Monday, August 10, 2009

Struggling to Understand Health Care Reform: Some Thoughts From Forum President Richard Sugarman

The CT Forum staff, along with a few volunteers and one YOUTH Forum member, had an impromptu mini health care Forum in our office last week in an attempt to understand all of what is meant when we talk about health care and the proposed reform. However, when it was all over we still felt like we had more questions than answers. In the days that followed we kept returning to our questions, sharing articles that we each found helpful, and continuing our discussions.

Yesterday, Richard shared the following email with the rest of us - it's his working out of his thoughts on paper. It stimulated more discussion here at the office, so we thought that others might be interested in reading it too.

Let me try to clarify my understanding of the difference between health care reform and health care insurance reform.

Health care insurance is a business, just like any other business, with business models and profit as the incentive. In this case it supports many large industries: Pharma, Physicians, Hospitals, Medical Equipment and Suppliers, Insurance... oh, and Lobbyists. All of these industries are structured to reap the greatest financial return - profit for themselves. ALL the incentives in this model go toward greater profits and revenues. Outcomes are measured by financial returns. There is often a disconnect, or at least a poor connect, between the customers of this model and the industries in this model. The customers fall into 4 general groups.

1.) Uninsured 47m people. They typically only use emergency rooms and hospitals and have limited access to physicians or clinics for services. They tend to be much sicker, wait longer for care, are under-served, and suffer real pain from rather ordinary illnesses - dental problems, colds, diarrhea, etc.

2.) Underinsured This is a very large group, possibly most Americans who have insurance of some sort and pay for some or most of it. The insurance includes large deductibles, co pays, and limited coverage.
This group has the "illusion" of coverage, but when they get sick often realize how little is covered.

3.) Those who are insured and are either paying for it personally or sharing costs with their employer, are reasonably covered for care, especially serious illness, but are scared about the future. Paying for their annual total health care costs has become a burden and any little financial problem could tip them over into the first or second group. They are often dissatisfied with the quality and timeliness of care but they at least are covered. This group is also very large.

The first three groups share in common a frequent and purposeful denial of claims, fear of the loss of coverage, having to fight with providers over coverage, frequent over-medication and unnecessary treatments. This is all a part of the business strategies for the industry.

4.) The final group is those who have coverage, pay for it or share costs with employer, and are truly satisfied, content, and at ease about their coverage. They don’t worry about getting sick or about any financial problems affecting their coverage. They have great doctors, and easy timely access to any and all care as needed. The system is working great for them. I don’t have any idea how large this group is, but I suspect it is very small.

It seems to me that the current reform plans are generally about this group of businesses and customers. The reform seems to be limited to tweaking some of the costs/revenues/profits of the industry players. Hospitals are giving back $80 billion over 10 years, Pharma is giving back $100 billion over 10 years, and insurance is giving back...? This is only tweaking, something like offering a 3% discount to a customer or in this case many customers. There is nothing reformist about that - every business in the world is giving discounts to its customers today and has become the way to do business.

If we want true reform…a reset of the health care insurance industry…we will have to look fully at the incentive system that is so firmly in place and introduce new incentive models that reward things other than fees for service, tests regardless of need and effectiveness, medication that is way too expensive and way over prescribed, and insurance that denies coverage as a business strategy. How about incentives like the Mayo Clinic where all physicians are paid a salary, work as collaborative teams with true continuity of care, and are judged and rewarded based on quality and effectiveness of care not frequency of tests and treatments? Even with a public option, if we continue the current old incentive business model, not much will change and we will find ourselves in a worse spot in 5 -10 years.

Now about the other piece…health care reform. This is not a business model full of industries and for-profit companies. This is all about health: healthy people, healthy practices, healthy reinforcements, a healthy society made up of healthy communities. In this reform effort health care prevention is not a lost, diluted message; it is a central value. Good health and health practices are everywhere, for everyone. Schools offer healthy good food to children, the workplace is not just the provider of health insurance and a source for unhealthy lifestyles, but rather includes many healthy lifestyle elements that employees expect and value. Healthy becomes the norm - it is everywhere for everyone. In this health care model good care is also available to everyone for no or low cost. Care is not a business, it is a core part of life in our country. Care services are offered in a coordinated collaborative system. When people get sick they all receive the highest level of care and service. Treatment is based on what is needed, what works, what is effective. Look again at the Mayo Model. The dynamics of costs, incentives, and profits are viewed totally differently in this system of health care.
My only other thought for the moment is: who is satisfied with our current system of health care -- insurance or care -- and who is dissatisfied? I would love to know.

A few articles we've been sharing:
Atul Gawande on health care payment reform in The New Yorker.

Jacob Weisberg's article in Slate, surveying health care across the world

We'd love to hear your responses.

No comments: