Jenny works at a Burger King and has no health care coverage. Her front teeth have decayed into brown stubs. She is forced to choose between her teeth and her children's occasional medical care. Meanwhile John, a businessman, does have insurance, and opts to take a $60 per month antihypertensive drug before even trying to lose a modest amount of weight to ease his hypertension. Jenny and John are both working Americans. What is wrong with this snapshot?
Does an insured patient have a responsibility to spend health care dollars wisely? I think so, and want to discuss ways in which wise spending and good lifestyle habits play an important part in my health care reform plan, Health Security America. Along with taking an active part in an independent single payer administration, taking greater care with our own lifestyle is a key way in which we citizens can take back our health care.
Please make the jump and find out how.
This diary is the seventh and final in a series, based on the
book I wrote about health care reform. To recap:
- Retired M.D. & HMO administrator speaks out introduces myself and the health care reform plan
- Health Security America: Kicking the donkey explains the need for independent administration of he new single payer plan, and why Democrats have gotten nothing done in 30 years
- Health Security America: People-powered health care introduces the blueprint of HSA's independent administration
- Breaking the special interest hammerlock on health care outlines the "8 inviolable rules" to free up competition.
- Health Security America: Howard unbound In which I use my M.D. colleague's example to show how HSA will trim expenditures in physician and clinical services
- Cutting health insurance premiums by optimizing hospital use talks about stopping the excesses of inter-hospital competition.
Let's begin with a quick recap of the Health Security America plan's administrative structure, an independent, publicly elected and accountable governing body. I'm increasingly convinced that we can not have effective health care reform without it.
A GUIDE TO REDUCING PREMIUMS WITH PATIENTS' ASSISTANCE
Without citizen input into the governance and policymaking apparatus of Health Security America (HSA), it can not succeed. One of the three principal mandates of HSA requires self-funding by the participants--that is, for the recipients to pay a premium --so the patient has real incentive to protect his or her health and pocketbook. It is vital that participants in HSA be close to the process of decision making, not isolated by layers of unresponsive bureaucracy. And by identifying three regions in each state where policy will be made through the hearings process, I have made close citizen involvement and responsive policymaking possible.
Here is how close involvement and patient responsibility works. The board of information described earlier will present the regional representatives with a set of issues to be decided. The citizen, through the hearing process and web site, will have all the necessary information at hand. He or she may choose to participate by actually going to the hearings in his or her region or through the HSA web site. He or she will participate in the debate and ultimately make a decision on an issue, casting a vote either at the hearing or through a secure web site.
I will give you a very simple example. The board of information may want to know if new rooms built in hospitals and rates to be paid by HSA will be based on four patients to a room or two patients to a room. The board will furnish information on both situations' effect on premiums, as determined by their actuaries. The actuarial studies will be based on the hospital infrastructure required for 295 million people and will be accurate. The board will present pros and cons as they see the issue. All the information will be forwarded to the regional representative, who will include it in the hearing process. The regional representative will vote on the issue as he or she sees fit, but also based on the hearing process that has transpired. Each citizen, I am sure, will look at the effect on the premiums and evaluate items such as privacy--with four to a room as opposed to two, more noise versus less noise--and other conditions before he or she votes. The 150 votes will be tallied and the issue decided. After the matter is decided, the board of information will implement the change to the premium.
In a time when the only sacrifice we were asked to make after 9/11 was to go shopping, it may seem a little uncomfortable to consider two to four people sharing a hospital room. But I believe that with a little hard common sense, we can easily and even willingly make wise decisions regarding our own health care. The distribution of health care is extremely lopsided in the United States, and those of us with "Cadillac" coverage will need to think twice before opting for the "easy" pharmaceutical or surgical fix and take a more active role in our own health.
Some cost-reduction measures will practically decide and implement themselves; I don't foresee waterfalls in the hospital atrium, valet service, television ads, multi-page, five-dollar brochures, round-the-clock room service, or any similar type of expensive perquisite lasting past the first regional meeting. Nor will hiding these costs under non-profit foundations' auspices keep such items going since all hospital finances will be open and in my opinion citizens will not allow these excesses. I am not advocating building spartan cinder block hospitals, just building to a reasonable standard. After all, hospital stays are getting shorter. Most gallbladder surgeries keep people in the hospital less than 36 hours, in contrast to the six to seven days spent hospitalized not too many years ago. I doubt that patients will be upset if the atrium is missing a waterfall, and the 24/7 room service might be cut to three times per day at the usual meal times.
