when we moved from all volunteer force to a token hourly payment for our firefighters, "I don't want to get to the point that you're telling fire fighters who've responded not to get on the truck because we're worried about costs."

And I'm going to give a shout out to Hot Chick Janiece, who sometimes comments here, to write her own post on healthcare giving us the knowledge she accumulated doing the report for her class (at least I think it was on healthcare).