Life Insurance

Patient cost sharing does not control medical costs. Patients are not trying to decide what type of car to buy. In that situation, they have all the information they need to make a rational decision. However, if a person has belly pain or chest pain, they have to know the diagnosis before they can make a rational decision about whether to seek care. If those symptoms can be cured with Tums, then they don't need care. If they are from a heart attack or a leaking abdominal aneurysm, then not seeking care could lead to the cheapest medical outcome of all - death. Then there is no more need to spend money on health care. It's not easy for doctors to tell whether symptoms are from a dangerous or benign cause, so how can we ask patients to try to do this without medical input? Should people choose not to treat their scleroderma or their ovarian cancer?

The United States already has the one of the highest levels of patient cost sharing in the industrialized world, yet our per capita costs far exceed those of other nations. Proponents of patient cost sharing often point to the Rand study from the 1970s as evidence that cost sharing controls costs. This study compared usage and expenditures between four groups of patients. Patients paid for 0 percent, 25 percent, 50 percent or 95 percent of their costs. The group that paid nothing used more services. But there are several problems with this study. They excluded the elderly, who are most likely to need care. Once a patient's costs exceeded $1,000, they were no longer responsible for the costs no matter what group they were in. This reflects the reality that 70 percent of health care expenditures are incurred by 10 percent of the population. These are the people with chronic or catastrophic illness. So Health Savings Accounts with high deductibles are a great tax shelter for the healthy and the wealthy, and they provide another product for banks and insurance companies to sell, but they don't address the real problem.

Not all expensive and complicated medical technology contributes to health. Some of it even contributes to outcomes that are worse. Vioxx is but one current example. We need to find a way to impartially evaluate new treatments to assess their benefits and risks. As a culture, we need to change our mindset from fixing things expensively and dramatically to focusing on preventing them in the first place. It is extremely important to understand that medical care is not the main determinant of health.

The Institute of Medicine said this in 2002: "Although as much as 95 percent of health care spending goes to medical care and biomedical research, lifestyle behavior and the environment are responsible for more that 70 percent of avoidable mortality."

I tell my patients "If you eat right, don't smoke, exercise, drink in moderation and wear your seat belt, I'll be out of a job in ten years." I believe that individual behaviors are extremely important when it comes to health. However, individuals cannot by themselves affect many major determinants of health. These include food, soil, water, and air pollution. Why do we subsidize production of corn we don't need instead of healthy local food? The excess corn gets turned into cheap high fructose corn syrup, effectively subsidizing soft drink and junk food manufacturers with taxpayer money. Their products are advertised to children on TV and in public schools. Those are public policy issues that individuals cannot control. Another example is smoking. The Harvard School of Public Health recently published evidence that tobacco companies are increasing the amounts of nicotine in cigarettes to help ensure a strong consumer base. They also advertise quite effectively.

We don't have to spend more to achieve high-quality health care. We have to get rid of the waste and profiteering that contributes to high cost but does nothing to achieve better health. Medicare's overhead is 3 percent. It doesn't waste money on plan administration, marketing or huge salaries for CEOs. The overhead for private insurance companies averages about 13 percent. A 2002 Commonwealth Foundation Survey showed that, compared to those with private insurance, Medicare patients had less access and billing problems, spent less out of pocket, and felt the quality of care and the insurance itself were better. Most people now agree that we need some form of universal coverage. I believe that Medicare for all is the most effective and efficient way to do this. Doctors, hospitals and other providers are not owned or run by the government in this system. This is different from many forms of universal coverage.

The primary goal of health care should be the health of the community. In our current market-driven system, this often takes a back seat to profits. Real reform requires real change, not cosmetic tinkering that preserves the inefficiencies and waste of the current system. We don't suffer from a lack of money, but from a lack of will to make health care work for the health of the nation. I hope policy makers and citizens will insist on finding the will to make that change.

This is cache, read story here