Why more health insurance isn’t necessarily better

Whenever a discussion of health care policy is initiated, the importance of health insurance, of extending coverage, takes center stage. The need for insurance quickly becomes an undeniable truth, a universal imperative. And no one ever seems to question this subtle premise before getting more patients fitted with shiny, new policies. This was precisely the case with the Affordable Care Act.

My question, however, is simple. Where is the evidence that insurance plays any role in improving anyone’s health? Why is it assumed that more coverage is always the answer? I would argue it is little more than a myth, one found nowhere else in our collective understanding of insurance.

First, let’s take a look at our experience with insurance in other areas of our lives. In most states, it is mandatory for drivers to carry automobile insurance. To the extent they protect one’s financial interests from being threatened by an uninsured individual, these mandates probably make sense. But car insurance doesn’t reduce the incidence of accidents or extend the life of a vehicle, nor does it cover oil changes, car washes, flat tires, oil leaks, or any other form of maintenance or unfortunate mechanical reality.

Homeowners insurance is another example many of us are familiar with. It, once again, helps protect our financial interests in the event of uncommon occurrences, things like fire, theft, liability to third parties, or, depending on the nature of the policy, natural disasters. But it generally doesn’t cover any maintenance, either. It doesn’t cover dry wall repairs when your kids put a hole in the wall, the price of engineering services when your foundation cracks due to age, or, in most cases, even the removal of mold due to leaky pipes or unsealed windows.

Why, then, do we expect health insurance to function any differently? There is no evidence that simply having health insurance improves patients’ health.  Access to health care improves outcomes; the problem is we always assume the best route to greater access is health insurance. We seem to believe coverage for routine medical care, for everything from checkups to preventive care procedures, makes any difference whatsoever in our collective health. It does not; it only appears to because of numerous confounding variables.

What is known, however, is the total amount of money available for health care, generally some large percentage of our GDP. That number is static at any given point in time and cannot be magically increased. In fact, by definition, insurance companies decrease the total amount of capital available for actual medical care. Relegating any aspect of health care to their control necessarily decreases the funds available at the bedside; these companies must extract a profit. That’s how capitalism works. Moreover, by forcing the insurance industry to increase the scope of coverage, patients and physicians give up more control as to the nature, timing, and extent of the routine care that can be provided.

All insurance, even health insurance, should be procured to protect one’s financial interests in the event of unusual or unforeseen events. Engaging it for routine activities, including all but the most costly drug therapies and procedures, serves only to dilute valuable resources and relinquish essential control. Some argue that health care is too expensive for patients to handle without insurance. But the truth is insurance increases costs. It raises physician and hospital administrative overhead and artificially inflates prices in several other ways, not to mention the aforementioned profit reality. More importantly, focusing exclusively on insurance ignores the importance of other factors that actually do affect health.

Improving access to education, reducing unemployment, increasing wages and household income by stimulating business and innovation, safeguarding the food supply, limiting environmental hazards, reducing poor health behaviors, and increasing the number of primary care physicians available, to name only a few, would have a greater impact on health and outcomes than more coverage. These are some of the confounding variables that lead us to believe insurance is always the answer. And focusing directly on these true determinants of health status, which can be achieved through better policy or, in some cases, less, does not force patients to relinquish control or artificially drive up the price of health care goods and services. Increased reliance on insurance paradoxically does both.

For the last several decades, we have increasingly relied on insurance (public or private) as an intermediary between patients and doctors. The results have been perpetually increasing health care costs, increased infringement on physicians’ independence, and an ever growing psychological barrier that prevents patients from understanding the true costs of, or seeing the real value in, health care services. We have conditioned patients to believe that a long visit with their physician is worth about twenty dollars. Meanwhile, most Americans recognize and accept that a similar session with any good attorney costs many times that number.

We need to move to a system where health insurance is procured only to protect patients’ financial interests in the event of catastrophic injury or illness, and routine, less expensive health care services are paid for entirely and exclusively by patients. Patients will be better served, having greater control over their health, seeing any doctor they wish, and purchasing competitively priced services from independent physicians free of unnecessary administrative burdens. The transition would, of course, be difficult, but it would be no more difficult than any other transition we attempt.

