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Thanks to Andrew Sullivan who cited my post on the uninsured, I’ve gotten a lot of new comments on that subject.  While my post was just a gripe about the problem, the comments were mainly focused on solutions.  How do you fix the problem?  I even got an e-mail specifically asking me what I would do to deal with the problem of the uninsured.

You have to realize that I’m basically chicken (as are most doctors).  I like to point the finger and avoid the fingers of others.  It’s much easier to gripe than to fix things.  It’s much easier to criticize than it is to say things that can be criticized.  But I will break from the safe position of critic and give some thoughts on what I think needs doing on the problem of the uninsured/underinsured.  Those who doubt the reality of this problem have only to spend a few days in primary care physician’s office to realize that it a huge problem that is getting worse.

So here are my suggestions:

1.  The government has to take on tasks that are in the best interest of the public.

Preventive healthcare should be paid for.  This could be done via public health clinics, but having having some sort of preventive health insurance for the uninsured would not have much overall cost (compared to the whole of healthcare) and would potentially save money.

There certainly is debate as to what prevention is really worth it (the PSA test debate is a good example), but some prevention is clearly beneficial (immunizations, Pap Smears).  Simply building a relationship between people and primary care physicians also has benefits by itself.

The overall goal is to improve the overall health of the American public.  Promote behavior that deals with problems when they are still small or before they happen at all.  Just visiting a PCP isn’t the solution by itself, but it is probably a necessary component to achieve a healthier public.

2.  Promote proper utilization

One of the main costs to any system, public or private, is overutilization of services.  Any solution that does not somehow look at utilization will automatically fail.  More care costs more.

Here are areas of increased utilization:

• Emergency room visits for non-emergencies.
• Visits to specialty physicians for primary care problems.
• Unnecessary tests ordered – more likely in a setting where the patient is not known.
• Patient perception that “more care is better.”
• Nonexistent communication – ER doesn’t know what PCP is doing, PCP doesn’t know what happened at specialist or in the hospital.  This causes duplication of tests.

Solutions to these problems include:

• Better access to primary care or other less costly care centers
• Increase the ratio of primary care to specialists
• Care management for high utilizing patients
• Public education (not through the press but through better public health).
• Promoting connections between information systems – better IT adoption would help, but that IT must communicate.
• Make the malpractice environment less frightening to doctors.  A large amount of questionable care is given to protect physicians from lawsuits.  (A good example is PSA Testing.  Even though recent studies question the benefit, many doctors fear that not ordering them will expose them to risk should the patient develop prostate cancer).

How does this help the problem of the uninsured?  It reduces the overall cost of non-catastrophic care, which makes either public or private insurance focused on this more feesable.

3.  Fix problems with Pharma

Medication costs are a huge problem to my uninsured and insured populations.  There are many reasons for this, but some of them are simply due to a bad system.  For example:

• Medication discount programs cannot include Medicare patients.  Why should I be able to give a discount card to my patients with private insurance, even my uninsured, but not Medicare patients?
• High cost of generic drugs.  When a drug goes generic, there is usually only a slight drip in the price.  The system allows only limited competition for price, so the cash price remains high.  Encourage cost competition.
• Drug Rebates.  This raises the overall cost of drugs to everyone.  Rebates are sent to insurance companies by drug companies for inclusion on the formulary.  It pretty much looks like extortion.  The cost of these rebates is not absorbed by Pharma, it is passed on to those who aren’t covered by insurance companies getting the rebate.  These need to be eliminated.
• Get rid of direct to consumer marketing of drugs.  This is pure capitalism that encourages over-utilization.

All of these programs would allow reduced overall cost of medications, which would make either drug coverage more possible or make the cash price of drugs more affordable.

4.  Address Conflicts of Interest

Insurance companies are largely publicly-traded companies.  This means that their main business goal is to maximize profits by either cutting their costs or increasing revenue.  Having them the ones managing care is like putting the kid in charge of the cookie jar.  Insurance companies should get back to the business of insuring.  Care management is certainly important to control overutilization, but that should not be done by those who could profit from it (insurance companies, hospitals, physicians).

Insurance companies promote themselves as healthcare companies.  They don’t provide care, and they shouldn’t.  Perhaps there needs to be a third-party that does care management – I am not certain – but it is clear that good care management would greatly reduce overall utilization and profiteering.

How does this help the uninsured?  It reduces the footprint of the insurance industry on healthcare as a whole, which should bring down the cost if insurance.  It should let insurance companies compete solely on cost, not on provider pannels or other services they shouldn’t be giving in the first place.  If insurance costs less, there are less uninsured.

5.  Focus on the “uninsurable”

5% of Americans account for over 50% of the overall cost of care (reference).  These are the uninsurable people – those who are truley expensive to treat.  There needs to be very close management of these people.  Leaving them uninsured doesn’t reduce cost, it just shifts it to hospitals and local government.  It also leaves them unmanaged.  Of the waste in healthcare, the likelihood is that a very large percent of it is in the high-utilizers (by definition).  These people need management, either in a “medical home” or by some sort of care management.

There you have it.  Follow these rules and everything will be fine.

Yeah, right.  Alright everyone, have at it!  Tell me what you think, but don’t be a chicken: criticism should be accompanied by an alternative solution.