As I sat through the second day of a continuing medical education course, I was confronted by a hypothetical in which a 59 year old Mexican-American man presented with high blood pressure, obesity, diabetes, and abnormal blood fats. The instructor emphasized that this man was at very high risk of a heart attack or stroke. The instructor and audience carefuly considered the diagnostic and treatment program needed to reduce this man's very high risks of death and disability related to diabetes, arteriosclerosis, heart and blood vessel disease and high blood pressure.
As I listened to the expert instructor's exquisite analysis, it struck me that the wrong questions were being asked. This man was approaching the end of his disease shortened lifespan because when he was 19 years old, no one was interested in intervening and preventing or ameliorating the diseases he was genetically programmed to develop. Why not?
Our health care system's insurers, PPOs and HMOs, had no incentive to spend a significant amount of money on a man who would likely be the customer of a competitor when he finally developed expensive serious sickness. In previous blogs, I have described the practice of employers to frequently shift insurers, PPOs and HMOs to save money. Perhaps Kaiser, which works hard to retain members, might have a long-term interest in its members' health. But most of the country's health care is not provided through Kaiser. For the working population it is provided through relatively few insurers, PPOs and HMOs which focus on short term profits and yearly executive bonuses rather than long term health of clients. And it is left to Medicare to pick up the costs of caring for the disabled and elderly who may have been victims of systemic neglect early in their lives, when intervention might have made a big difference.
We have a dysfunctional expensive and wasteful health care system in which the principal players have disparate goals and in which the intention is not to further the health of our nation but to game the system, maximize profits and leave it to others to pick up the shattered lives of unhealthy Americans when they are - for example - 59. Let's all agree that we must take care of our young people, when that intervention can make a major difference in their lives, their health, their contribution to our nation and its economy, and our common good.
Showing posts with label PPO. Show all posts
Showing posts with label PPO. Show all posts
Thursday, March 20, 2008
Sunday, March 16, 2008
Are Commercial Sex and Health Care Commodities?
Former New York governor, Spitzer, purchase sexual services to meet his needs. From the available reports, he treated sex as a high-priced commodity, to be obtained as and when he wanted it, from relatively anonymous sources. There are some parallels with health care which is increasingly being treated as a commodity, available from commercial sources through relatively anonymous providers.
Brief encounters with physicians who have no previous meaningful experience with their patients and who does not expect to encounter these patients again, represents poor health care. Despite the current hype, no electronic medical record can replace the nuanced interaction between patient and physician (or other health care provider) which profoundly affects the care given for that event and future events. The paper or electronic record, no matter how complete, is a dry recitation of a limited number of facts - a current complaint, history, drug allergies, physical findings, laboratory tests, diagnosis and treatment plan. It does not evoke the expression on the patient's face as she describes problems at home, does not describe a daughter's interest in having her mother continue to drive her children home from school, notwithstanding mother's progressive dementia, or detail the brief encounter's actual conversation between physician and patient.
When health insurance was a side-line business, undertaken so that the insurer could do more important and lucrative business with employers, physicians rendered "usual and customary" care and were paid for it. The payers paid, and physicians rendered care. In the early 1980s, interest rates skyrocketed and insurers suddenly discovered that they could take advantage of the float on their accounts payable. And suddenly, a commercial revolution in health insurance occurred. Then HMOs appeared, facilitated by President Nixon's legislation fostering their development. Initially the HMOs were non-profit, with community rates, and provided appropriate care while, with physicians and other health care providers, they explored methods of providing more efficient care. But the dollar flow and profits to be made led to conversion of almost every not-for-profit HMO into a for-profit operation. The service that the HMOs provided was not high quality health care: it was system development, which meant that they provided an easy way for employers to purchase health insurance, development of networks of physicians, hospitals and other providers, and the generation of substantial profits. PPOs, the next stage in health care insurance coverage, tagged on after HMOs, enjoying the benefits of the more efficient services physicians and others were providing without paying the development costs. Health care became a commodity and ownership of a network of providers became a valued asset which allowed enterprises to generate enormous capitalized values. The relationship between patient and his or her provider became almost irrelevant: the employer would choose one insurer, HMO or PPO one year and leave it and its network of providers for another the next year. Health care became an almost anonymous uninformed commercial transaction. Which brings us back to Mr. Spitzer and raises the question why the public isn't as outraged about the health care it receives as it is about his conduct?
Brief encounters with physicians who have no previous meaningful experience with their patients and who does not expect to encounter these patients again, represents poor health care. Despite the current hype, no electronic medical record can replace the nuanced interaction between patient and physician (or other health care provider) which profoundly affects the care given for that event and future events. The paper or electronic record, no matter how complete, is a dry recitation of a limited number of facts - a current complaint, history, drug allergies, physical findings, laboratory tests, diagnosis and treatment plan. It does not evoke the expression on the patient's face as she describes problems at home, does not describe a daughter's interest in having her mother continue to drive her children home from school, notwithstanding mother's progressive dementia, or detail the brief encounter's actual conversation between physician and patient.
When health insurance was a side-line business, undertaken so that the insurer could do more important and lucrative business with employers, physicians rendered "usual and customary" care and were paid for it. The payers paid, and physicians rendered care. In the early 1980s, interest rates skyrocketed and insurers suddenly discovered that they could take advantage of the float on their accounts payable. And suddenly, a commercial revolution in health insurance occurred. Then HMOs appeared, facilitated by President Nixon's legislation fostering their development. Initially the HMOs were non-profit, with community rates, and provided appropriate care while, with physicians and other health care providers, they explored methods of providing more efficient care. But the dollar flow and profits to be made led to conversion of almost every not-for-profit HMO into a for-profit operation. The service that the HMOs provided was not high quality health care: it was system development, which meant that they provided an easy way for employers to purchase health insurance, development of networks of physicians, hospitals and other providers, and the generation of substantial profits. PPOs, the next stage in health care insurance coverage, tagged on after HMOs, enjoying the benefits of the more efficient services physicians and others were providing without paying the development costs. Health care became a commodity and ownership of a network of providers became a valued asset which allowed enterprises to generate enormous capitalized values. The relationship between patient and his or her provider became almost irrelevant: the employer would choose one insurer, HMO or PPO one year and leave it and its network of providers for another the next year. Health care became an almost anonymous uninformed commercial transaction. Which brings us back to Mr. Spitzer and raises the question why the public isn't as outraged about the health care it receives as it is about his conduct?
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