All you can eat

Another late night Google adventure and too much link surfing led me to an interesting website tackling the health care issue from a view quite different from mine.

This post is an excellent explanation of one area of waste in health care.

Managed care sought to make a profit on cheap care. The only way to entice people to join managed care was to make it so very cheap that people willingly locked themselves into a very narrow selection of providers.

I remember when I was young, and most Kaiser plans had a $5 co pay for office visits and prescriptions. You couldn’t actually get in to see anyone, but at least it was cheap.

Over time, people did come to expect cheap care. Traditional indemnity plans had to try to keep up, but didn’t have the same built-in cost controls (direct control of a gatekeeper, denial of care, capitation) and so started down the same morally bankrupt path of using any method they could dream up to deny access to care, or refuse coverage so they could bring their costs in line with the managed care model.

Utilization of medical services appears to the medical consumer’s eye to have increased substantially. I lay some of the blame at the feet of ambulance chasers. Once upon a time, you used to be able to call the on call doctor, and see if you really needed that trip to the ED. You used to be able to call the ED even. Heck, used to be advice nurses could actually give, you know, advice. In my experience, even Kaiser advice nurses are saying “go to the ED” these days for things that probably aren’t emergencies.

The problem is cheap ED visits have dramatically increased the use of the ED. Sprains are not emergencies. The common cold is not an emergency. Insect bites are not emergencies. These can all look like something more serious though, and since we can’t be sure, off to the ED people go, to wait hours, spend a good chunk of change, all for the sake of defensive medicine.

We’re becoming conditioned to over-utilization of the most expensive care.

I’ve advocated here before for major hospital EDs to have a round the clock urgent care, with a common triage. At least then we could funnel urgent cases to a less costly setting, and improve delivery of care to those truly experiencing an emergency, without any further risk. There are some interesting models that could also be used in that instance, such as allowing patients who are comfortable with choosing urgent care to call to get their name on a list, and when they are so many patients away from being seen, be notified so they can head to the urgent care.

If there’s one thing the above mentioned blog post gets right (in spite of having the facts wrong), is all you can eat care is a disaster. Whether it’s insurance care, or single-payer, the cautionary tales out there tell us that patients are going to have to assume more responsibility for both their premiums, and day to day costs.

Preventive care (physicals, well child checks, and immunizations) need to be incentivized, since they have greater implications beyond just the care delivered, and are of minor expense. However other routine costs shouldn’t be dirt cheap. Chronic disease care shouldn’t be cheap, but out of pocket needs to be capped, or the uneven access to care when money runs out will negate some of the benefit of all that chronic disease management. Catastrophic care similarly should cost, but should not bankrupt a person.

The candy in the dish can’t be free. If there is a real cost, an uncomfortable but not painful or deadly cost, patients will be conditioned to be wiser users of health care resources, be more informed medical consumers, and be more motivated to get and stay healthy to the degree they are able to do so.

We need better tools to help us succeed. We need increased regulatory oversight and enforcement so that insurers can not make promises they have no intention of keeping, so that patients, at the point they are least able to advocate for themselves aren’t left to the wolves. We as patients need an objective means to find and use quality health care, and evaluate comparative costs.

Over the years patients have been encouraged to take more responsibility for their health care. We know that providing education can change outcomes. Now is the time to provide the quantity and quality of information that will help patients make decisions about their own health, their own care. Now is the time for patients to understand there is no free lunch.

That said, everyone needs to understand that starvation isn’t an acceptable option either.