For almost 50 years, private and publicly funded healthcare plans have tried to make healthcInitially, these plans reimbursed patients for their medical expenses; when patients found it increasingly difficult to pay upfront, these plans began to pay medical providers directly, requiring the patient to meet a modest copayment. Coverage has also expanded from hospital-based care to include outpatient care and medications. Again, patients are usually required only to meet a copayment for theses services—a fee that represents only a fraction of the true cost of the service provided.
Making healthcare more accessible by making costs more convenient is an effective method of encouraging patients to obtain care before it becomes emergent and difficult to manage. But making healthcare appear affordable does not really reduce the true cost of medical care. In fact, adding convenience to any service always adds to the cost of that service. Full-service gasoline costs more than self-serve. Direct reimbursement of medical care by insurers to medical providers requires claims handlers, billing personnel and sophisticated computer systems dedicated to claims management—all of which add to the cost of medical care.
Making medical care relatively convenient also contributes to the overall increase in annual healthcare expenditures by encouraging utilization—an intentional result of shielding patients from the true cost of medical care. We want patients to get care; we just haven’t figured out a way to control this use. This problem is made worse by the fact that we shield a large number of patients not just from the cost of the office visit, but from the cost of the insurance plan providing coverage.
A majority of private plans are paid by employers—the costs of which are often hidden from the employee. Public plans are funded primarily through tax revenue with their true costs hidden from the consumer. What individuals do not realize is that they are paying for these costs either by giving up other benefits (e.g, a raise) or through higher taxes.
Perhaps most disturbing is the fact that in our effort to make healthcare more accessible by hiding its true costs, we are in fact encouraging unhealthy behavior. Have we made it cheaper to “just take a pill” for our high blood pressure, elevated blood sugar, elevated cholesterol and obesity than to change our diet or undertake an exercise program? The U.S. healthcare system has tried to improve accountability in an effort to improve quality and rein in overutilization.
Hospitals and medical providers are being asked to report outcomes data to demonstrate improved quality, and many payers are beginning to refuse payment for medical services that are not evidence-based. It is becoming increasingly evident, however, that it is the patient, not the healthcare provider, who has the biggest influence on outcomes and utilization. If we continue to try to shield patients from the cost and waste of medical care, we will never make significant gains on quality or cost containment.
Can we increase patient accountability without dramatically sacrificing accessibility? We could return to the days when patients had to pay first and be reimbursed by the insurer after the visit. I have no doubt that, by “removing the middle man,” utilization would drop and quality would increase. American consumers are very savvy and would quickly learn how to find the highest quality at the lowest price. Unfortunately, I believe the cost of medical care has gotten so high that few patients could afford care on that basis.
Perhaps the system we need to evaluate is one that directly provides incentives to the patient to improve quality and reduce costs. I propose a single-payer system to provide not a basic, but a fairly comprehensive healthcare package. The budget for this program would be much higher than a “basic benefit program.” Taxpayers and employees would be asked to pay higher taxes and sacrifice pay raises to pay for this system. Individuals would then learn the true cost of their health benefits.
However, they will be given the opportunity to recoup these additional costs through adoption of healthy habits—rebates for smoking cessation, keeping their hypertension under control and avoiding unnecessary emergency room visits. Much like the good driver discount programs for car insurance, benefit is directly derived by the person most able to improve outcomes and reduce costs: the patient.
As we look seriously into healthcare reform, we need to re-examine some of the well-intentioned policies we have adopted in the past that have unfortunately contributed to our healthcare delivery-system problems. We must all recognize the true cost of care and how we contribute to this cost. We must recognize that it is the patient, not the provider or insurer, who has the greatest influence on quality and cost.
And finally we must realize that convenience, no matter how well-intentioned, costs more. We are a do-it-yourself nation. Perhaps it is time to offer patients an opportunity to invest sweat-equity as a means to make quality healthcare affordable.