Healthcare and ACA: Part 1

This is a very touchy subject right now. Our sitting Senate has voted to repeal the Affordable Care Act (Obamacare) without having an alternative in place. I have mixed feelings about this.

I want to start out that our healthcare system, like many of our systems, are broken. The biggest reason for this is our failure as a society to provide adequate education. From this system alone all our other systems fail. However, I am going to talk today about the ACA, insurance, and our current healthcare system.

Let’s talk about insurance first, or what insurance is not. Insurance is NOT a guarantee of quality health care. Insurance is NOT there to take care of all your little medical expenses. Insurance is NOT there to keep you healthy. If you have great health insurance but you eat four times a day at McDonalds your health insurance will not be able to prevent your heart disease. Insurance IS there for emergencies (appendicitis or a broken bone). Insurance IS there (or should be there) to cover passing medical disabilities (pregnancy or slipped discs) and should help cover the costs of care during these types medical needs.

Insurance is a gamble. I am betting (though praying not), with my premiums, that I will need some sort of emergency care. The insurance company is betting that I won’t. Much like a casino the insurance company makes its money when you are perfectly healthy. You make money… when you are sick. Does that sound like a win to you?

Why should insurance NOT be a guarantee of quality healthcare? Because we, as healthcare providers, should be attempting to provide quality healthcare no matter what. There are very few healthcare workers out there who wake up in the morning and say to themselves, “You know what? Today I am going to provide shitty care to all my patients. What do I care? I get paid the same.” I am not saying we don’t have bad days. I am not saying some aren’t out for the money. We do and some are. The vast majority of us want to do our jobs and do them well. We also want to get paid appropriately for our skills.

Why should insurance NOT take care of all your medical expenses? Does you car insurance pay for your gas, tires, and oil change? If it does for a reasonable price please tell me which company you use ’cause I will be on that like white on rice. How about your life insurance? Does that cover your rent/mortgage and food? Again, what company!? I am not pointing this out to be rude, but we don’t expect any other insurance to cover our routine costs in life, so why do we expect our health insurance to? Because we don’t go to the doctor every other week? So? You don’t get your oil changed that often either. Preventative maintenance should be our responsibility in all aspects of our life, including out health.

I pick out emergencies for the obvious reason. You buy life insurance for when you die, car insurance for when you wreck, and homeowner’s insurance for when your house burns to the ground. An EMERGENCY. I added the caveat of short term disabilities because they are emergent non-emergencies. I planned on getting pregnant. I did not plan on going on disability for complications of pregnancy. It is also a temporary medical condition. I will not always be pregnant and will be able to go back to work. If not, there are other financial securities I should have in place to cover my costs. No one plans on getting cancer, but it happens and the cost can be astronomical. Again though, this is for a limited time or it is terminal. Care should extend to treatments and continued screening for cancer.

So, now I have covered what insurance should be doing in an optimal system. Does this sound like the system we have? No, it doesn’t. It has been fed to us that health insurance should cover all our costs. This is impossible and a bad business model. It drives up the cost of health insurance and the cost of health care! Insurance is a band-aide on a symptom of our poor healthcare system, not the cause and certainly not the cure.

Now that we have covered insurance, let’s talk a little bit about the system of care. It is a service industry. Just like waiters, taxi cab drivers, and your lawn guy, we provide you with a service. Our main difference is you will need us at some point. This isn’t a question of if, it is a question of when, because you will need our care. And you probably will not like it.

I am not sure where this idea developed. I suspect because it is an easy parameter to measure is the excuse. Your hospital is NOT a hotel. Your doctor’s office is NOT a restaurant. Your satisfaction is not our markers for successful treatment. Why do you have to be at the doctor’s office 15 minutes before your appointment and wait an hour before you see the doctor? Because of these stupid scores. Why is there a spiking opioid addiction in the US? Because of these scores. Why do your nurses sound like robots and you get asked the same question over and over? Because of these scores. What scores am I talking about? HCAHPS and Press-Ganey surveys. This is a painful subject for me.

