One of the tragic aspects of America’s healthcare reform discussions is that so many people have so many opinions based upon a complete absence of knowledge or accurate information. For example, while many of our political Leaders have stressed the importance of preventive medicine in saving healthcare’s financial hide, this expectation has absolutely no basis in reality. In a recent post, Dr. Rich over at the Covert Rationing Blog eloquently describes the innate hopelessness of this proposition. Preventive medicine (perhaps more accurately termed “routine screening medicine”) may be the right thing to do from an ethical and health perspective, but it’s not going to save us any money.
A second area of misinformation deals with the cost-saving potential of health information technologies (HIT), especially when it comes to electronic medical records. We’ve talked about the deleterious and sometimes even life-threatening aspect of HIT in previous posts here and here, and Scot Silverstein has done a far more thorough job of doing so in his portion of the Health Care Renewal blog. EMRs and HIT may save money for administrators, laboratories and pharmacies, but they certainly don’t make economic sense for the vast majority of physicians or others involved in clinical care. Spending billions of dollars in government funds and as a result of government mandates is not going to do anything to change that.
However to me, one of the most peculiar misconceptions surrounding the healthcare debate is that somehow government provided and administered health insurance is better, purer, more efficient or less expensive to society than private health insurance. Anyone who believes this has simply not dealt with enough public insurers, such as Medicaid, Medicare, or the Tri-Care program for the dependents of our armed services personnel.
To be sure, there is much that is despicable about many private health insurers. No one who has ever filled out their forms, dealt with their arbitrary rejections, been refused insurance for a trivial reason or been thrown from the rolls as a result of developing an actual health problem could possibly think otherwise.
For you see, health insurers are health insurers are health insurers. When it comes right down to it, every insurer has the same long-term goal: to avoid paying as much money as possible. Think about it. Whether you’re running a health insurance company or Medicare, what are you going to be graded on? Will you be promoted or receive bonuses if your operation is losing money? Not bloody likely. Will you be rewarded if inflows are larger than outlays? Absolutely. Any health insurer, whether public or private, is a business, and accumulating money is how businesses keep score. If you’re running a private insurer, keeping lots of money is good for your shareholders. They’ll use the profits to buy themselves the goods and services they’ve always wanted. If you’re running a public insurer, keeping lots of money will please your constituents in Congress and the Administration. They’ll use those surpluses to buy votes. No insurance administrator in any healthcare system in the world is ever rewarded for making it easy for insured patients to utilize lots of services.(Note 1)
To illustrate, it might be useful to relate some of the experiences of “Dr. X”. (She’s too publicity-shy to have her real name used.)
Dr. X is the type of doctor that our political Leaders claim that they’d like to see more of in the United States: a hard-working, industrious and dedicated general practitioner who has dedicated her life to taking care of rural Americans. She’s a short, (about 5 feet 2 inches tall) average-looking middle-aged doctor with brown medium length hair, glasses, and a calm demeanor. She’s worked in general practice for 30 years, and now takes care of people in an emergency room of a 25-bed hospital in a small Iowa town. And she’s just about had it with Medicare and Medicaid. I had the opportunity to speak with her recently, and she related some particularly galling examples of “the public option” gone nuts.
“Case #1. I had a 30 year old woman with a severe asthma attack in the emergency room. We treated her and she was finally stabilized, so I gave her a five day prescription for prednisone, 40mg per day. [Ed. note, this oral steroid medication has got to be one of the least expensive drugs on the market. The entire prescription would have cost $10 or less.) She returned from the pharmacy a short while later and explained that Medicaid denied the prescription because they had not pre-authorized it. Of course, if she didn’t get the medication there was an excellent likelihood that she would end up right back in the ER. I couldn’t manage to get to talk to anyone at Medicaid who would authorize the drug. While I was on the phone the patient finally chimed in that she liked breathing so much, she’d pay for the medicine herself. “
Score: Medicaid 1, patient and provider 0.
