Are you worthy of health insurance and high-value care?

Who is worthy of having adequate health insurance and high-value (safe, cost-effective) care; what makes them deserving? And who, on the other hand, is unworthy; what makes them undeserving? Note that this is the first post of a four-part series.

Let’s start with health insurance. It seems to me that the American Capitalist model currently considers three groups as worthy of having at least minimally sufficient healthcare coverage: Those with adequate financial resources (employees with employer-based insurance and the wealthy); older adults (receiving Medicare, at least until the program defaults); and the poor (who receive Medicaid). But even with these “worthy” groups, only those with the financial means have regular access to high-priced healthcare providers (such as “boutique clinics” and expensive specialists who refuse Medicare and Medicaid) versus overworked and underpaid primary care physicians and community/public health centers. And some argue that these groups should be further restricted to only those people who take good care of themselves (e.g., drug addicts, smokers, alcoholics, over-eaters, etc.) are undeserving and should lose their coverage.

On the other hand, our form of capitalism considers the tens of millions of working poor, undocumented aliens and others without adequate financial means as unworthy of health insurance. These “unworthy” adults go without needed care, including preventive and routine care, such as mammograms, pap smears, or screenings for colon cancer. Almost half of uninsured individuals will not seek care when they have a medical problem, compared to just 15% of insured individuals. They also have worse health outcomes, including breast cancer have 30 to 50% higher mortality rates, colon cancer have 50 to 60% higher mortality rates; and a 37% higher mortality rate from accidents. If they have chronic conditions, they are almost twice as likely to visit an emergency department or be hospitalized as insured patients because the lack of routine care means their chronic conditions are often poorly managed, increasing the likelihood of serious, acute complications. And once hospitalized, they receive treatment for acute needs but probably don’t receive appropriate follow-up care, resulting in worse health outcomes over the long term. Uninsured children also lack access to care and experience worse health outcomes. [The above contains snips from the CalHeatlhReform web site.]

Interestingly, the great equalizer is our failure to deliver high-value wellcare and sickcare consistently to anyone, no matter how wealthy one is and how much insurance coverage one has. Safe, effective, appropriate and timely care—delivered efficiently and affordably—is rare in America. Problems with poor care quality and waste are endemic, and our nation has been doing little to gain and use the scientific knowledge and information tools needed change things around. For example, as discussed on our Wellness Wiki :

• Medical treatment causes between 80,000 and 250,000 deaths a year usually due to physician mistakes and negative drug effects--including unnecessary surgeries, medication errors, diagnostic errors, infections, and negative effects of drugs—which ranks the U.S. 15th out of 19 countries in deaths potentially preventable with excellent medical care. The total cost of medical mistakes, including medical costs and lost production, totals $17 to 29 billion a year. Furthermore, at least 30 percent of all direct health care outlays are the result of poor quality care, consisting primarily of overuse, misuse, and waste, with $2 billion being spent annually in excess medical costs alone. All this means our government's annual bill for healthcare spending significantly exceeds that of other nations, and could reach $4 trillion by 2015, with one of every five dollars being spent in our country on healthcare.
• Our “practice variation” problem means that more care and higher spending are not associated with better outcomes, and may, in fact, result in worse outcomes. A patient could be hospitalized for nine days in one part of the country and three in another for the same diagnosis, and those differences would have no impact on outcomes. In other words, more expensive care isn’t necessarily better care.
• Over 44 million people in the U.S. lack access to primary healthcare, even though such care is essential for improving outcomes and controlling costs by being patients’ first point of contact with the healthcare system, as well as their main source of preventive and essential care.
• Compared to other industrialized countries, the U.S. is among the least likely to have extensive clinical information systems or quality-based payment incentives, the least likely to provide access to after-hours care, and the most likely to report that their patients often have difficulty paying for care.
• The total Medicare debt will require over 90 percent of projected federal income tax revenues by 2075. And healthcare costs for promised medical benefits to retiring public employees — and estimated $1 trillion — have not been budgeted and is a looming disaster. Aging baby boomers are in for a rude awakening: Medicare is insolvent.
• Nearly 40 percent of physicians have manipulated insurance reimbursement in order to give their patients needed care by exaggerating patients' symptoms to allow for longer hospital stays, and changing patients' diagnoses for billing purposes. In addition, providers are growing so frustrated with the reimbursement rates that receive from health plans that they are starting to sever ties with those plans. The low rates have an additional negative effect: They force providers to increase patient rosters, resulting in shorter office visits, longer waits, and growing dissatisfaction among patients.
• There is simply not enough information about the quality of care — outcomes data about what works and what doesn’t — to enable them to make appropriate decisions. Their decisions, therefore, are based on limited or poor quality information. In other words, those who pay for and receive healthcare don’t have the knowledge they need to make informed decisions.
• An estimated half of all surgical operations and other medical procedures lack strict scientific evidence of their effectiveness and safety, and common procedures are prescribed that are not proven effective — up to 85 percent lack adequate scientific validation. In other words, healthcare providers often don’t know what treatments work best for a particular patient. And even when good information is available to support healthcare decisions, it often isn’t being used to improve care quality because the unaided human mind, no matter how competent, simply cannot focus on all the necessary details nor possess all the knowledge needed for continually making the best clinical decisions.
• A growing body of research in mind-body medicine not only demonstrates an undeniable interplay between biomedical, psychological, and social factors, but points specifically to a causal link between mental/emotional problems and many physical illnesses. This means that medical practitioners must somehow be certain a patient’s bodily symptoms are not significantly influenced by psychological problems, even though few have the knowledge to make such determinations.
• Knowledge about prescription medication safety and effectiveness is sometimes lacking. The Center for Drug Evaluation and Research is described as being broken. In a rush to approve drugs, a powerless FDA has been unable to assure that drugs it approves are safe and effective despite clinical trials.
• Billions of U.S. tax dollars are spent each year on research and hundreds of billions are spent on service delivery programs. However, relatively little is spent on, or known about, how best to ensure that the lessons learned from research inform and improve the quality of health and human services and the availability and utilization of evidence-based approaches. And there has been resistance in the healthcare industry to use scientific knowledge to help decision makers improve their performance.
• Obtaining the knowledge to improve decision-making requires a commitment to ongoing clinical outcomes research and a focus on continuous quality improvement — things that our healthcare industry has largely avoided. If studying clinical outcomes was given the same degree of attention as optimizing financial gains and resource utilization, we would have much better knowledge for supporting diagnosis and treatment decisions.

