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Wednesday, October 22, 2003If you allow people to withdraw money from an insurance pool it eventually only insures the sick and therefore collapses under its own weight. That's more or less what's happened to the individual insurance system in this country over the last 20 years and is what the Democrats are afraid will happen to Medicare if the "healthy" seniors are allowed to leave. (I'm not sure they are right to be that concerned about that happening given the record of Medicare Risk HMOs, but that's another discussion.) I’m not necessarily a supporter of MSA’s (although my family has one now that I’m self-employed.) What I do think we need is a paring down of our current insurance benefits rather than the politically popular expansion of them. In the 1990’s, when managed care was all the rage, we went from insurance that covered illnesses to insurance that covered everything. This, coupled with the aging population, is one of the main drivers of the increase in healthcare costs over the past several years. The idea behind managed care was that if insurers paid for things like mammograms and pap smears and immunizations they’d save money in the long run by preventing disease. But that’s not necessarily so. If one disease doesn’t get you, another one will - eventually. So, the healthcare dollar saved by preventing cervical cancer may be consumed by heart disease further on down the road. The insurance companies don’t necessarily gain any dollar savings. (Although the patient certainly gains in years of life.) That may seem like a cold calculus, but the sad truth is that preventive care ends up making overall healthcare more expensive. Having a third party pay for preventive measures may make them more utilized, and it probably saves lives in the short term, but it isn’t clear that it make us an overall healthier population, and it does come at a significant cost. (Note: I’m not against prevention. On an individual basis it’s good to screen for preventable diseases like cervical and colon cancer. The question is whether it’s a cost that society should bear for everyone regardless of their ability to pay.) To make matters worse, the number of things that we offer and promote for preventive health are growing more numerous every day. We now recommend bone density screening at $200 a pop, followed by a drug if it’s abnormal, at $70 a month. It isn’t at all clear if the treatment improves the quality of life for the majority of people. We just assume it does. And we don't even ask if it's worth the cost. We give Hepatitis B shots to every infant to prevent a disease that's transmitted through sex and contaminated blood. Is it worth the cost? We give chickenpox vaccines to avoid the possibilty that a small percentage of immunocompromised children won't get chickenpox. Again, is it worth the cost? Cholesterol screening can cost up to $200, depending on the lab, and the drugs to treat high cholesterol cost up to $120 a month. The kicker is that the expensive cholesterol medication needs to be monitored every two to six months with the expensive lab tests. The costs add up quickly, but no one ever questions whether that money is worth the small percentage decrease in incidence of heart attacks, because no one involved in the treatment decisions has to pay the price of the therapy. The first step to reigning in medical costs - and insurance costs - would be to scale back the coverage so that well-care and routine visits are paid for by the patient. It would lead to a wiser use of resources by both physician and patient, and to tell you the truth, it would be cheaper than the several hundred dollars a month that most people pay now in insurance premiums. Even the elderly with chronic, stable diseases seldom see the doctor more than two to four times a year. Where insurance is needed is to cover the very big expenses - like hospitalizations and surgeries. Those don’t happen all that often in most people’s lives, but when they do, they can be financially devastating. But, spreading out the risk over the entire population should mean that this sort of coverage could be offered at cheaper rates than our “everything -but- the- kitchen -sink -spread -over -small- risk -pools -of -employers” system. And another thing, although the people in the polls are enamored of their employer-sponsored health insurance, they’d think differently if they ever lost their job or got a divorce. That’s one of the most common laments I hear in my practice. Women who have relied for years on their husbands’ health insurance benefits suddenly find themselves cut off without insurance in middle age. Divorced, unemployed, and unemployable after spending the prime of their lives raising a family, they have very little recourse when it comes to health insurance. Even if they get a good divorce settlement. And laid off middle-aged workers fair no better. It wouldn’t be an issue if health insurance plans were designed for individuals, not corporations. (How many people do you suppose are staying in lousy marriages and jobs they hate just for the insurance coverage? I get the sense that there are plenty, unless I just have a lot of complainers in my practice.) That’s why proposals like this are so appealing: Under the Breaux plan everyone in the United States would be required to have health insurance, similar to current state laws that require drivers to carry auto insurance. Breaux’s proposal would encourage businesses currently offering employee health benefits to continue doing so, but it would not require all businesses to offer coverage. The proposal also calls for states to establish purchasing pools to ensure that people without employer-sponsored coverage could buy insurance at group rates. In addition, the government would offer tax credits to help people with low to moderate incomes purchase insurance. Under the plan, the government would fully subsidize health plan premiums for people with annual incomes lower than 150% of the federal poverty level, or about $27,000 for a family of four, and would partially subsidize premiums for those with incomes up to 250% of the poverty level, or about $45,000 for a family of four. Breaux said he will attempt to convene a bipartisan group in Congress to draft a specific proposal. And that’s the direction we need to move. Unfortunately, it’s also a politically unpalatable one. No one wants to give up something they’re already getting for free. (Or think they’re getting for free.) UPDATE: Health Care Blog responds here. I'm not so sure that end-of-life care is what's driving most of our high healthcare costs, even though conventional wisdom has it that it is. When I look at my practice, very few of my dying patients end up in the hospital in the ICU before dying. Some die suddenly at home, some are diagnosed with terminal cancer and go straight to hospice, some die at nursing homes. A very small minority die in the hospital after days of expensive care. On the other hand, a lot of my patients request CT scans and MRI's for headaches and sciatica, excercise stress tests for indigestion. They want bone densitometries, cholesterol screenings, and any other new test they read about in the paper that might predict a predeliction to disease. They want expensive drugs to prevent those diseases that they don't yet have. And I'm sure that my practice isn't an anomaly. posted by Sydney on 10/22/2003 07:25:00 AM 0 comments 0 Comments: |
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