I tend to believe in people, in the individual. And I think a well-educated, fully employed individual, in consultation with easily accessible, well-trained, independent physicians, will generally make the right choice. In a free society, however, it is their right to make the wrong choice; no insurance policy will change that reality. Unless we limit our reliance on insurance, costs will continue rising, physician reimbursement and therapeutic autonomy will continue declining, and patients’ understanding of, and control over, their own health will continue to wane. Insurance is great if used judiciously, but let’s not continue to assume that more of it is always better; it isn’t.

Luis Collar is a physician who blogs at Sapphire Equinox. He is the author of A Quiet Death.

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  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Amazingly, the arguments for market based health care and universal health care are pretty much the same, until we reach the last mile, so to speak. This leads me to believe that if we eliminated the interests of big corporations from consideration, we could have settled on a pretty good solution eons ago.
    This country has become ungovernable not because of differences in ideology from right or left, but due to massive interference from financial interests that are way too big….

    • Luis Collar, M.D.

      I actually agree. Free market or single payor solutions are both better than the hybrid “pseudo-free market, pseudo government-run, pseudo-who-knows-what-else” system we increasingly find ourselves with, a system where winners and losers are artificially picked. Though compromise is often necessary and even useful, I do think we could do much better than this middle ground which is not very ideal for patients or doctors.

      Hope all is well, Margalit. Thanks for the insights.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        All is well, Dr. Collar, thank you.
        Just watching how the “pseudo health care” is sprouting and growing nicely this Spring….. :-)

        • Luis Collar, M.D.

          lol… Well,once I hit the pseudo-lottery none of this will matter anymore… lol… Sadly, given the average price of an MRI and a night in the ICU, I better hit it big… None of this 2 or 3 million dollar stuff… Glad to hear all is well…

  • Luis Collar, M.D.

    Thanks for the comments, ggbaby… I am generally all for the innovation and competition that a free market driven by profit motive (though tempered by oversight, social awareness, and compassion) can bring. But what I can’t understand is why we continue to increase our reliance on insurance in healthcare. The for-profit insurance industry is a useful one. It is, however, one that should be relied on for risk management, not for financing everyday necessities. The more we rely on insurance in healthcare, the greater the chasm between existing prices and patient access will grow. And there will also continue to be decreased autonomy for both patients and physicians.

  • Luis Collar, M.D.

    Thanks for the thoughtful comments, RL. I agree with virtually all of your assertions, particularly with regard to stagnant wages and lack of disposable income. The problem is, though, that increasingly relying on insurance is simply not the answer to any of those issues. As a society, we have limited resources available. So why would we want to further involve for-profit insurance companies other than as part of a prudent risk management strategy? In other words, the more care we relegate to insurance company control, the less money we actually have available for patient care (they must extract profit) and the more autonomy patients and physicians relinquish (insurance executives, in effect, control both the quantity and quality of care available at any given time).

    Another issue is that with stagnant wages, relatively high unemployment, and all of the other struggles Americans currently face, greater price transparency and lower prices altogether are both sorely needed in healthcare. Paradoxically, increasing our reliance on third-party payors makes both of those outcomes less likely.

  • Bradford Lacy

    I believe your article points out some very sound free market economic principles. From a patient perspective here is where I believe there would be some challenges:
    1. Status quo is and will always be any policy’s toughest competitor. If you think there was an uproar over the current Individual Mandate requiring a few million uninsured people to get insurance, imagine the uproar on a policy that would presumbably “take away” insurance for many more millions of people.
    2. Geographic monopolies. Millions of Americans live in rurual America where there of fewer choices for hospitals and outpatient clinicians. Without competition these clinicians and hospitals would still have little incentive to lower prices to a level that middle class America could afford.
    3. Big Pharma (and Big Medical Device for that matter) still have to make their Big Profits and they have patents on many important perscription drugs and devices that lock less expensive generics out and keep prices high.

    • Deceased MD

      It’s even worse than that. Generics for asthma and gout have been legally turned into expensive brands again at 10 times the cost. And with the FDA’s help (for the gout med)

      • hawkeyemd1

        Technically, pharma companies can extend a patent just based on designating a new indication for use. They don’t even need to rearrange one carbon or hydrogen atom in the existing drug to do it.

