It took me a while to learn that unless you hold a substantial understanding of a subject, you should express your opinions with an extra dose of humility.
So, what I have to say today, please accept my limited understanding of an extremely complex subject: President Obama's mission to reform our healthcare system.
Whether you agree with him or not you have to admit that the healthcare system is reasonably messed up. Unless you're actually in the healthcare business though, you have no idea how truly messed up it is.
Most of the people talking about this have not actually worked in the system and even though I have for 28 years, I still don't know or understand all of the issues that come together to create the problem we all face.
The problem is very complex, multi-threaded and the solutions are equally complex. But, here are a few of my observations:
- Most insurance companies pay providers by the procedure. Physical therapy for example. Therapists get paid way more to do things to you than to figure things out. A consultation or evaluation is one of lowest paid things on the list yet one of the most important. If you don't get the problem well identified at the start, the rest is just junk (Albert Einstein once said that if he had 60 minutes to save the world, he would spend 55 minutes figuring out the problem and 5 minutes implementing the solution). So, some clinics have very short evaluations - 15 or 30 minutes by mandate. Trust me. When you have someone who has torn a ligament in his or her knee and a torn cartilage in the hip and also has some residual back pain, you're just barely getting to know each other in 15 minutes.
- As technology improves, patients want access to it whether they actually need it or not. Some patients want an MRI or a CAT Scan because they just can't believe that from an interview - a story - that their doctor could figure out what was wrong with them. My father spent all of his career as a family physician in a small town in New York and used to tell me how his patients would demand an x-ray for a sprained ankle. They didn't believe him when he said it wasn't broken. But, there wasn't much of a choice of doctors then either. The patients learned to trust him but now, they may or likely would just switch doctors until they found someone who would order the test.
- Physicians are incented to refer for tests and treatments if they have a financial interest in the facility or use of the procedure. I played golf a while ago with a surgeon I've known my entire career. When the subject of medicine and business came up in our discussion, he said he was very discouraged. His group practice had purchased an MRI machine so they could refer to themselves and pocket the testing fees but the images from the machine were often too poor to trust so he had to send his patients out and when he did, his partners chastised him for it. And, instead of referring patients to a physical therapist elsewhere, they hired a physical therapist and pocketed the profits for that too. He said, "I just want to practice medicine; not be a businessman." Agreed, but good luck.
- Patients want an aspirin; not a vitamin. A lot of people want their pain fixed now and are often uninterested or unwilling to learn how to take care of themselves for the long run. This then drives the over utilization of prescription drugs, surgeries, and other therapies.
- There are some conditions when doing less is better and is not only good enough but exactly right. Most lower back pain will respond to non-surgical, conservative care and the solution is more of a lifestyle adjustment than a treatment. The current view of "treating" back pain is outdated and costly. Instead of sending patients for an MRI, prescribing narcotics and surgery, physicians should send their patients to other providers who understand how to help people with back pain and monitor the situation. A small percentage of patients who see a physician ever make it into a spine-focused strengthening and conditioning program - only about 3% (see Dr. Timothy Carey's article on this here). There's a lot of room for improvement and for lowering the overall cost of a back pain episode.
- Providers are paid by procedure and some procedures pay less even though they are much more complex. I know of a urologist who finally decided to stop performing kidney transplants and instead perform more vasectomies. He was paid about 1/3 as much for a transplant as a vasectomy and transplant patients require a lot more risk and work. He's paid more to prevent a life than to save one.
I don't have the answers but I think that unless you remove some of the drivers of cost escalation it doesn't really matter whether people are insured or not. The cost will still go up and maybe even more with more people insured.
In the meantime, somethings you can do to help:
- Take care of your self. Examine your diet and make changes to help keep your body fat in the ideal range for you. Don't smoke. Exercise and train your body regularly. Learn how to deal with stress. Don't short change your self on sleep.
- Don't go to the hospital for non-emergent issues like colds, viruses, etc. These can be handled very effectively in physician offices or walk-in clinics.
- Ask this question when a provider suggests something to you (like a test, surgery, referral, etc.): "Would you do this for your mother or your son or daughter?"
- And ask this question too: "Will you make money by referring me there?" If the answer is yes, it doesn't necessarily mean the referral is a bad choice but at least you know going in that there's an incentive in play that may work against you. Sometimes it's best to ask this question first and then the previous question. I've had some clients tell me that when they've done this that the provider changed his mind and sent them someplace else.
I'm sure there are other ideas and maybe someone reading this would like to join the discussion. Please feel free to share them by hitting "COMMENTS" at the bottom of the article.