Another Perspective - One-dimensional healthcare

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By Frank Splendoria

With a doctor in the family, I’ve learned some interesting things about our current approach to healthcare. I must mention that the following is based on conversations with three doctors and information from just one healthcare insurance company though I’m told others are doing similar things.

Over the last several years, you may have noticed a move from paper files to electronic medical records in your doctor’s office. There are a variety of reasons for doing this, from making your medical history quickly and easily available from just about anywhere, to hopefully reducing medical costs.

Part of the drive to reduce costs includes a desire to provide relevant information to the public, so we all can make informed decisions on where or who to go to for medical help.

Generally each medical provider is measured in terms of “quality” and “cost efficiency.” Insurance companies measure cost efficiency for each medical issue for each patient in dollars by various parameters: Management (e.g. office visits); Surgical Procedures; Pharmaceuticals; Lab Work; Radiology; and, “Ancillary” actions. The respective costs for each patient are totaled and compared to regional averages for the respective medical problem.

The doctor or facility is informed about their costs and if they are above or below the averages. Below is good; above is bad. Providers are given an opportunity to describe how they are going to reduce costs if their costs are “comparatively” high.

Regarding “quality,” the federal government in conjunction with insurance companies, and national healthcare groups, determine the proper treatment for each medical issue. If a doctor strays from these guidelines, their “quality” of care is given a lesser grade.

Quality and cost efficiency information is aggregated and displayed in some kind of a general ranking like 1–5 stars for each provider. The more stars the better.

A favorable rating of course looks good and should benefit the doctor by attracting more patients and also improve their reimbursement rates from insurance companies. It’s beneficial, therefore, for providers to follow relevant guidelines and standards.

All this sounds good, until you know and understand it is a simplistic, “one-dimensional” approach. And herein lays the problem, an unbelievably big problem.

When I go see my doctors they always take into account my:

1. Family medical history;
2. Mental and physical condition;
3. Personal lifestyle; and,
4. Conformance with past medical advice.

The medical evaluation system described above includes none of these things! Why? Because it is simply too complex to computerize.

Given this, medical practitioners are forced to choose between having a good ranking and the accompanying fiscal benefit, or doing what they believe is best for you, their patient. Providers who choose to do the latter may well be “dropped” from an insurer’s “network” because they don’t or won’t lower their standard of care.

On the other hand, if the offending provider is allowed to remain in the network, a patient’s co-pay and premiums may be increased, and the providers’ reimbursement rate reduced, both as penalties. As a result, some doctors have responded to this economic reality by simply retiring, or refusing to honor a patient’s insurance entirely. Unfortunately, in either case each contributes to a smaller medical network work, i.e. more patients for fewer overbooked and overworked doctors, giving poorer health care.

I was told by one doctor that the Centers for Medicare and Medical Services, the folks in charge of Obamacare, are working on a better evaluation system, that is to include a level of patient “complexity,” i.e. the interaction of all our individual medical issues, our family history, etc.  That’s good, but can they really incorporate what a doctor knows about each of us into a computer?  Can they even come close?  And, from the same folks who had three years to develop Obamacare?  I’m not holding my breath.

The moral of the story is to make sure you have a doctor that is more concerned about helping you, than anyone else. Or put another way, as the “most interesting man” in a certain beer commercial might say: “Stay healthy, my friends!”

Frank Splendoria resides in Gascón and may be reached by email at paintedwoodsranch@gmail.com.