        • Deceased MD

          yes You are so right hawkeyemd. There seems to be many ways to manipulate the system. Although with asthma drugs was easier to do it I think their way this time rather than create a new study to prove a new indication. What do you think of all of this?

          • hawkeyemd1

            I think bright, young students should steer clear of the medical profession. And I think people should do everything in their power to stay healthy and avoid any contact whatsoever with our healthcare system. I may be a simple person with simple ideas, but I believe both of those things with every fiber of my being. And, as the great Forrest Gump once said, that’s all I have to say about that. (Wink, wink…)

          • EmilyAnon

            On another doctor blog, similar advice was given to patients: ‘Eat healthy, exercise, look both ways before you cross the street. Do everything you can to stay out of hospitals.’ When doctors are the ones giving the warning, I’m taking it seriously.

          • hawkeyemd1

            Seriously. I’m not trying to spread fear. If you’re sick, go and get help. But health care is a mess. It is the same advice I give my own family. Hospitals are bad, bad places, for so many reasons. If you can avoid them, you really should. Live healthy, read, exercise, eat well and often, get enough sleep, make time to laugh, avoid things you know stress you out, focus on important relationships-sounds corny. but it’s true.

          • Deceased MD

            Hawkeye believe me I am smiling. You are quite amusing on a most serious subject. I tell you I can’t agree more. I am surprised that there is not more written and reported about on how the broken system is creating increased morbidity adn mortality. It has to be. IF PCP’s can’t diagnose and treat or refer if necessary and take there time to use cognition rather than typing skills, it is a lost cause. Specialists will not take any time to think outside of their specialty or collaborate if necessary. Which leaves pts out in the cold. THe PCP certainly has no time for that. THe best that can be done is reading the computer screen on the EHR. That is the new collaboration. Answer don’t get sick in this country. Brilliant.

          • hawkeyemd1

            See my “Forrest Gump approach to healthcare” in response to EmilyAnon below. I spent so much on medical education just to find out the answer to better health is, in most cases, damn simple.

          • querywoman

            There will always be people who want to be doctors.
            I’d avoid doctors if I could. But the medicines make me feel better and keep me functioning. I’ve been on thyroid pill since I was 17 and eventually went into diabetes.

    • Luis Collar, M.D.

      All great points. Here are some thoughts on each:

      1.) Agree with you on this point. However, I am not proposing we take all insurance away, nor am I proposing we do anything all at once. I simply point out that we need to stop increasing our reliance on insurance in healthcare. And, over an appropriate amount of time, we could benefit from scaling back that reliance.

      2.)The needs of rural America certainly need to be taken into account. But I would point out that the issue in rural areas is often one of insufficient availability of physicians and healthcare services, not one of price. For example, the cost of an office visit in areas densely populated with physicians and hospitals is often greater than a similar office visit in rural areas. Because of the way healthcare is structured and paid for, greater competition does not always lead to lower prices. (It would, however, if there were no third-party payors. We’ve seen that happen with some elective procedures not typically covered by insurance (e.g. Lasik surgery, several cosmetic procedures, etc.) In those cases, competition for patients spending their own dollars resulted in rather significant decreases in price.)

      3.)That is very true. Many drugs are, in my opinion, so unconscionably expensive that they do merit treatment as “catastrophic events.” And there I believe insurance should play a role. But there are many generics (not all) that are reasonably priced and relatively affordable. What the cutoff should be between “affordable” and “catastrophic”, I honestly don’t know. But I do think we need to have those discussions.

      Thank you for contributing to the discussion.

      • Bradford Lacy

        Dr.
        Collar, you do have some great points. I have read some of your previous
        articles and comments before so I believe you understand the “law of
        unintended consequences” as well as anyone else. In addition to deciding
        the line between catastrophic and affordable, we also would need to be
        concerned with what “Big Companies” would do to move their services
        and products out of the affordable range and into to catastrophic range, thus
        being paid for by insurance and insuring greater profit margins (Deceased MD eludes
        to this scenario already happening today in his comments). Furthermore,
        physicians might want to consider what a true free market would do to their
        demand. Patients may decide to save
        money by visiting a NP or a retail clinic (or a NP in a retail clinic). I do agree that we Americans do have an
        over-reliance on health insurance. How
        to change this perception is still up for debate.

