Health Care Reform Individuals Matter

Health care reform emphasizes government role and role of large organizations. It is necessary to empower individual patients who can really make a difference in this process.

Most, though not all, would agree that some sort of health care reform is necessary. The main reason is that current levels of health care expenditures are not sustainable. The access to the top of the line diagnostic tests, specialized care, novel drugs and surgical therapies, all come with substantial costs. The current health care reform strives to decrease expenditures by somehow making health care system more efficient and eliminating unnecessary expenditures. The definitions of "more efficient" and "unnecessary expenditures" are, of course, a matter of various opinions.

Meaningful health care reform will most likely be carried out by individual consumers and not by huge government regulation. Why is that so? Let's look at the current delivery model. Someone gets an ache, gets injured, or goes for routine checkup. The standard of practice dictates the next step. There is some inherent variability in these next "standard" steps, and the steps are influenced by a variety of factors. In general, health care providers will recommend what is available. Here is the main dilemma: is the recommended test really necessary for a particular individual, what are the risks of getting or not getting test or procedure for specific individual, is the cost justified? By encouraging accountable care organizations and other large "systems" of care, the health care reform is shifting the responsibility of answering these questions from patients and their health care providers to policy makers and other third parties.

So, what is most likely to happen next? The third parties will figure out a way to cut costs and will be rewarded with incentives and bonuses. Number of available services will most likely decline. It would be reasonable to assume that some patients and some providers will not be happy with the new arrangements and will look for alternatives. Alternative organizations will be formed and will offer more services for a premium. The larger organizations will be forced to return to full complement of services in order to compete, and the costs will never really decrease. In fact, it is very likely that the costs will increase over long term because compliance with the new regulations will also be associated with additional expenses.

The arguments in favor of current health care reform include points that it will decrease costs by encouraging efficiency and by implementation of electronic health records. Efficient care is a wonderful concept, but whether overall costs will decrease is another issue. In fact, efficiency may discover more incidental problems. No one knows whether these new incidental problems discovered early will decrease or increase cost over the long term.

Electronic health records (EHR) are the way of the future and the sound of EHR definitely has a positive connotation for most people. Those who dealt with implementation and maintenance of electronic health records may or may not agree. Will large scale EHR projects somehow result in overall savings, or will constant updates and reboots result in higher indirect costs?

The real answer to solve the problem of overutilization and over expenditures on unnecessary procedures and services is to empower patients and their providers to adjust care on an individual basis. Each individual after being properly educated can make a decision whether a particular recommendation or an option applies, and whether risks of proceeding or not proceeding are justified. The patients should be educated on the concept of cost versus benefit. The option for a procedure, test or new treatment should always be given. The decision to utilize or not utilize what is available should come from individuals and their doctors and not from the third parties. As co-pays become more noticeable by the patients, health care providers are being asked questions like “is this really necessary?” If every patient learns to ask that question, the overall costs are likely to decrease very quickly.

The government can have an invaluable role in cost reform by dealing with coverage levels rather than trying to apply one size fits all approach. There is no question that basic coverage should be provided to all regardless of the ability to pay. The luxury services such as non-restorative elective natural look modifying procedures should probably remain in fee for service arrangements. The role of the government should be to define and continually update of what the basic coverage should be at any given time. Emergency care is an easy one. Everyone is eligible right now. Other services will need to be updated as time passes. If a cost effective treatment is truly beneficial and results in meaningful recovery or definitive extension of life expectancy, such treatment should be part of the basic universal coverage. The decision of what should and should not be covered have to be based on large studies. Here, once again, government can step in and fund large scale studies that can answer specific questions: “Does disease modifying drug X really change return to work time?” “What age group should be covered and in what age group the effect is not justified?” The role of the government should be to guide and support the decision making and not to dictate decisions.

In summary, meaningful results can be achieved if each individual patient’s problem is approached on a case by case basis. The basic universal coverage is necessary to address emergencies and to fund truly beneficial treatments that some may not be able to afford on their own. Everything else should be tiered into various levels of available care. Some of the tiers can be paid for by additional insurance. Some should probably remain in fee for service arrangement. Each individual will be able to choose what is important to him or her realizing that having access to top notch therapies that have not yet been proven to work for their particular case has associated costs.

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