I contend that the only way to improve healthcare quality and control costs—and sustain these benefits well into the future—is for our highest priority to focus on obtaining and using clinical knowledge wisely by rewarding the use of evolving evidence-based knowledge to support decisions about how best to prevent health problems and treat them cost-effectively. Such solutions would overcome devastating effect of today’s healthcare “knowledge gap” and broken economic models.

Sadly, this is not the case. While our society considers certain people worthy of having health insurance, we consider no one worthy of receiving high-value care. So, why don't we deserve it?

I believe there are many reasons for this. One is our failure to invest adequately on the science of evidence-based medicine and health information technology. Another is political pressure from those with a stake in maintaining the status quo because they gain financially from a low-value, error-prone healthcare system in which ignorance and misaligned incentives dominate. Our system considers them worthy of high income and profits, while the healthcare consumer suffers. This is a model for disaster.

I suggest the solution start with a shift in the way we think of “worthiness.”

First, we ought to consider all Americans and other legal residents as being worthy of adequate health insurance coverage. This is the realm of universal healthcare and there are different models for paying for such care, which should be examined and compared. Unfortunately, the idea of universal healthcare runs counter to the American Capitalist model and its “free market” principle. So, the very idea of universal healthcare requires national debate about the goodness of our economic system and how our society determines human worth and deservingness.

Since people’s addictions, emotional problems, poor lifestyle choices, etc. worsen their health and increase costs, we ought to change the things in our society that promote these kinds of problems, rather than simply dismissing these people as unworthy. We could, for example, do such things as:

• Replace advertisements of foods laden with harmful fats and sugars, cigarette smoking, alcohol drinking, etc with adds promoting healthy eating and living
• Make unhealthy foods more expensive than healthy ones, along with increasing the tax on tobacco and alcohol
• Offer better health and wellness education and social programs and incentives for healthy living
• Prove better “compliance counseling” to help people manage chronic conditions m ore effectively.

Second, we should consider all Americans and other legal residents as being worthy of high-value (safe, effective and efficient) care. This means transforming our current healthcare system into one that focuses on eliminating waste, errors, over-treatment, under-treatment, inappropriate treatment, ineffective interventions, dangerous medications, etc. It also means doing a better job with prevention and other aspects of well-care.

In conclusion, let me say that I strongly believe our country could afford to deliver high-value care to all our citizens and others (including undocumented workers and their families) if we replaced:

• Waste & inefficiency, ineffectiveness, greed, ignorance, secrecy and misaligned incentives, which benefit an “economically worthy” few

… with …

• Efficient, safe & effective, economical, scientific knowledge-based, transparent, and appropriately incentivized wellcare and sickcare for all.

Anything less is lunacy!

Click here for part 2.