American health-care reform
(c) Dick Locher
True health reform may well take a generation, as the nuts and bolts of a massive new system are sorted out and
assembled. But it seems clear that a sea change is coming in the way Americans experience and pay for healthcare -- one that
will require us to develop a whole new set of muscles. The thousands of pages of legislation penned to overhaul the nation's
healthcare system touch every nook and cranny of medicine, changing the relationship of doctors and patients, rewriting
textbooks of medicine with more focus on staying well, and setting new rules for how treatments are -- or are not --
blessed. "The ball is moving, and once you get it going downhill, it can't be stopped," predicts
The soothing promise of healthcare reform is that all will be covered and that insurance can never be canceled and won't run out. That will come as a huge relief to Americans fearful of losing coverage along with a job or facing financial ruin because of a health catastrophe that overwhelms their insurance limits and their savings. But the promise is by no means a signal to relax. Getting the best care in a system steered by black-and-white medical guidelines ultimately set and enforced by faceless governmental bodies will not be easy, especially for the passive patient unwilling to engage or question the system.
Consider the ways you'll be called upon to manage your healthcare in medicine's new era:
Learn to work with a team
Today, about 80 percent of healthcare is delivered by free-standing mom and
pop shops. You see your primary-care doctor for a cold; an old ligament rupture has you looking for an orthopedist
specializing in knees; a racing heart speeds you to a cardiologist who handles the organ's electrical systems. Three
separate medical charts, none connected to the others. The knowledge explosion in medicine has led to superspecialization
and fragmentation -- if not chaos -- that bedevil the system today, says
What must replace this chaotic approach, he argues, is a team-oriented organization that closely coordinates care. Some have called it a Mayo-ization of medicine, after the clinic, where for almost a century doctors from every medical domain have worked together as a salaried staff, fully integrated with the hospital.
It's coming. A variety of models being tested as part of health reform draw from the Mayo design. In an "accountable health organization," a population of patients is cared for by an integrated system of hospitals, generalist and specialist doctors, and other health professionals, who track people's use of services and outcomes and are paid as a group based on performance. Similarly, a "medical home" model puts primary-care doctors, or perhaps nurse practitioners, in charge of patients, paying them a separate fee to be the overseer of your health and your chart and to help you access specialists in a coordinated way. In both of these models of "patient-centered" care, the individual becomes part of the team and is expected to take an active role in his or her own care. The first key responsibility: Find a doctor who is available to you and part of a network you trust and are happy with. The swine flu epidemic has given a lot of people a jolt about the need to have a doctor they can call their own -- ahead of that fever of 103.
Keep tabs on your medical records.
If things go as planned, everyone's medical record will soon be in
highly accessible digital form and become part of a national data trove available to patients, caregivers, and researchers
through the Internet. Actively involved patients will find every page good reading and each new entry a reason for thought.
No doubt the privacy issues raised by electronically transmitted records are being taken seriously, but ask: Is it necessary
to add details that you consider sensitive and highly personal, such as past mental-health or marital issues or a distant
history of illegal drug use or gonorrhea? Consider the story of baseball player
Be an educated patient
Today, with any medical issue a few intelligent Google clicks away, patients are empowered to freely pursue the latest therapies. That freedom is almost sure to be curtailed; by relying on comparative-effectiveness studies to determine what should be standard care, a more centralized medical culture will focus on what's best for most people. This will narrow patient and physician choice, experts predict, and sometimes collide with medicine's drive toward more personalized therapy tailored to an individual's genetic makeup. The bottom line: It will be more important than ever to understand what science is discovering about your colitis treatment, say, or your child's recently diagnosed leukemia.
Comparative-effectiveness studies that tap large patient databases to compare both effectiveness and cost are
unlikely to get it right every time. Individual patients don't always fit the mean, and newer science can quickly outdate
older studies. Moreover, medicine is rife with reasonable but conflicting interpretations of the same findings. Just
recently, two respected studies of prostate-specific antigen screening initiated in men at middle age -- one of which found
that PSAs saved lives and decreased the disease's spread to bone and the other of which showed no benefit -- were published
at the same time in the same journal. Currently, the
Under health reform, a new governmental committee will follow the lead of the preventive task force when it rules whether preventive tests should be covered, and equivalent advisory groups when it comes to treatments -- not the specialty physician groups closest to the patients. While it remains to be seen how dueling judgments will be handled, know that you might need to decide whether to pay for a test or a therapy out of pocket.
Or perhaps you might agitate politically for a different ruling. The British national health system, which is
comfortable making tough rationing decisions, has recently experienced a few dust-ups with the public after denying some
very expensive drugs for some very serious illnesses, like cancer and blindness, with anguished patients and furious doctors
taking to the streets.
Manage your pocketbook
The Congressional Budget Office, the financial Yoda that has been modeling just
what health reform would do to government outlays, estimates that it will require
Lately, there's been an acerbic war of numbers between the
In any case, you'll retain some control over your premiums.
As is true now, a health maintenance organization would generally cost less than a plan that offers a wider range of hospital and doctor choices. On the new health insurance exchange, people would shop for the best price available for the same mandated benefits among a variety of private plans and possibly one set up by the government. They would also be able to lower their premiums by accepting higher copayments, should they get sick. (On the other hand, one could elect to pay more for such supplemental benefits as dental and vision care that aren't in the mandated package.)
Managing copayments wisely demands two things: that you have money set aside to pay them and that you start insisting upfront on information about the price of any treatments you face. Comparison shopping can save smart patients hundreds to thousands of dollars, since prices of even standard tests like an MRI or an exercise stress test can vary wildly for no apparent reason. But patients will need to nudge a medical culture that's not been comfortable laying out charges ahead of time.
Price-conscious folks, particularly the young and healthy, might want to think seriously now about choosing a low-cost, high-deductible "catastrophic" plan that allows them to funnel tax-free dollars into a medical savings account. These policies will be phased out under health reform, but the president has assured people they can keep a plan they like even if it doesn't meet new specs as long as they're in it before the new program is implemented.
When President Obama began selling health care reform, he cited the threat of healthcare costs to the entire economy as a
prime driver. But savings will take time. In late October, the chief actuary at HHS reported that over 10 years, total
national spending on healthcare will rise more under the proposed system than without it. That doesn't surprise
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Healthcare - Even if health care insurance worries end soon work as engaged informed patients just beginning
(c) 2009 U.S. News & World Report