The Issues: Health Care
As a citizen, former state legislator and professional nurse, I have watched, listened and learned as America’s topic du jour for 11 months has been health care. Politicians have ideas, concerns and solutions. But, few if any have a health care background and “grass roots” understanding of the complex issues regarding health delivery.
There is a difference between “healthcare” and “health system”. The quality of care in America is generally not debated. But the “health delivery system” has some challenges. There are roughly 4 types of delivery system:
- Government Run and Funded- i.e. VA
- Government Funded-Private Provider- Medicare/Medicaid
- Private Provider and Private Pay
- Out-of-Pocket, Private Pay “Self Pay”
Each model has its own pluses and minuses.
1. Government Run and Funded (VA)- care is usually considered adequate to good. The patient does not have difficult time consuming insurance paperwork to fill out. When one arrives for care, you sit sometimes for a long time to be seen. Even before that it takes awhile to even get an appointment- can be up to 3 months for specialty clinic- i.e. eye clinic. It is run like a ‘bureaucracy”- like it or leave it. One size fits all model. In this model there is no incentive to take ownership for your own health.
2. Government Run-Private Provider- Medicare/Medicaid Since care is tax payer funded, providers have constantly changing, onerous rules to follow. One example is the nursing home industry which is the most regulated industry in the U.S., even more than the nuclear industry. Nursing homes have nearly 550 rules to follow which are audited on a nearly yearly basis by surveyors employed by the Colorado Department of Public Health Environment. Of-course because the care of elderly and disabled is at stake, we all need to know someone is truly watching out for their best interest. Nursing homes are inspected by surveyors (inspectors), and then again by Center for Medicare/Medicaid to insure that the surveyor did their job. For the nursing home staff this is a double whammy and more expense for the taxpayer. Medicaid reimbursement to nursing homes is notoriously low. The incentive for inspectors is to fine “something wrong”- called job security.
3. Out-of-Pocket-“Self Pay”. Usually a sign to the provider that the patient is indigent and they likely won’t get reimbursed. Sometimes the patient may make on-going payments, but this is difficult due to the nature of the patient who may be transient or illegal- yes, illegal. Hospitals provide care whether person is legal or not. These patients receive the same quality of care as someone with commercial insurance. Hospitals absorb cost or in some cases can apply for state Medicaid money to offset their losses. As a society we do need a “safety net” for those with no insurance and ill.
4. Private Pay- Private Provider. Cash or commercial insurance. A few hospitals are now trending toward not accepting Medicare due to fewer insurance forms, but mostly they don’t need to jump through the hoops of JACHO (Joint Commission on Accreditation of Hospitals) which visits the facility with a fine tooth comb in every effort to find problems.
I am not an advocate of a single payor, national or “government option” government run system such as Canada. I do not want a government committee deciding what care I can have and when it will stop. I want to make those decisions myself. Single payor systems must ration care in order to make it work. No country can afford Cadillac care from birth to death for every member of society. We will go broke. Age is the definer for care.
But, we must look at the whole American system and rising costs and come up with a more efficient and cheaper way to deliver health care.
1. Our American paradigm and culture must shift and put the ownership of our health on our own shoulders. Too often people decide not to take their medication, loose weight, exercise or stop smoking and that costs us all.
2. Increase use of Health Savings Accounts. You decide when and for what to spend your health care dollar. Human nature dictates that when it is our OWN money we spend it more wisely.
3. Allow private insurance to transfer from one job to another. Since we move from one job to another so frequently some doctors skimp on prevention because you will be under another plan in a year. No incentive to keep you healthy.
4. Allow purchase of insurance across state borders. Colorado alone has 46 legislatively directed insurance mandates that increase cost for all of us. Example- currently, all newborns in Colorado have audiology screening before they leave the hospital. No one has been able to tell me how many of these babies actually are deaf. But, we all pay for it none the less. Expect new parents to pay for audiology screen if their baby is considered high risk. Allowing us to purchase insurance across state lines increases competition in the marketplace.
5. Tort reform. Some procedures or tests are done to verify a diagnosis rather than to make a diagnosis. We live in an imperfect world and can not expect “perfection” and cures from providers. But, we can expect appropriate tests only when needed.
6. Reform Medicare. Relook at the onerous HIPAA law (Health Insurance Portability Accountability Act) which was passed in 1996. One portion of that Act was “intended to lead to improved security of health care information, privacy for recipients of health care and to improve administrative efficiency of health care throughout the US. How many times have you signed in to be seen by the doctor, only to see that after each signature is written, it is hidden for the next patient? This is ridiculous and a waste of staff time and energy.
Additionally, HIPAA wanted all hospitalized patients to know they have “rights”. The intent is good. The implementation is ridiculous. When you are admitted in the hospital, you sign a Medicare Letter which must be resigned at time of discharge. This consumes way too much staff time and auditors’ energy to make sure it is done.
Last, Medicare states that patients must be hospitalized for 3 midnights before they can be transferred to a skilled nursing facility. This too is ridiculous. Some patients can be treated in 24-48 for simple infections such as a urinary tract infection, but they must remain inpatient for 3 midnights which cost us all money!
7. We will never be able to expect or collect payment from any country of origin for medical care of their own. However, say in the case of Mexico who is the 3rd largest supplier of oil to the US, why don’t we expect oil concessions to compensate for uncompensated health care for their citizens. I have personally witnessed undocumented aliens who come to the US for health care that can only be delivered in a hospital setting.
8. Recycle durable medical equipment such as walkers, wheel chairs and commodes. There are instances when folks will be given a walker with each admission. This is an unnecessary cost for all. Expect everyone to take ownership in the health of our system.
Whether Congress passes health care reform or not, the debate has been at times healthy and constructive. Unfortunately, health care and delivery are complex and Congress needs more time, transparency and informed data to make any changes. Back room closed door negotiations that allow one state to have Medicaid paid in perpetuity by the rest of us only polarizes the country and hurts the sacred process of democracy.
That’s my take. What is yours?
