Healthcare needs you

Ask not what healthcare can do for you but what you can do, with incentives, for healthcare.

Published June 19, 2008 10:29AM (EDT)

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.

One of the most common reasons for chronic lower back pain is degenerative disk disease. Depending on a doctor's training, or point of view, you'll be told to have either surgery (pricey) or physical therapy (cheaper). A 2006 Journal of the American Medical Association study showed that either way the outcomes were essentially the same. Another 2006 study found that certain areas of the country have higher rates of surgery than others, without any rhyme or reason. That kind of inconsistency, regardless of results, shows just how much we need to learn.

We can better rely on technology as well. Over the past several years, politicians, health policy experts and doctors have been talking up an electronic medical record (EMR). Besides the fact that a 12-point Geneva font is a whole lot easier to read than a doctor's handwriting, an EMR can integrate so-called best practices into a doctor's diagnosis and treatment decisions. If you come to me with high blood pressure, I will have a whole array of medications to prescribe, which vary in terms of effectiveness and cost. An EMR can remind me which medicine is the most effective, safest and least expensive. That kind of information can always be updated based on the best available medical evidence.

But deep and lasting change needs to be about more than information, coverage and cost. It needs to be about behaviors and incentives. Our current system is driven by illness. When you're not feeling well, you go to the doctor, have some tests, get a prescription and go home. Then your doctor sends your insurer the bill, which reimburses her for her services. You tap into healthcare dollars only when you get sick, and the sicker you get, the more we see each other and the more we spend.

Specialists, in particular, benefit from this model: Performing complex procedures is rewarded handsomely. But there's not a lot of money to be made in preventive care and counseling to deter diseases. Those aspects make up the crux of primary care medicine, and the lack of reimbursement for them is driving doctors away from making a career out of internal medicine, pediatrics or family practice.

Incentives can be directed at doctors. A new game-changing concept is called "pay for performance," whereby doctors are rewarded based on whether they meet quality goals that push prevention, such as making sure a patient's asthma or diabetes is well controlled.

It sounds ideal, and doctors can work to counsel against, screen for and prevent disease. But it neglects patients' role in making healthcare better. Most health decisions are made at home in the little things we do, and most of those choices aren't very good ones. Economists refer to this as a lack of moral hazard, and healthcare is riddled with it. Only about half of Americans regularly exercise, and less than a third of us eat the recommended servings of fruits and vegetables each day.

We also seem too casual in our acceptance that medical breakthroughs will help us live longer, and too quick to forget that there are things we can do to prevent us from needing those breakthroughs (and their expensive price tags) in the first place. It would be better if our health insurers reimbursed us for buying healthier groceries or taking laps in the swimming pool at the local Y instead of paying for heart bypass surgery or the Lipitor we take just before we go out to eat a double cheeseburger and fries.

I recently attended a healthcare conference, where a representative from IBM told the audience how it provided a $150 break on insurance premiums to employees who joined a gym and worked out regularly for eight weeks. The IBM rep claimed the gym policy has made its healthcare costs rise more slowly than other companies'.

Of course, all of this is much more complicated than it sounds -- how will small businesses provide their employees with incentives? When will drug companies develop drugs we need, such as new classes of antibiotics, rather than lifestyle drugs like Viagra or Botox? How will medical schools encourage students to pursue primary care?

There's no magic bullet, but whatever healthcare system we end up choosing over the next decade, we'll still be wrangling over money and resources. As the debate storms on, let's make sure that as both patients and doctors, we get our priorities right and emphasize prevention and healthy choices rather than just treatment and costly procedures.

By Rahul K. Parikh

Rahul K. Parikh is a physician and writer in the San Francisco Bay Area. He wrote the Vital Signs column on Salon in 2008-2009. His pop culture-medical column, PopRx, runs on alternate Mondays.

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