Tuesday, December 23, 2008

Hatred of Insurance Companies

The Obama transition team is sponsoring 4,200 house party-based grass roots discussions of health care in December. Today's New York Times reported on one of them.

In my work on health system ethics I've often invoked the need for a "societal learning curve" with regard to the health system. The Obama health care house parties will provide HHS Secretary Tom Daschle with a huge opportunity to see where the U.S. public is coming from in its understanding of the health system.

Here are some excerpts from the account of the health care house party, followed by my comments in italics. The report suggests just how much teaching and leadership we need from Secretary Daschle and President Obama:
"When a dozen consumers gathered over the weekend to discuss health care at the behest of President-elect Barack Obama, they quickly agreed on one point: they despise health insurance companies.

They also agreed that health care was a right; that insurance should cover 'everything,' not just some services..."

I run the ethics program at Harvard Pilgrim Health Care. It's a not for profit health insurance company that insures a million people. For the past four years it has been rated #1 in member satisfaction and quality of care by U.S. News and World Report and the National Committee for Quality Assurance. I respect and admire the organization.

That said, health insurance companies are in an unenviable and perhaps impossible position, poised between (a) employers and government agencies frantic to control what they pay for health insurance (b) providers who are largely not held accountable for costs, (c) insurees who want "everything" covered, in a context of (d) severely limited public and political understanding of how health care really works.

"Dr. Lawrence M. Nelson, a scientist at the National Institutes of Health who emphasized that he was speaking as a private citizen, said: 'The incentives in the current health insurance system are upside down. The less care you provide, the bigger your profits.'"

In the 1990s, public policy asked insurers to mediate the gap between what payers wanted to pay, providers wanted to provide and patients wanted to receive by determining which proposed interventions were "medically necessary." That role wouldn't be easy for anyone - even Mother Theresa or Dr. Schweitzer. Insurance companies, especially for profit companies, were ultimately pilloried for setting limits. They've backed off from taking that role. Costs, of course, are skyrocketing again.

But Dr. Nelson's comment suggests just how tough a teaching job Secretary Daschle will face. Less care is often (a) as good as more care or (b) better. That's a counterintuitive lesson for much of the public. Entities that profit from providing less care aren't able to teach it. The Secretary has to find ways to help us learn.

The Obama transition team did not ask people how a new health care system should be financed, but several people here said that individuals and businesses should have to pay a small health care tax — some preferred to call it a “contribution” — so that everyone could be covered.

Not asking how the health system should be financed strikes me as a major error. There is no way we will come to grips with health care costs until we set a true budget for the health system. The idea that "small contributions" might get us to where we need to go suggests how much we are still living in lala land with regard to health care finances.
If Secretary Daschle uses the health care house parties as an opportunity to refine his agenda for leadership they will provide valuable insight. But if the house parties are used to define the content of proposals we'll just continue down the same path of inexorable cost increases we are on now. Our political leaders - always excepting former Oregon Governor John Kitzhaber - haven't had the guts to help us face the need for limits and to begin to understand health care in a more nuanced way. It remains to be seen whether the new administration is up to the task.


eric said...

But if we can afford a trillion for a war and a trillion for a bail-out, why can't we afford to cover "everything?" What are the priorities here? Well, I for one don't want to be considered on a par with institutions that waste our money due to poor judgement and greed. I'd like to think that parsimony is part of honesty and good manners.

Jim Sabin said...

Hi Eric -

First, warm best wishes for the holiday season and for a happy & healthy 2009!

In my view the war has been a tragic mistake and the bailout is a necessity brought on by years of poor judgment, lax oversight and greed. The only way we "afford" these huge expenditures is by borrowing from abroad and passing the debt on to our children and our childrens' children.

In addition to honesty and good manners, medical parsimony is often the best care. Sadly, greed to over-provide and over-receive combined with poor judgment have been at work in medicine as well.



Anonymous said...

I would add that while I view the war as a tragic waste of lives and money, it is not a recurring expense.

Like the bank bail-out it is a "one-time" expense (unless we expect to be start another war after we finally get out of Iraq, and then another war after that.)

When we define what healthcare will or should cover we are settting the stage for a recurring expense, year after year, as far as the eye can stretch.

It is very difficult to roll back coverage once a decision has been made.

Dialysis offers a good example. Lobbyists pressured Congress to make an overly-generous decision about dialysis reimbursement which has reaulted not only in an enormous waste of money, but in needless pain and suffering as so many patients have found themselves tethered, for life, to dialysis machines.

Jim Sabin said...

Hi Maggie -

You make (as always) an excellent point about the difficulty of rolling back any piece of insurance coverage. I may be a cockeyed optimist, but it seems to me that when we've developed a more empirical, less ideological/theological political culture for our health care system, we may be able to say "This looked like the right thing to do X years ago, but in light of ABC we should change the policy..." With life sustaining interventions we have learned over the years that while it is emotionally difficult to turn off the equipment, it is ethically acceptable to do so when circumstances change, and it may even be ethically manditory.

I want to send New Year best wishes to you, and to thank you for your superb Health Beat blog!