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Sunday, Jul 12, 2009
Ask not what healthcare can do for you but what you can do, with incentives, for healthcare.
By Rahul K. Parikh, M.D.
Read more: Health, Health Care, Life, Dr. Rahul Parikh, Vital Signs, Environment & Science
June 19, 2008 | In February, Blue Cross of California (owned by Wellpoint, one of the country's largest health insurers) sent letters to physicians asking them to report conditions that their patients may have hidden when they applied for health insurance. The company's intention was to use the information to cancel policies.
Asking doctors to blow the proverbial whistle on their patients goes well beyond bad taste. If I had received one of the letters, I would have gladly sent Blue Cross my reply -- a picture of my middle finger photocopied on some nice office letterhead.
Just another day in the monstrous mess that is American healthcare. Indeed, poll after poll shows that most Americans (including the doctor writing this) agree that the time for healthcare reform is now. Many reform advocates point to the nationalized systems in Canada, the U.K. and other European nations as better alternatives to our employer-paid, fee-for-service system.
But from my vantage point as a primary care doctor, there's a bigger problem than just dollars and cents. We need to look deeper into the incentives of healthcare. We need to examine our motivation to go the doctor and my motivation to see you. The fact that healthcare appears to be all about treatment is the crux of the problem, and one that won't be fixed no matter who's paying and who's being covered.
Let's review Insurance 101. Basically, insurance of any kind is a pool of money we pay into for someone else to spend. In healthcare, the stakes are much higher, but the concept holds: Somebody gets sick and the money we put into that pool pays for the doctor's visit, prescriptions and tests. Of course, as we've learned the hard way over the past couple of decades, that pool of money is finite.
That problem exists in government-run healthcare as well. Governments keep costs under control the same way that insurance companies do -- by budgeting a certain amount of money for services. So someday it could be Uncle Sam instead of Blue Cross sending you a letter denying your coverage.
Before you urge to me to see "Sicko" (I already have), consider the following story about the U.K.'s government-run brand of medicine, the National Health Service. Six years ago, it endorsed the use of photodynamic therapy for age-related macular degeneration of the eye. Left untreated, macular degeneration is a major cause of blindness. But given its finite resources, the government had to decide who would qualify for this treatment.
In a document posted on an NHS Web site, it considered who should receive photodynamic therapy by measuring its cost-effectiveness with something called quality of life adjusted years (QALY); that is, for the cost of the therapy, how many years of sight would a person get? QALY appears to be the standard measurement by which the NHS makes decisions about treatments, endorsing those that provide the most years for the money. The NHS issued this peculiar recommendation: If you are going blind in both eyes you can get photodynamic therapy, but only in the eye that is more severely damaged. In other words, under the U.K. healthcare system, you can save only one eye.
As you see, there are limits to a single-payer system. Which doesn't mean the U.S. system isn't crying out for change. Ending the hypocrisy of having 50 million uninsured citizens in the world's richest country should be our first priority. Doctors, hospitals and clinics can function far more efficiently. As doctors, we can provide wiser use of dollars and services, making sure the drugs we prescribe, the tests we order and the surgeries we perform make sense for individual patients.
