Waiting for an oil change the other day, I picked up a magazine in the office of our town gas station and opened to a thick how-to advertising section paid for by local hospitals and health systems. Its goal: to turn me and other readers into "savvy consumers" of healthcare services.
The section was packed with advice. It told me to be "wily" and to "shop" for healthcare as shrewdly as I would for a car. It decoded PCP, PPO, FFS, PHO and PHP, and admonished me to "learn the lingo" if I hoped to "extract" the full benefit of my health plan. It wrapped up with a review of my rights of appeal of denials. Appeal of what?
There has been much debate lately about the reasons for managed care's slipping public image. Some in the industry find it convenient to blame the media: too many horror stories and not enough emphasis on the contributions of managed care to medical quality, cost control and health promotion. Others think public opinion can be turned around by massive education campaigns to make consumers comfortable with the new complexities in healthcare.
May I suggest that the problem is the complexity itself? And that the solution lies not in handing patients lingo dictionaries and treatises on caveat emptor but in purging managed-care plans of everything that would make such dictionaries and treatises necessary.
The surprise might be that cost control and quality don't suffer a bit. The surprise also might be that the public image mends itself. There is, after all, nothing inherently unappealing about the concept of managed care. Most of us would gladly forgo unnecessary tests and procedures, and we don't, for the most part, visit doctors recreationally.
So limits on choice or frequency of use or any of the other elements the media has spotlighted cannot account for the public's sour mood. What can account for it are health plans so onerous that going to the doctor has become the stress equivalent of a trip to the department of motor vehicles.
The only remaining question is whether this bureaucracy-the phone trees, prior-approval hurdles and byzantine referral systems-is necessary for cost-effective care. That it may not be necessary is one of the early findings of some ongoing experiments in providing healthcare services to poor people who lack health insurance.
If anyone has an interest in delivering healthcare at the lowest possible cost, it is the folks who are giving it away for free. Thirty-nine such volunteer-based projects in 25 states were launched (with seed money from the Robert Wood Johnson Foundation) shortly after Congress threw in the towel on comprehensive national healthcare reform. Mostly free clinics or medical home networks, their goal is to deliver timely care to the working poor and reduce the catastrophic-and costly-consequences of medical neglect.
Project leaders realized early on that if they built too many procedural hassles into their programs, patients wouldn't come. Rent, groceries and other immediate survival needs likely would take precedence over blood pressure checks. Project staff also didn't want to squander the goodwill of volunteer doctors and nurses by letting paperwork eat up the time they had to spend with patients.
These concerns-part of a clearly articulated mission of service to patients-led to the design of exceptionally efficient, user-friendly health systems. Some of them now are proving to be quite cost effective. Consider:
In West Virginia, where 19% of the population lacks health insurance, a network of free clinics last year pulled some 25,000 uninsured people into regular primary care for an average cost per visit of $15. This compares with about $300 per visit at local hospital emergency rooms. The clinic is organized to handle lab work, testing and prescriptions on the same day as the appointment, so patients who may have transportation problems don't have to make two trips.
In San Francisco, volunteer surgeons running a free outpatient surgery clinic have brought the cost of hernia repair down to $88 (mostly for materials such as sutures and kits), compared with roughly $3,000 paid by commercial plans in that market. All surgeries are scheduled on Saturday for the convenience of the volunteers (their day off) and the patients, many of whom would have trouble getting time off from their weekday jobs to go to the doctor.
In Tallahassee and rural communities of the Florida Panhandle, 187 indigent patients received $502,000 in specialized medical services last year, the project's first. Called the Physicians' Outreach Project, it fills in where bare-bones county clinics leave off, providing, for example, free endocrinology consulting for diabetics, orthopedic, cardiac and gastroenterology services, and even major surgey.
To simplify record-keeping for volunteer doctors, hospital personnel and everyone else involved in the care of these patients, the project adapted itself to to the systems already in use at local clinics and hospitals. That alone eliminated a mass of redundant paperwork, saving patients and medical staff from having to learn new rules and procedures. A one-man office matches patients with specialists, coordinates lab and hospital services, and keeps the records.
The ratios of value to expenditure in these charity projects are, of course, greatly boosted by the fact that hospital and lab charges and professional fees are mostly waived, and many supplies are donated. The relatively small size of the projects, compared with commercial health plans, also makes it easier to individualize patient care than may be possible for large, multistate systems.
But the volunteer base of these projects doesn't entirely account for their cost-effectiveness, just as size doesn't justify the burdensome complexity imposed on patients by many of today's commerical plans.
The fact is these charity projects are quite complex internally. Imagine, when your health plan's only source of income is the occasional foundation grant or charitable donation, what sorts of bartering networks are necessary to provide a full spectrum of care. Just stocking the pharmacy is a feat. But this aspect of clinic operations is kept invisible to patients, on the theory that they may have enough to contend with just getting well.
Patients accustomed to being turned away for lack of money predictably say many grateful things about these programs. Their comments, though, go beyond the dollars and cents to reveal the hope of every patient-even those of us paying for our care.
"They treat me like a person here," said a soft-spoken woman on her third visit to the HealthRight clinic in Charleston, W.Va.
I'd rather be that than a savvy consumer any day.
Irene Wielawski is a journalist who is tracking local health reform efforts under a grant from the Robert Wood Johnson Foundation.