One of the first items I see being presented for hearing is a proposal for the establishment of a planning agency in each region to determine the location of expensive diagnostic equipment such as MRI and CAT scan units. I doubt a clinic will be allowed to have its own MRI or CAT scan unit if the hospital just ten blocks away has them. Hospitals do need them for emergent problems, and because hospital patients may be too sick to transport off-site for the test. In clinics, MRI and CAT scans are elective procedures and there is no reason that people could not make an appointment at the hospital for the tests. The cost of such medical equipment runs into the millions of dollars, and we must get maximum use out of it. We can not allow placement of such hardware unless we are sure that it will be used effectively, efficiently and with the utmost fiscal responsibility. If and only if existing units are working round the clock and more capacity is needed, perhaps purchase of additional units would be allowed. Of course, the aforementioned example is hypothetical, but optimizing placement and use of expensive medical hardware has to be addressed for the sake of cost control. Is this rationing or common sense? I have no doubt that critics will object to some cost controls such as these, but I trust that citizens will see past their objections and do what is reasonable.
In addition to optimizing use of expensive equipment, all kinds of contentious issues will arise to be decided, and there will be no choice but to grapple with them. Will HSA fund abortions? This book will not presume to answer that particular question, but as citizens we will have to decide. Presently, payment for abortion with government money is not allowed, but under HSA, the money--and the decision--will be decided by a simple vote of citizens through the hearing process.
I have given examples of questions that will have to be answered but I have not given the answers. The citizen will make the decisions. The decisions will be put in the pot and out will come a health plan, premium and insurance coverage. The aforementioned examples are fairly cut and dried, and most reasonable people will easily agree on what to do. However, if we are going to lower health care costs in a serious way, we will also have to take an active role in managing our own health.
Patients--citizens--will have to take charge of their health and take more responsibility than they have in the past. What follows are descriptions of actions crucial to HSA's success--actions close to the core of premium reduction.
Shouldering the responsibility of our own health will be tough, but it will have to be dealt with and not avoided. I have seen numbers showing that 25 percent of all Medicare costs are due to diabetes and its complications of obesity, blindness, kidney failure, stroke and cardiac disease, among others. The complications of what are, arguably, poor lifestyle choices comprise a big part of over 1 trillion dollars of annual health care costs.
I am going to give examples of the type of decisions that citizens will need to make; I will not decide the ethics of any of the scenarios, but eventually citizens in control of their own health care will. The citizen should regard himself as a neighbor trying to help a neighbor-but how much help? What is the responsibility of your neighbor to you, the patient, through premium costs that he, too, must pay? Each citizen will have to weigh questions of standards of care, and decide who should take responsibility for his neighbor's health, the neighbor or to what extent -the citizen patient. The answers to these questions will be made evident through premium or coverage adjustments. I have great confidence in how patients will need to resolve the upcoming examples of health plan decisions, but many more such decisions will come up as we fine-tune our new health care paradigm using the hearing process.
I can cite many cases that have come into my office over 40 years concerning the common problem of high blood pressure; the names are not real, but the stories are. "John" was a successful businessman in our community. He came to see me when he was in his early forties. John liked drinking beer and grilling ribs for his friends and was about 75 pounds overweight. His blood pressure read 150/95-100 on repeated samplings, and all of his laboratory examinations still were normal, except for a slight elevation in cholesterol. That blood pressure was too high to expect long life without significant health problems such as stroke, heart attack, and other blood vessel diseases. I had instructed him adequately about the risks of stroke, heart disease and other potential problems. We discussed his lifestyle, and he understood the need to hold back on the beer and food. Over the next several visits, John clearly understood the instructions, including dietary instructions that I dispensed. But John just wanted some medicine and to move on. I gave him the generic drugs atenolol and Dyazide at the usual doses, but it did not do anything to lower his blood pressure. His weight did not change and John admitted to not being very good at his diet.
Now, here is a step that we took that will have to be broached and understood by all: I added an ace inhibitor, an expensive drug, which at the time was not generic at the usual doses. Its cost was--in the range of 40 or 50 dollars per month. John's insurance paid the bill, and we got the blood pressure back to normal, yet we still had a man with an overweight condition and a lifestyle that was going to lead to more health problems within another five to ten years. I told John as much, and before he took the very first pill, John knew that he had to take the responsibility for his own health or he would die; his father had died of a heart attack in his early forties. John knew what he had to do, yet he simply was not ready to take responsibility for his own health. He took the easy approach of expensive medicine.
