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Saturday, January 24, 2009

Two Non Insurance Parts of Health Care Reform

Bob Laszewski had an excellent blog post about some of the aspects of health care reform that we don't think about. They don't require transforming the system but rather are important adjustments that are needed regardless of what kind of health system we have. These are not easy adjustments or really "shovel ready" as he describes but compared to universal health coverage, they are more like the 80 pound primates. Two adjustments that I want to address are making primary care sexier and data.

Primary Care: making it sexier
I'm not talking about making primary care appointments like Thai massage with an option for a "happy ending". Right now, primary care physicians are only 30% of practicing physicians while specialty care makes up 70%. These numbers are the reverse in other countries. Our local medical school, Oregon Health and Sciences only graduated 10 primary care physicians last year. While we can give everyone health insurance, if there are not sufficient primary care physicians, we cannot give everyone efficient health care.
From remembering conversations with our pre-med classmates, we can all imagine why those who enter primary care are only the ones who are really passionate about it. Doctors are smart and follow the data. They see hours, lifestyle, prestige, and earnings and primary care doesn't pencil out compared to some specialty care. That's why so many people become urologists or opthamologists. The penis and eyeballs are not that exciting, well the first one cannot really be called unexciting, but that's a different topic. Instead, rather than deep passions for those parts of the bodies, classmates see lucrative careers with manageable hours.
The residency programs will follow supply and demand so if the health care industry makes primary care exciting where primary care physicians are every mother's nightmare but every school boy's dream, the medical students will follow. Costs for primary care visits have not increased more than the cost of inflation which makes them an efficient method of managing health. Give primary care physicians more control over the health care dollar and specialists less. When I present this proposal, I get asked if someone really needs to go to a primary care physician when they know that their throbbing shoulder should really be seen by a specialist. It befuddles me that someone thinks they know better than someone who studied the body for 7 years and that someone thinks they can bypass a general physicians because they can identify the specialist most appropriate for them. To me, it's like telling a teacher that they will not come to school on Fridays since they have identified a curriculum that they think is better suited to their educational needs.

Data: this is the Highlander's Sword
While in the classic movie series, "The Highlander" in the end there can only be one, there will be multiple winners in the roller derby of health care reform. I'm going to stop with the 80's culture references now. As I have posted before, health insurance companies have the best data which is why despite being as popular as plantars warts in a yoga class, the insurance industry will not disappear. Health insurance companies have the population data to measure the outcomes, the holy grail of health care reform and the cost data to know how to operate their business. Physicians don't staff for this kind of data. Hospitals have become too complicated and their charge master work around billed charges to maximize insurance revenue has made their pricing as vague as a lot of Dennis Miller references. Billed charges for hospitals is unfortunately a meaningless number. The story of pharmaceutical and medical devices companies is low marginal costs but high prices in order to recoup research and development which is a tough cost structure to defend. Insurance companies know their administrative expenses well, their medical costs, and their revenue and have the data to defend it. Other players in the health care industry do not.
In the blog post that I linked to, Laszewski does ask why health insurance companies don't share that data as that would truly benefit the health system. Doctors would get reports on their patient care and hospitals could get a better feel for their cost data. It's a good point as that would benefit all. However, currently health insurance companies are refining their data capacities as a competitive advantage to show improved health outcomes and improve provider network outcomes by rewarding those providers who demonstrate good outcomes. The data is a potential revenue generator. If sharing data or reporting in a certain universal fashion becomes a mandate, than it is no longer a potential revenue generator but a cost of doing business. Goal of any business is to drive costs down which will limit the investment in data (except to reduce costs).

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