Commentary on Managed Care
(licensed vs non-licensed de facto practice of medicine)

CHAB

Wednesday, February 13, 2008

Commentary by
Roger S Case, MD

 (Health Officer, Island County & Commissioner, Whidbey General Hospital)

Here we are again, ninth in a series begun in April 1997 to focus attention on the changing world of health care in America… and more to the point, how it affects you and I... and everyone else you know. It's been a year since I addressed the issue of "Convenience Care" — that drop-in clinic operated by a chain store / pharmacy staffed with mid-level providers. Hasn't happened yet? It's coming.

"YES WE CAN !!"

This seems to be the mantra of every candidate running for office these days. But we don't hear a word from that all-powerful industry gobbling up our health insurance premium dollars, do we. An industry that pays their CEOs astronomical stipends, and continually attempts to short you (us) on covered services. I wonder why they are so silent. And just HOW are "yes we can" candidates going to resolve the issue?

We all know that medical insurance is necessary, and that insurance is a business that must remain profitable to accomplish its task. It does so by spreading risk among the insured. . . and that to properly assess risk, accurate information about would-be patient's health status must be considered. Today I learned that one of the nation's largest health insurers is demanding that providers report to them any health problems they find that were not listed on their patient's applications for insurance — making your provider an extension of the company's application assessment process. Is this what we have now come to accept as a proper activity for our physician, nurse practitioner or physician assistant?

The health insurance industry arose from the need to address several issues among which are:
     1. A reliable method of payment to the physician / hospital for services rendered
     2. An individual's need to have a way to keep health care costs as low as possible by
         joining a 'pool' of like-minded citizens to spread the risks among the many
     3. A way that individuals could 'bank' funds by buying insurance for the unexpected
          medical problem
As we moved further from direct payment for services, insurance companies were happy to step into the breach. . . resulting in what has now become an untenable situation with the industry's consuming an unacceptable proportion of premium dollars to provide this "service" for us. A considerable percentage of the premium dollar never reaches the health care community.

The American public must take control of how the health insurance industry functions, ideally at the State level. . . doing so at the Federal level would remove control too far from the individual, too susceptible to political influence. But a uniform state-regulated health insurance program absent the cancerous siphoning of premium dollars to pay for stockholders, multiple staffs, large buildings and huge CEO salaries would permit some degree of uniformity in plans, and considerably more funds available to pay for hospital and provider remuneration — where the actual funds should go.

I believe a state-run health insurance program would eliminate much of these funds being used for other-than-health-care purposes. Anyone devising the most efficient way to fund health care would arrive at establishing a single-payer, multi-level plan that the individual could buy into at whatever level (s)he preferred, conducted with the least overhead cost possible. That would rule out the typical health insurance company. Stockholders, huge buildings, massive staffs and multiple forms would be eliminated. Why do we put up with this?

I'll tell you why. Apathy, disorganization, listening to the hype of the present health insurance spokespersons, the doomsayers of single-payer health care, the "free enterprise" advocates and even many physicians. Let's face it. There are some things that the government can provide more effectively and efficiently than private industry — things that require absolute uniformity of application and access, easy oversight and control. It is for the latter two components that I would insist the program be a state-level operation vice federal. . . closer to home and much easier to monitor and control..

It is clear that something must be done about our health care problem. We cannot demand everything possible in health care and expect to pay nothing (or very little). We cannot ignore our lifestyle issues and expect medical miracles to restore and/or correct the results of our indiscretions. We must consider whether spending 27+ percent of our health insurance dollars on the last 6 months of life is a prudent expensing of scarce funding, (i.e. the Oregon experiment) and what, if anything, we are willing to do about that issue.

Atop all this, retaining primary care providers (especially here in Washington State) has become a very serious concern, particularly in rural areas. Note some of these sobering health care statistics, largely due to financial issues:

• The percentage of vacant physician assistant and staff nurse positions in
   Community Health Clinics* (CHCs) in 2006: 10%
• The percentage of vacant family practice physician and internist positions
   in CHCs that same year: 20%
• Increase, from 1997 to 2004, in the time heart attack victims had to wait
   for care at U.S. emergency departments, in no small part because of a
   shortage of care providers: 150% — from 8 minutes to 20 minutes

*(Community Health Clinics are the one place where anyone can be seen for any medical concern, regardless of ability to pay, so staffing of these clinics is of vital concern to the growing ranks of patients who find themselves without a health care provider) 

So, what are your thoughts about how we should begin to work ourselves out of this ever-growing dilemma that is not going to just "go away"?

Again, I implore you to keep yourselves informed. The pending revolution in our health care will literally be a life-changing event for us all over the next few years.
_______________________________________               

Roger S Case, MD, FAAFP, retired Family Practitioner         

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