        • Luis Collar, M.D.

          Again, great points. With regard to increased reliance on retail clinics, we’ve already seen that trend developing. even without a “free market” in place. I think physicians need to do more to drive convenience and accessibility in healthcare, but that response seems to be taking the shape of a concierge or direct-pay approach. The ever growing administrative costs associated with accepting insurance from multiple carriers makes it virtually impossible for physicians to compete with the large corporations running those clinics.

          As far as how we as a society should address pharma and other Big Business pricing in healthcare, I honestly don’t know what the right answer is. These are hard questions that have a very real impact on human illness, suffering, and even death. And so it is imperative that all citizens become increasingly aware that these issues even exist and come together to pick a direction in healthcare.

          I do think, though, that many of the policies we have implemented thus far harm the independently practicing physician and benefit Big Business. And I don’t believe that is a good thing for patients or society as a whole.

          Thanks again for the thoughtful comments.

  • Deceased MD

    Another great blog Dr. Collar. I think you are spot on. I find it interesting how people can afford high tv cable bills for entertainment and high priced cell phones. Try going to a sports event and see the price of a ticket. Go to a bar and see the cost of a drink. People seem to afford these costs some of which I find absurd. But when people have a medical co-pay, that’s a different story. In their minds, it is “covered” and they are not really responsible. Well if the pt is not responsible for their health and its cost, then who is?

    I assume your article is geared to the working middle class. What were your thoughts about the poor, elderly or those unable to work since there is some reality that they would have limited means. On the other hand, many of them have money for drugs, alcohol, tv cable and cell phones.

    • Luis Collar, M.D.

      Thanks for the feedback, DMD. I absolutely believe policies need to be sensitive to the needs of the poor, the unemployed, etc… But, in a truly compassionate society, those needs should be addressed by a streamlined public safety net capable of actually yielding improved outcomes. I don’t think that just getting more people covered by “bad” insurance policies that really only benefit for-profit insurance companies will make anyone healthier (we’ve seen that to a certain extent with the Oregon study).

      I do think the next decade will yield two distinct systems. One driven by insurance (high volume, limited true access to physicians, long wait times, high administrative overhead, limited patient and physician autonomy, etc..) and one driven by a concierge approach to care (low volume, greater access, low administrative overhead, high degree of autonomy). Whether or not that schism if fair or just to the society as a whole is debatable, but I definitely think that is where continued reliance on, and transfer of authority to, third-party payors will lead…and soon.

      • Deceased MD

        i think you are right where we are headed. The problem though is that as much as concierge sounds like an answer, physicians that are tied to hospitals can’t really become part of concierge (certain specialists). They can work with concierge PCP’s but I don’t think concierge PCP’s have much control over academic centers where certain pts are headed with less common or complex issues. Although for bread and better medicine concierge seems like a good choice.

        • Luis Collar, M.D.

          Very true… The biggest challenge for any concierge physician is effectively interacting with the rest of what is a predominantly payor-driven system. For primary care physicians, they remain the PMD for their patients when they are hospitalized and still work to coordinate their inpatient care. Hospitalists generally welcome this anyway because they regularly seek guidance from the PMD, who knows the patient’s clinical history and has a stronger relationship with the patient. The only difference really is that, rather than “rounding,” concierge doctors are actually “visiting” their patients because most don’t maintain hospital privileges. This just means they aren’t listed as the “admitting physician” but are still the PMD of record coordinating care from the outside (and they don’t bill patients for these services separately as they are included in the monthly / yearly fees paid by patients).

          As concierge / direct pay practices continue to grow, there may be changes that allow even specialists to move to this model in greater numbers (at least for part of their business). Hospitals may find that contracting with specialist concierge practices that deliver certain procedures in their ORs or procedure rooms is beneficial to their bottom line. Direct “lease payments” from these concierge groups, because they don’t involve any of the billing / administrative overhead of third-party payment systems, may be quite lucrative even at much lower prices.

          I agree, though, that alternative practice models won’t “fix” everything. But, over the next decade, I do think they will become a major player in healthcare and the more “traditional” systems will adjust to accommodate their presence and reap the value they can bring.

