Health Care Reform Is a Political Shell Game


When the focus is on medical loss ratios and cost shifting instead of on access to patient-centered care, doctors and patients lose.

In last week's post, I decried the current insurance paradigm, noting that its greatest failure is that it really doesn't care about the patient and certainly does not care about the equitable right of individuals to health. As an advocate, I have reached the point where I consider “It's the Patient, Stupid!” as my new motto.

Indeed, none of this reform stuff is really focused on the needs of patients at all; rather, it's all about the business of medicine. While I'd like us to be focusing on equity in access and reinforcing the idea that healthcare is a right, not a privilege, the insurers discuss profits and fund balances, marketing and medical loss ratios, and the only “solution” they can come up with is to shift costs to patients and/or practitioners. Unfortunately, patients have limits and when the out-of-pocket costs of care are raised too much, they stay home until their care is really unbearably expensive.

Who's kidding whom? It's a political shell game, shifting much of the burden of health care (rising medical costs and the aging of the population are projected to account for 2/5 of the federal budget deficit by 2035) to individuals. Cost shifting is indeed a game) and a dangerous one at that)! Putting doctors at risk is risky business and no way to control medical expenditures. (Watch, for instance, how fast a doctor will refer when you don't adequately reimburse them for a workup.) Cost sharing with patients is even worse. Because of huge out-of-pocket expenses, their needs are dammed up. It's like the levies in New Orleans -- pretty soon they can no longer hold back the flood, and downstream the cost of repair is mounting.

Practitioners? They flex -- pay them fee-for-service and they'll shine at piecework, generating pieces. Pay them prospectively and they refer the tougher cases. Discourage visits and they'll over-test or over-treat. Here's one of many examples: The number of ER visits that included a CT examination increased from 2.7 million to 16.2 million, or a 5.9-fold increase and a compounded annual growth rate of 16.0%, from 1995 to 2007.

But it's not that simple: Providing care free to patients did not improve their health more than where they had to share some of the cost.

What is going on here? In “A Physician = Emotion Passion Science,” Robert H. Brook, MD, ScD, wrote "Why was the medical care system so sloppy and chaotic that more care did not lead to better health? I was angry that I would spend part of my life defending co-payments because the American public could not be offered a system in which care was free at the point of service and actually produced better health." (This in reference to the NEJM article “Does Free Care Improve Adults' Health? Results from a Randomized Controlled Trial.”)

We have work to do, but let's face it -- healthcare cannot be accomplished if the patient's needs are left out of the equation, if the doctor is treated like a churning technician or if the insurers put profits before patients. On the other hand, I like what I read in U.S. Pharmacist by Editor-in-Chief Harold E. Cohen, RPh: "I know time is of the essence in the world of medicine today, especially at most retail pharmacies; but the next time you are filling a prescription, take into consideration both the physical condition and the emotional fragility of the patient getting that prescription. Patient care, both physical and emotional, is not a myth; it is real and should be practiced without exception with every patient. There is no medicine or treatment plan that can substitute for some words of kindness from a health care professional to an ailing patient."

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