Thursday, September 3, 2009

Saving money on healtcare: PCPs etc.

You can save money in a healthcare plan in two ways. One is to control the "supply side" -- i.e. the amount charged by either the insurer or the actual care provider (hospital, doctors, drug supplier). The other is to control what the consumer chooses to purchase -- the "consumer side."

Conservatives, who purport to believe in individual choice, pretty much believe in saving on the consumer side. This usually means offering the healthcare purchaser financial incentives to purchase less healthcare. Ways to do this are to present high deductibles and large co-payments, with certain tests and procedures made particularly expensive. Briefly, this is controlling costs through worse care -- John Mackey's position, discussed in previous blogs. Most of us generally have little medical expertise and can not effectively choose between expense and safety. When you have to pay for tests, you tend to get fewer tests. Sometimes this is OK (saves money) sometimes not (you get much sicker). Statistics show that consumers exert almost no leverage on actual prices charged, just on the care they get or afford. This is the plan most insurance companies prefer, since they have to provide less and can always blame poor outcomes on bad consumer choices (rent and food over higher premiums). Is it at all realistic to think that patients will argue with their doctor to keep expenses down by questioning various tests and procedures that the doctor prescribes? Conservatives, in order to defeat healthcare reform, have whipped up a storm about healthcare "rationing." But this is contradictory: you can't ask people to resist rationing and then ask them to argue against their doctor's recommendations.

Non-conservatives tend to favor regulatory controls over health care which include forcing rates to be affordable and requiring insurers to pay for "pre-existing" conditions. Hardly anyone could directly argue against this in principle, but regulations have to come from government, and by trying to discredit government at every turn, convervatives in effect are advocating the status quo where largely unregulated insurers control healthcare.

I personally think that it is essential for every patient to have a Primary Care Physician (PCP) who is familiar with the patient's entire medical history and can help make decisions about tests, procedures and medicines. (PCPs used to be called "family doctors.) These days, PCPs are found in all Health Maintainence Organizations (HMOs) and in some PPOs (Preferred Provider Organizations) as well; they are often assisted by highly-trained Nurse Practitioners. PCPs can help control expenses by filtering out unneeded or redundant tests, and by helping make informed and realistic decisions about treatments and medications. PCPs are particularly crucial when you have to be hospitalized, because a whole new set of doctors become involved. A close family member of mine who didn't have a PCP to check on her care was badly medicated when returning from a hospital stay because there was no single person who knew her history and could spot a duplication of medication on one hand, and a contradictory series of prescriptions on the other (all from two sets of hospital physicians who did not coordinate their treatments). This kind of thing happens all the time.

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