I want the hearing process to recognize and discuss this philosophy of taking responsibility for one's health. We know that, with weight loss, that blood pressure of John's type drops very quickly--even with a loss of only five or ten pounds, although it could take more. And in today's climate of scarce health care resources, it presents a question that can no longer be ignored: is it John's neighbor's responsibility to pay? After all, he is paying through his premium increase for John to advance to newly patented drugs that might cost up to $60 per month when John failed to take even the smallest of steps (weight loss) to fix his blood pressure problem. My opinion is no--the neighbor should not have to pay, not without some serious questions asked. The line is drawn. We need individual responsibility in these kinds of cases. And in deciding standards, through the hearing process, a rule stating that, in the cases of blood pressure problems of this type, only generic drugs would be used until after a trial of at least weight reduction. The percentage of weight lost might be used as a cutoff. Such a rule is not rationing, but common sense. When John and others like him are told that we, his neighbors, will not help him through our increased premiums for branded new drugs until he helps himself--he will lose weight. Call this tough love. Fellow citizens will decide the ethics of such a rule, not the insurance company or the government.
The next example of a patient's going for the expensive surgical fix over the inexpensive lifestyle fix is frustrating, since it is common and there are no present guidelines to curb it. I have a friend who is 75 pounds overweight. His knees started hurting, and he was found to have degenerative arthritis of both knees. There is a 40 percent greater chance for an obese person to get knee degenerative arthritis than a normal weight person. He was told to lose weight and instructed how, and in fact his wife was a home economics teacher with all the cooking and diet answers he could desire. However, he did not follow instructions and his knees became very painful. He called me about a year ago to let me know that an orthopedic surgeon had volunteered to replace both knees with artificial knees at the same time. At that point, he had not even attempted to lose weight. The prospect of his having surgery frightened his wife, since he was putting himself at risk of having a complication (my friend has some controlled heart disease as well) with the surgery, and the lives of his family members would have been affected, too. In these situations, we know that if the patient loses weight and does gentle physical therapy--swimming, for example--up to 30 or 40 percent of the time he or she will get adequate relief and will not need surgery. Again, my friend's demand is "Fix my knees--the insurance will pay the bill!" It will indeed, but the neighbor's premium will also reflect this expense.
My friend eventually did take the weight loss route, with swimming and physical therapy, and he did get relief without surgery--but it was due to his wife's concern, not the expense that would have been incurred. And the expense would have been considerable. In Minnesota the average charge for total knee replacement among Minneapolis/St. Paul metro hospitals was $29,817 during the fourth quarter of 2004. Nationwide, the average physician charge for total knee replacement is $1,419, according to the Medicare web site. The cost for my friend's insurance company based on the aforementioned fees is $62,472. That cost does not reflect any percentage for complications, and there are some complications, including bloods clots, heart attacks, infection or anesthesia problems. The added costs of complications would have to be dealt with and are a statistical certainty. Every year, there are 270,000 knee replacements performed in U.S. hospitals. The cost amounts to $8,433,720,000 per year being spent in this country on this procedure. Possibly as much as two or three billion dollars--a not insignificant sum--could be saved with increased personal responsibility, such as weight loss.
Policy on knee replacement protocol and many other items will be on the table for everyone to decide. Medical professionals, actuaries and other informed people will present the facts and figures of each contingency--and its effect on the premium. Then neighbors--all of us--will decide on what is best to do. I think that the consensus will be that it is most prudent to attempt weight loss before rushing to surgery. A time frame could be set by citizens during which weight loss must be attempted before surgery is authorized. I believe the savings will be in the billions. Is it rationing--or hard common sense? Is it ethical? The consumer gets to decide.
I am adding a caveat that we will start implementing HSA with new conditions--that is, with new diagnoses, not longstanding ones. By no means will we take away the medicines and care for people already disabled with their diseases. I will leave changes to the plan for presently afflicted people up to the hearing processes previously described. There is room for debate.
These two cases of lifestyle change versus expensive treatments highlight some of the key principals of HSA governance, and a mechanism whereby we begin to save up to 50 percent of present-day premiums. Citizens will make many very common sense decisions based on the two examples given and the principle, I am paying part of your health care and all of us want to be treated fairly. The savings here will be enormous as no group of healthy individuals paying monthly premiums will allow expensive health care decisions that are not reasonable and do not take into account that he is paying part of the health care of his neighbor.
So there you have it: Health Security America. I have a hunch that many fine Americans are aching to do something constructive to help us all out of this completely unfair, undemocratic health care mess. I ask you to consider my plan and the coalition forming around it.
Thanks to everyone who has taken the time to read and respond. Please visit the web site for more information and updates as to our coalition's activities.
Fred Bannister, M.D.