Health care reform was attempted by President Clinton and we know how that went. Along comes a new president who believes he has the conviction and the management style to get it done finally. I applaud him for this however there are problems that the current reforms fail to address.
1. Our current system is a monopoly with a drug biased ideology. It is based heavily on Allopathy which is very symptom based. In many areas of the world, there are many types of health care providers who feed the system, both drug and non drug based. In our country, the providers who feed the system (hospitals, specialists, etc are educated and inundated with the philosophy of drug based care supported by pharmaceutical interests. Since there is no true competition (there are provider groups like chiropractors and other complementary providers being used by the public in increasing numbers) to this system, it has become overpriced in many respects and bloated. Many of the preventative regimens are not preventative at all but are invasive and many of these ideas are pushed as part of preventative care. Unfortunately, many of these have not been proven to improve our quality of life long term, while it is of high cost and the social costs as well as the cost of treating the side effects of these interventions has been quite high. Many procedures done to resolve symptoms and many tests done to diagnose them are a result of our lack of understanding of the integrated systems that make up the body. In other words, the body dysfunctions in systems, and we are the sum of our functioning parts which is part of the whole. This differs from what health care has turned into which is overspecialization where doctors look at your parts rather than the hole. In parts of the country with fewer specialists and more primary care, the overall costs are lower and people do better under the healthcare system. Unfortunately, insurance companies have over reimbursed the specailsts and starved the primary care model causing patients to have visits that are more brief even if more time would yield better thought processes, less testing and better doctoring.
2. We need tort reform and we need better medical practices. Malpractice rates for chiropractic have always been very low based on safety and risk, however, many medical providers pay very high rates for their insurance because of lawsuits. Some of these are justified however, without limits and large pain and suffering rewards, it has pushed the rate of insurance upwards. Many doctors practice defensive medicine because they can be sued if they avoided a test or for another technicality. In many instances, it is justified, and in others, it is a product of the fact that physicians are penalized financially if they spend too much time with a patient and rewarded if they order or perform procedures. This is not only risky, but also has contributed to more doctors being sued and as we learned from the first section of the blog, it has been shown that less is more with regards to patient care. More specialists costs more but does not make them healthier which leads to further tests, etc. Some things like childbirth are risky and as long as the doctor did not violate community standards during a childbirth, they should not have to fear reprisals if they did everything right and the delivery did not. Most OB's have very expensive malpractice which has deterred many from delivering babies which sends the wrong message. In closing, we need better medical practices that are rewarded for results, not doing more and doctors should be reimbursed for their time, rather than for performing procedures that add further risk.
3. Medical Ethics. When is technology appropriate and when is it not and at what age do certain interventions have little benefit? This is a tough question because there are many babies that would not make it without an incubator and even with it may have horrible chronic problems during the rest of their lives. Other children with genetic malformations or disease processes who would otherwise not survive and kept alive but their quality of life is horrible until the inevitable end. These excesses are horribly expensive and have little benefit. Are we really helping by keeping a dying child alive further torturing the child, the family and financially draining them. This is an ethics question to be sure.
On the other end of the spectrum, when is enough care enough. At what age do cholesterol lowering drugs serve no benefit. Recently, a study suggested that men over 85 should no longer have PSA tests because many of them are positive, and the therapy or surgery caused more problems than they had before at great cost. At what point do we leave them alone? This is another ethics question.
4. Results orientated reimbursement - Now we have a more is better ethos and about 1/2 of our health care resources for a person gets used up in the last year of life with no change in the outcome. Doctors with better outcomes of all types should be rewarded. Cost effectiveness should be rewarded.
5. Paradigm Shift - We need to move from a disease and sickness model to a wellness model. We need to question the benefits of many tests that justify a drug but do not improve a patients quality of life or have a measurable improvement on ones lifespan. With all the information on cholesterol lowering drugs, the long term estimate is that these meds may improve life spans a year or two while having many side effects. Is this type of intervention worth it?
We need to get back to basics, where primary care handles many conditions cost effectively and allow other providers such as chiropractors, natropaths, napropaths, acupuncturists, nurse practitioners and others be point of first contact providers. In my own profession, we are terrific as first contact for musculoskeletal problems, weather in workers compensation or in general care of the population. Most medical providers are less comfortable with this but are more comfortable with diseases and hospital coordination. Provider Groups must work more hand in hand for better patient experiences.
6. Central data bases for health care records with less duplication and better care coordination. Having all patients medical records will allow for better coordination of care between providers of health care both local and across the country. Currently, many tests are duplicated because a provider cannot go into a national data base and pick out what they need. We are closing in on this slowly.
7. Sanity on in and out of network fees. Medicare actually started the upward spiral of medical costs by issuing a blank check in the 1970's when it was young. doctors sent in bills and Medicare paid it. Many medical/surgical fees are outrageous and are supported by the fact we have insurance. Coding for health care has become a game, manipulated by providers and by insurers which has helped health care costs march onward. Insurance carriers have made changes such as primary care doctors no longer being reimbursed for vsiting their patients in the hospital. Many have hired hospitalists who visit you for a minute, charge you handsomely and report to the doctor. Many doctor would prefer to visit their own patients but not if they do not get paid.
8. Insurance companies have blown managed care and instead of cost savings, they have squeezed consumers into more restrictive plans for their benefit, not the benefit of the patient. This yearly bait and switch has allowed insurance carriers to be very profitable and pay themselves and their investors instead of paying for care. They have become owners of parts of the market and the patients and physicians are merely pawns. We need a public option run by a non insurance entity who can help explore an evidence based paradigm for better care in the future. We also should have this paid for by a VAT (value added tax) so it is properly funded rather than our current recommendations which make us partners with the people who created the problem in the first place. It also makes it so if you lose your job, you still have insurance. Doctors should be paid fairly for their services, and their patients should be charged fairly for what is done in their best interest. This is different from the free for all money care we have now. It is also simpler to have one insurance with one set of rules rather than a medicaid (paid for partially by the states with low reimbursement), medicare (for seniors over 65 mostly, and has better reimbursement for most primary care and point of contact physicians ) and the regular insurance which is all over the place but generally pays poorly in network and way too handsomely out of network. How about one carrier, properly funded that works toward a model of preventative care that helps the puiblic.
These are some of my questions and thoughts. I know the problem is more complex but our paradigm is broken and is making people broke. If it does not get fixed (the current proposals do little to fix the paradigm but does address some of the problems of coverage and affordability), the costs will continue to balloon and we will all find ourselves paying cash for care. This will force the current model into a tailspin and many doctors will likely leave the profession if they cannot earn a living. If the current model does collapse, it could mean true reform of the painful kind. Hopefully, our government can come together after tuning out some of the noise and put together a better system for all of us. Health care dollars should go toward healthcare, not corporations and americans should not be drug addicts without realizing they are. Perhaps, we will find a better way.