Thursday, May 14, 2009

HR 676 - The Good and the Bad - Part 2

Continued from Part 1.

The health insurance benefits under this Act cover all medically necessary services, including at least the following:
(1) Primary care and prevention.
(2) Inpatient care.
(3) Outpatient care.
(4) Emergency care.
(5) Prescription drugs.
(6) Durable medical equipment.
(7) Long term care.
(8) Mental health services.
(9) The full scope of dental services (other than cosmetic dentistry).
(10) Substance abuse treatment services.
(11) Chiropractic services.
(12) Basic vision care and vision correction (other than laser vision correction for cosmetic purposes).
(13) Hearing services, including coverage of hearing aids.

All medically necessary services are covered. One of the cost containment measures may be to reduce unnecessary testing and procedures. A huge problem with our US system is unnecessary services, also known as "defensive medicine" because they protect doctors from getting sued. People need to accept that even best practices don't always work, and it's not malpractice. Doctors should be protected from lawsuits as long as they follow best practices. This will reduce costs without disproportionately reducing quality of care. It is also good that HR 676 explicitly includes mental health and substance abuse treatment, which both have cascading effects on health and quality of life over time and generations.

"Medically necessary" will still usually mean "whatever a doctor says". Many doctors fall prey to biases in their decisions that reduce quality of care in the face of current medical research, but doctors as a group refuse to let anyone else question them, no matter how much data suggests they do something different. Large payers have had varying success controlling service provision by controlling payments per diagnosis ("prospective payment" for "diagnostically-related groups" (DRGs)), but also have had trouble spotting shenanigans like hospitals "upcoding" patients to more severe diagnoses to justify additional treatment.

Chiropractors? Seriously? They seem to have had good lobbyists since at least the early 1970's. What an unnecessary waste.

Such benefits are available through any licensed health care clinician anywhere in the United States that is legally qualified to provide the benefits.

Totally standard.

No deductibles, copayments, coinsurance, or other cost-sharing shall be imposed with respect to covered benefits.

No financial barriers to treatment means that everyone can afford health care. Fewer poor people avoiding basic and preventative care means fewer poor people in the ER increasing our costs and reducing their productivity.

This is an obvious lesson we should have learned from other socialized health care systems, and from experiments within the US: cost-sharing is good. When health care is completely free, people go to the doctors when they don't really need to. This is when the lines and waits get unnecessarily long. This is when practitioners' time is wasted. Even the poorest people can scrape together a $10 co-payment if they really need a doctor, and just $10 will make people think twice before running to the doctor every time they sneeze. This is not about the money as much as it is about disincentivizing waste.

We should also charge for missed appointments. Years of working providing services in poor communities has given me much experience with no-shows and last-minute cancellations. This population has many reasons for missing appointments: no transportation, the health complication itself, being unable to better schedule other necessary conflicting appointments, but often they are just not motivated to do things. The linking factor between their poor health and poverty is often that they are characterologically immediately-gratifying and avoidant of putting forth effort or exposing themselves to additional stressors such as discussing problems with a doctor. For a number of etiological reasons, they are compelled to sit at home, watch TV, eat junk food, smoke, complain, and have kids that they don't raise effectively. These behaviors lead to both poverty and health problems, and perpetuate the problems through generations. I am not saying that this describes all poor people. This is just a common issue among the poor. Service providers of Medicaid recipients are lucky to have show rates over 60%. My current clinic has instituted a number of measures to improve the show rate, and is happy to report consistent rates between 70% and 75%, and we do not get paid when the clients don't show. We use phone call reminders, and we discharge anyone who misses two consecutive appointments, but we have no cost-sharing at all. I am privy to an experiment conducted by a dental practice that serves a poor area. They tried different charges for no-shows or same-day cancellations. They found that clients were more cooperative when the charges were used for a specific and known purpose (toys and magazines for the waiting room). They also found that $20 was the sweet spot for motivating attendance. Anything less than $20, and the clients would rather stay at home and pay it. Anything over $20 and the clients would never come back. $20 kept clients on the list and coming in for appointments. Take advantage of the people's desire to avoid stressors. Make the possible loss of money more stressful than the trip to the doctor.

Charging some money makes the system more effective and efficient than making everything free.

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