Sunday, December 30, 2007

Obscure Store and Reading Room: I finally got around to watching "Sicko" last night, and then...

Obscure Store and Reading Room: I finally got around to watching "Sicko" last night, and then...

This posting, and the resulting comments, are interesting - but not surprising. Cigna has been in the news lately due to the news reports about the tragic death of a young girl who was denied payment for a transplant until it was too late. Cigna was the bad guy this time, but it could have been any "Payor," including medicare or medicaid.

The comments highlight the fact that people are frustrated by the US healthcare system - and should be. Our system is badly broken, and every part of the system needs to be involved in fixing it. To put it simply, our incentives are all wrong.

1. Insurance companies have every incentive NOT to pay for treatments that either are not covered under their plans (determined by Employers, in most cases) or are not deemed helpful or necessary (which I believe was the case in the recent Cigna example). A lot of people don't understand that their employers purchase specific services from insurance companies for a cost; often when a claim is denied, it's because their employer decided not to cover it when it bought the plan.

2. Doctors and Hospitals are incented to see lots and lots of patients, and to do lots and lots of tests and treatments. There are statistics* that indicate that millions of patients each year receive treatments that are medically unnecessary or unhelpful (or even dangerous). NOTE: As the son of a physician and a clinical psychologist, I know that 99% of doctors prescribe treatments that they believe are best for their patients. However, the system works against them just as it does for their patients. They're fighting an uphill battle.

3. Consumers have inadequte incentive to become educated about their health and treatment options, and typically have no idea what treatments are effective, which doctors and hospitals provide the best quality care for their needs, or what various treatment options cost. NOTE: Payors and providers have not done consumers any favors here; shielding them from cost and quality data and making it very difficult to access the right information at the right time.

I do not believe that simply socializing medicine is the best option; the only way to make things work is for all 3 groups to get together and align their needs in a new health care system. That's the reason that my company has started ChangeNow4Health []. This is an open forum designed to give all the stakeholders in the system a voice in how to fix things.

Please understand that this is not an advertisement for insurance companies; my industry is as guilty as any of the stakeholders in the system (and perhaps more than most) in creating the system we have today. But no one stakeholder, including (and perhaps especially) the government, is positioned to come up with "the answer."

*The following is excerpted from the Agency for Healthcare Research and Quality's 2002 fact sheet, Improving Health Care Quality []
Overuse of services. Each year, millions of Americans receive health care services that are unnecessary, increase costs, and may even endanger their health. Research has shown that this occurs across all populations.
For example, an analysis of hysterectomies performed on women in seven health plans found that one in six operations was inappropriate. A study examining the use of antibiotics for treating ear infections in children on Medicaid found that expensive antibiotics were used far more often than indicated.
According to the findings, if only half the prescriptions written in 1992 for more expensive antibiotics had been written for amoxicillin, a less expensive but equally effective antibiotic, Colorado's Medicaid program would have saved nearly $400,000 that year


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