Health care reform, part I

I know only one certainty regarding health care reform in the US: I won't be a significant policy maker. And neither, likely, will you. But that doesn't mean we shouldn't educate ourselves, try to understand the problems and potential solutions, because whatever our government implements over the next year, health care reform is going to be a process, rather than a single, achievable endpoint.

I've been consciously avoiding writing this piece, but people keep bugging me. One of the reasons I've avoided it is because I'm not a policy expert, and I don't want to do the extensive research necessary to create a comprehensive piece. I also want to create a relatively objective piece, as much as that is possible. To make my goals a bit more realistic, I'm pointing out some of the problems and solutions that are more clear to me, meaning this is in no way comprehensive. Given the scope here, I'm going to break this down into a few separate posts.

But first, why should we even care? What's so important about health care reform? Economically and ethically, our system is a mess. If we are to create a society that is not some sort of ultra-libertarian hell, we have to consider the morals of how we take care of each other. We spend too much, achieve too little, and leave too many people out.


Current challenges (Digression: I hate euphemisms, and I'm not going to fool around with them)---current problems in our health care system can be divided roughly and somewhat artificially into three categories: problems centering on the patient, problems centering on medical science and practice, and problems centered on physicians and other providers.

Patient centered problems

  • Insurance: It's already well known that an embarrassingly large number of Americans are uninsured or underinsured. This is both a moral and economic problem. As a society, we should not be OK with this. If you don't agree with that, we're not going to agree on anything. Economically, we still provide care of some sort to the uninsured. This costs money. Lots of money.
  • Access: In many areas, patients perceive difficulties getting services they want or need. This is true of any system, and while Fox News may point fingers at Canada (which is sometimes justified, sometimes not), we have similar problems here. Part of it is geographical, part economic. There is little incentive for doctors to serve those who are underserved, either geographically or economically. Why would a doctor want to work in a blighted inner city or an off-the-beaten-path town in Nebraska? We cannot rely completely on altruism to take care of poorly-staffed areas. Medicaid, which covers many poor people, pays pennies on the dollar for services, so a doctor has to be willing to sacrifice both geography and income. That's a tough sell for someone with lots of medical school debt.
  • Continuity of care and communication: It's not easy getting in touch with a doctor's office, but this can be variable. Some doctors are easy to reach, others not. This can impact utilization of emergency and urgent care services. If your doctor cannot communicate effectively with you and with your other doctors, services will be duplicated and opportunities for collaboration will be lost. This impacts directly on the topic of electronic health records (EHRs). There are some standards out there, but basically if a doctor wants one, she has to buy it herself, and even when it is working properly it usually has no ability to interact with other EHR, say at the local hospital.

All sorts of solutions have been discussed for patient-centered problems, but any real solution has to create a system in which it's relatively easy to find affordable insurance (remember, the average health consumer is "average"---average intelligence, average medical knowledge, average income). Insurance forms with fine print that allows later rejection of a patient's claims is unacceptable. If an average consumer has to go online, go to the library, call various companies to compare plans, it's a set up for disaster. Yes, it is the responsibility of the individual, but many individuals don't have these skills, and private insurance companies have an incentive to deceive.

Insurance must be readily available to all, but so must providers. This doesn't mean that every village should have a super-subspecialist, but there must be ways to access theses services. There must be real incentives for doctors or midlevel providers (such as physician assistants and nurse practitioners) to practice in underserved areas. Modern communication can aid in this. A midlevel provider in a small town could teleconference via the internet with distant supervisors. These supervisors must also have an incentive---they must be reimbursed for the time and the risk.

This communication could be enhanced by protocols that allow EHRs to be mutually compatible. The competition afforded by the current system is strong, but building software bridges or requiring basic intercompatibility would make patient care safer and easier.

Next up, challenges in medical science...

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The EMR software is improving at an impressive rate. There are many systems that do not communicate, but there is also software out there that can create compatibility.

We are about to undertake an upgrade to our system that will allow patient's access to their own records and allow them to communicate with me via their on-line account. This will allow better communication. Of course, the older folks likely won't be using this much, but as generations age, this will become the expected norm. Reimbursement for such communication is actually feasible and not bad.

I have been increasingly annoyed by the extreme rhetoric coming mainly from the right about the proposed health care plan. Many are acting as though Mr. Obama is going to come into our homes and personally take away our insurance policies and ram government control down our throats. Come'on. There will be changes, for sure. But as a doctor, I am cautiously optimistic that many of my former pediatric patients (who are uninsured) may find there way back into the health care system. There may be a resurgence in primary care. Maybe. Maybe not. Let's watch closely. There will be some new rules. Let's learn them. Point out things that are unjust if they surface. But let's not act as though the sky has fallen.

By The Blind Watchmaker (not verified) on 28 Jul 2009 #permalink

Your post is well-written and manages many of the big issues. I am a strong proponent of EHRs, mostly because I believe that they will improve patient outcomes and save lives. And I also believe that many patients will use PHRs to help manage their care, and their parents' care. I personally use HealthVault for my family and am getting my mother on board, too, as we manage her hypertension. Healthcare reform is a complex issue, but you are doing a great job of breaking it down. Looking forward to your follow-up post.

Older people and modern communication: I called my 86 year old father on his cell phone the other day and he said he'd call me back because he was talking to HIS AUNT on Skype. She's also 86.

They were talking about... their health problems.

Of course, I know that these two are nowhere near the norm for their age. Hell, their age isn't quite normal!

My father lives 20 miles from the nearest doctor. There's also a minor emergency clinic in that town. He's 40 miles from a hospital that can provide advanced technical care, or where he can see a specialist of any kind.

Wouldn't it be nice if he could email his doctor vital signs and symptoms/problems(he's got a BP machine, are those oxygen sensors available for home use?) and then the doctor/NP could Skype him for an eye to eye short discussion?

Each side would then have a recorded version of the conversation. The patient could double-check... "yes, she said to decrease/increase dosage of this or that" or "that's an expected side-effect - call if it gets to point X - but it should go away in a few days"


There's no doubt this would be a cost and time saving thing for the patient (2 hours travel time, gas, possibly being away from home long enough to have to eat out... etc.)

Could it work as a cost-saving convenience for the doctor too? Or would it add to problems? That side of it I don't know. How would billing work? Would insurance go along with it? Would it require additional staff? I'd love to hear the doc's side of this scenario.