“Case #2. A 19 year old patient with asthma was proving really tough to control. She had had three emergency room visits and one hospitalization over the previous month. During her last hospitalization she had very nearly ended up in the intensive care unit. Finally she presented to the ER yet again after failing treatment with a high dose Advair inhaler. (Ed. note: Advair is a combination drug containing a steroid (to suppress the asthma) and a medication that tends to open up the airways.) We managed to get her stabilized by treating her with a budesonide (Pulmicort) nebulizer. (Ed. note: Budesonide is another steroid that is used to suppress asthma. However a nebulizer (which allows a patient to breath a continuous mist of medication) is much more effective than an inhaler when it comes to actually getting the medication into the lungs where it can do some good.)
In an attempt to keep her out of the ER and out of the hospital, I prescribed a budesonide nebulizer for her to use at home. Medicaid denied it, not for any good medical reason, but because their guidelines said that the patient had to fail to get better on a budesonide inhaler first. I fought to get this patient a nebulizer with a week of phone calls to Medicaid. I was never able to speak to a doctor or anyone else with the slightest bit of medical knowledge. Finally, I ended up prescribing the patient the inhaler that Medicaid wanted just so she could fail on it, and immediately followed up with the prescription for the nebulizer. The whole thing cost far more money than if they’d allowed me to do the correct thing in the first place.”
Score: Medicaid 2, patient and provider ½.
“Case #3. An 80 year-old gentleman was having an acute heart attack. Our hospital doesn’t have a cardiologist, so I called one in the next nearest city and discussed treatment options for him. We decided that he had the best chance of surviving and preserving heart function if he were immediately transferred for cardiac catheterization and intervention. Thank goodness we did, and he did fine afterwards. However Medicare decided that, although the transfer and procedures were medically appropriate, they didn’t want to pay for the ambulance trip. What was the patient supposed to do, drive himself? I wrote letters and made phone calls on the patient’s behalf, and finally got Medicare to agree to pay for the ambulance – but only two years after the initial event.”
Score: Medicare 1, patient and provider ½ .
“Case #4. This has got to be one of the silliest things I’ve ever seen Medicare do. They paid for parts of an emergency transfer to a hospital cardiologist. Here too, a 70 or 80 year-old man was having a heart attack and our facility was clearly not going to have the resources to care for him properly. The weather was bad, so couldn’t use a helicopter, but we could use fixed wing airplane from a relatively nearby airport. Medicare paid for the ambulance to the first airport, paid for the LIFEFLIGHT, but refused the ambulance from the receiving airport to the hospital with the cardiologist!
Normally I’m a pretty easygoing and quiet person, but for some reason this case really got to me. Medicare finally paid, but only after I wrote a letter explaining that they had agreed with the LIFEFLIGHT, so obviously they did believe that the patient was as critical as I said, but I didn’t understand why they thought the intensive care unit was in the terminal of the receiving airport. Did they expect the patient to walk from there to the major hospital? They finally paid after I’d spent hours on correspondence.”
Score: Medicare 1 ½, patient and provider ½.
There are a couple of lessons to be taken from all of this. (Other than the fact that our healthcare providers waste enormous amounts of time and money having to screw around with insurers when they should be providing care.)
The first is that it’s terribly naïve to suppose that public insurers are “good” and private insurers are “bad” simply because one makes a profit (or the non-profit insurance company equivalent of a profit), and the other doesn’t. From a patient or provider’s perspective, all insurers are pretty much the same; they’ll attempt to deny anything and everything that they can get away with.
The second lesson is that there is potentially a great danger in having a “single-payer” system – not because private insurers are so “good”, but because giving any insurer monopoly power in the marketplace can be so bad. Private insurers do have one endearing attribute that is not shared by their public colleagues – no matter how rotten they may be, they are unable to use the sovereign power and authority of the national government to work their will upon patients and providers. You can always tell a private insurer to pound sand and get another one.
In contrast, any government-run single-payer system is a monopoly. Monopolies are inherently untrustworthy – especially if they’re run by politicians. After all, in a country that politicians have already run deeply into debt, the road to financial stability is just a few billion denied procedures, medications and ambulance rides away.
Some of those are bound to be yours.
Note 1: If anyone needs one more illustration that there is no clear difference between the administration of public and private insurance – the same people basically run both systems. At the field level, all Medicare services are administered by private insurance companies that contract with the Federal government to do so. It’s entirely possible that the same bureaucrat who denies your mother’s Medicare claim in the morning, will be denying your Anthem claim in the afternoon.