Friday, September 21, 2012

My Ideas for Fixing our Healthcare System, 4

     My favorite patients are the ones who have no insurance, yet understand that they need to invest something in their own healthcare.  They don't want to pay exorbitant monthly premiums, only to find out--once they're desperate--that their insurance doesn't cover the first $5,000 if they have to be hospitalized, or doesn't include birth control, or insists on a 20% copay when they need surgery, or requires "prior authorization" for an MRI--which is likely to be "declined."
     Sometimes an uninsured person accompanies a relative or friend who has come in for a doctor visit. The uninsured person tries to "piggyback" a free visit on top of the insured friend's visit.
     "Would you mind looking at my throat?" she might ask.  Or, "I know I'm not your patient, but what do you think about this rash?"  What's a doctor to do in this situation?
      "Why don't you go up front and get established as a patient?"  I suggest.  "Then I can take care of you properly."
     "I can't," is the standard reply.  "I don't have insurance."
     "I'll bet you pay more for maintenance on your car every year, than you do on your body," I say.  "Which is more important."
     Since these individuals aren't paying monthly premiums--and how can I blame them, with family insurance rates now averaging $14,000 per year --I recommend that they invest a small portion of that in "body maintenance."
     I suggest $250.  For this amount, I can do a physical exam in my office, and up to four tests, such as a chest x-ray, EKG, urine test, spirometry, labs--whichever are relevant, based on the patient's age and condition.  I evaluate these patients fully, exploring their past history, daily habits, family background, and current symptoms, and I do a complete physical.  If they have an acute problem, I treat that as well.
     Afterwards, I sum up my findings.  "If I were you," I may say, "and I had another $250 to spend, here's how I'd spend it--to prevent problems down the road."  The recommendations vary, based on each patient's circumstances.  The money might best be spent on nicotine patches and acupuncture, to quite smoking.  Or, the patient might benefit from a stress test and additional labs.  Or, I may suggest spending it on a health club membership, a pair of running, shoes, massage therapy, herbs or vitamins, couple counseling, a pelvic ultrasound, dental care, surgery to remove a skin cancer, cortisone in a hip joint, or balance training to prevent a fall.
     My point is this.  Doctors work best when they are permitted to use their experience and training to help patients achieve better health.  We are good detectives, so long as we aren't subject to a long list of absurd requirements by government task forces, insurance companies, auditors, or other policing agencies.
     Let's give patients a budget to spend on their own health.  If patients had, say, $1,000 a year, I physicians could probably keep most of them out of trouble.  I'd counsel and exhort them, prescribe medicines as tools, measure their progress, and commend them on their successes.  Do any of the people who put together the Obamacare plan understand how vital these "soft" interventions really are?
     There are no recommendations that apply across the board to every patient--this is where "task forces" and "advisory boards" get it all wrong.  Medicare's new quality assurance panels, for instance, make the assumption that every diabetic patient needs exactly the same tests and treatments, at exactly the same intervals.  This information may be of some use to physicians, but forcing us to fit every patient into an algorithm, and punishing us when we don't, distracts us from who the patient really is, and what that patient is willing to do, and what is going to work, finally, in that patient's case.  This information is far more important when it comes to improving the overall health of our patients (and lowering their cost) than any edicts from above about what referrals to make, and what tests to do.
      Getting to know a patient as a person in a medical setting makes an enormous difference in the implementation of good medical treatment.  Since we family physicians relate to our patients over many years, with compassion and depth, we discover what makes them tick, and we know how to motivate them.  There are many factors--social, psychological, familial, economic, and cultural--that affect how people care for themselves.  Family physicians have the most leverage with patients, and can inspire them to change, when necessary, because we know them, and we really care.
     Patients should be allotted an annual budget, and could choose their own physicians, in the same way that consumers choose products and services in every free-market economy.  Physicians who don't meet a certain standard wouldn't survive--just as any business will fail if customers don't value its services.  Patients should be assigned a health score--based on their risk for hospitalization, severe illness, or death--and physicians should be rewarded for preventing bad (and expensive) outcomes.
     Medicare has suggested that doctors should be rewarded for keeping patients healthy.  But the methods proposed for doing so are too simplistic.  Some physicians have an affinity for the very old, or very sick, or for end-stage patients, while others have young, healthy populations.  Without a baseline measurement of a patient's risk, it's impossible to measure how well a physician has managed to prevent illnesses, or hospitalizations, or early death.
     Insurance companies use health status and age as predictors of illness and death--we could borrow their parameters to give each patient a "health grade."  Patients might be motivated to improve their grade by following health recommendations and taking preventive medicine seriously.  If you were given a health grade of 70 out of 100, and you trusted the system within which you were being assessed and treated, wouldn't you want to find out how to bring up your grade?
     As things stand, patients don't know their health grade.  In my clinic, I sometimes try to communicate this information to them, along with advice about how to improve their health and longevity.  When I speak in concrete ways--"You're are likely to have a stroke or heart attack in five years if you don't do x, y, and z,"--patients usually listen.  While I don't like to make predictions that might be interpreted, unconsciously, as instructions--for instance, to have a stroke or heart attack--I think it's important for patients to understand that their lives are finite, and their bodies are not immortal.
     Too few of us realize that our personal choices have a lot to do with our health--and our deaths.   Maybe we believe in magic, or we exclude ourselves from what we know about the human body.  Maybe the current medical system has infantilized patients, so that they become dependent on doctors for their lives, or blame them for illness, or set them up as autocrats, or deities, or idiots (I've seen all these)--then the patients are never forced to assume their own portion of responsibility for their health, wellness, sickness, and final outcome.
      A health score assigned to patients could bring home the reality of each patient's likelihood of getting sick and dying.  It could help patients value the gift of their lives, and might inspire them to take better care of their bodies.  It might make them more open to vital information about how to improve their health-- a health score that goes up as a result of personal effort would be its own reward.
     So, in my healthcare system, patients would be assigned a health grade, doctors would be rewarded for inspiring patients to improve that grade, higher grades would likely be associated with lower national healthcare costs, and patients would be given an annual budget to spend on their health, however they wish, under the direction of a family physician--whose understanding and assessment of each patient would be the cornerstone of a healthy population.

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