The parameter I am talking about is your satisfaction with your care. Not “did you get better,” or “were you given the appropriate information,” but “how do you feel you were treated?”. This is a terrible parameter and studies have shown that higher scores correlate positively (they both go up) with morbidity (illness) and mortality (death). You can be very satisfied with your care and still be dead. This paper showed that health outcomes did not affect patient satisfaction (isn’t that the point of the intervention?). This paper showed positive correlation with higher healthcare costs and higher mortality rates. This is not to say we shouldn’t strive to provide a satisfactory experience, but the current parameters we use to verify satisfaction are not well made. If you are constipated I will give you an enema and you probably will not enjoy it. But you pooped. Which is the greater indicator of successful intervention for your current problem?

You would think that the long waits have to do with greedy doctors trying to squeeze in one more patient so they can make more money. This is absolutely true, but not for the reasons you want to believe. With the rising cost of healthcare, doctors are feeling the pinch. It is not the financial windfall you think it is. Primary care doctors (your family doctor) don’t make bank. Most new MDs and DOs won’t go into family medicine because there is no longer financial stability there. Their student loans and the amount of overhead it costs to run a family practice is too high to contemplate. Less doctors equate to longer waits at the office and docs trying to see as many patients as possible to make ends meet. It is not an ideal situation. The same can be said for hospitals.

All of these things drive healthcare costs up without improving the system. Increasing healthcare costs on this front are reflected in our insurance premiums. The cycle continues.

The last part of this problem, within the system itself, is two fold. We have an over-dependence on drugs, pushed by Big Pharma, and a lack of ability to experiment with alternative medicine. Big Pharma first. These guys are not out to help cure you. They are out to make you loyal customers. Look how many ads are for different drugs for the same type of disease. Whenever I watch TV I see at least three ads for different medications for psoriasis and blood sugar. “Ask your doctor if BlahBlah is right for you!” The US pharmacopoeia is huge. Fine, whatever. But there was a reason the EpiPens hiked this past year and multiple Pharma CEO’s have been in the news for basically defrauding the public.

I am not against medicine. They are usually necessary. I don’t think medicine should be the end game and most medical professionals will agree with that.

The second part of this is the inability for healthcare providers to offer a multitude of different treatment options. You have pain? Here is your prescription of pain killers. You have high blood pressure, here are your BP meds. It doesn’t stop. I just read Dave Ramsey’s Total Money Makeover (go buy it. It will change your life) and, as of 2012, Big Pharma had paid over $88 million dollars in lobbying and advertisement, while alternative therapies spent $4 million. I haven’t looked at recent numbers, but I also haven’t seen any commercials for acupuncture. Doctor’s hands tend to be tied to what INSURANCE will cover (and since most of this is routine, existing conditions) not always what is best for the patient. I would love to see chronic pain patients get weekly massages. Cheaper to give them Norco. I would love to see obese patients get assistance with diet and exercise. Cheaper to give them meds to cover their many illnesses. Insurance tries to keep things cheap to keep their money coming in. You will only get eight physical therapy sessions, then meds will have to be your answer because INSURANCE won’t pay for more.

Are we seeing a trend here? This was the original problem with the ACA. Insurance never equates to quality healthcare. It is expensive and escalates healthcare costs. Big Pharma is out to make a buck and create long-lasting customers. This drives healthcare costs up and insurance up. Insurance reimbursement is tied to Patient Satisfaction, not health outcomes, which drives healthcare cost up. The system is tied so tightly to Big Pharma, Insurance, and Patient Satisfaction that healthcare providers are required to find the easiest, cheapest way to manage our health problems. Notice how I said manage and not fix. You don’t get out of the system. You wouldn’t be a loyal customer if you did.

Alright, I have covered a lot in this blog and it hasn’t even covered the biggest problem in our healthcare system. YOU. Let me know what you think. Please be courteous and respectful, even if you disagree with me. I am open to honest discussion but I will delete any comments that I feel are out of line (and yes, that is up to me). Thanks for reading and join me for my next blog!

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