          • Deceased MD

            Dr. Collar, can’t we just go back to the good old days. Please? LOL
            Thank you for a most thoughtful answer. What do you think? I kind of feel like there is good and bad in that scenario. If the PMD is not rounding, then they really don’t ultimately call the shots. i can see in ways they can be of immense help to advocate for the pt, and I can also in ways see, that hospitals can make decisions that are at odds with the PMD.
            OK playing devil’s advocate here. There was a recent post by Dr. Grumet I believe that was eye opening. He had an inpt and needed a specialist to see his pt. At first all went well but then the specialist who was employed by the hospital asked Dr. Grumet if he was also. When he said he was in private practice it all ended. The specialist said he was not allowed to see private practice docs pts. Hopefully an isolated incidence. But the more there is competition or rivalry between hospitals and private practitioners, i think the more problems like this may arise. But i am a pessimist. i just hope not.

          • Luis Collar, M.D.

            The “good old days of medicine” are dead. And they never even received a proper burial. Okay, I’m just kidding. But I do think that the competition / rivalry you refer to is going to exist whether concierge medicine grows in popularity or not. In other words, as medicine becomes increasingly “corporatized,” there will be tension between small, independent physicians and the larger, more corporate delivery systems. And I believe the tension is less a function of the particular delivery model than it is a function of the ownership structure behind that model (e.g. independently owned or small partnership practices, whether concierge, direct pay, or payor-dependent vs. large corporate enterprises).

          • Deceased MD

            LOL. I would say that the good old days of medicine are indeed dead. And yes i suppose this will rivalry will play out regardless of concierge.
            I guess I was thinking of concierge being private practice vs. hospital corporate but I see that corp med is actually doing their form of concierge in some places. ironic. Sorry to get so far off topic.
            But getting back to the subject, I think you are spot on that costs are going to rise with more insurance. I wonder if Obama even considered that or used real physicians to consult with for the ACA? This was another great article. i just wish the powers that be would listen to your sound views.

          • Luis Collar, M.D.

            I doubt they’ll listen; I get tired of listening to myself sometimes. lol… But I do think we need to stop viewing more “coverage” and third-party, administrative intervention as a solution to every problem in healthcare. We need to look at other ways to improve “access,” ways that bring patients and physicians closer together and empower them to make sound, well-informed choices together. Healthcare prices / costs got to where they are while insurance was already a major player; there’s no reason to believe that even more insurance will bring down costs, give people “true” access to the care they need, or improve the nation’s health.

          • Deceased MD

            Dr. Collar, you make sound points. Not sure if you have seen this but it answers your question about the idea of increasing third part administrators. “Investigators at a major research institution have discovered the heaviest element known to science. This startling new discovery has been tentatively named Administratium (Ad). This new element has no protons or electrons, thus having an atomic number of 0. It does, however, have 1 neutron, 125 assistant neutrons, 75 vice neutrons, and 111 assistant vice neutrons, giving it an atomic mass of 312.
            Since it has no electrons, Administratium is inert. However, it can be detected as it impedes every reaction with which it comes into contact.” Perhaps this sounds familiar to you?

          • Luis Collar, M.D.

            lol… that is great…. administratium must be cheap because it certainly isn’t rare… thanks, DMD… needed that…

          • Deceased MD

            So glad you liked it. I think with all the insurance admins and EHR consultants and all the people that really do little to nothing in medicine, that we have reached the critical morass (read on ). It was written 20 years ago by a physics professor who was disgusted with crazy admins-hence the physics metaphors. In case you’re interested here’s the rest of it. “According to the discoverers, a minute amount of Administratium causes one reaction to take over four days to complete when it would normally take less than a second. Administratium has a normal half-life of approximately three years; it does not decay but instead undergoes a reorganization in which a portion of the assistant neutrons, vice neutrons, and assistant vice neutrons exchange places. In fact an Administratium sample’s mass will actually increase over time, since with each reorganization some of the morons inevitably become neutrons, forming new isotopes. This characteristic of moron promotion leads some scientists to speculate that Administratium is formed whenever morons reach a certain quantity in concentration. This hypothetical quantity is referred to as the “Critical Morass.”
            I think we have surpassed in medicine, the critical morass Luis, don’t you?
            At the time I first read this, it did not have the same meaning to me as it does now. Hope you get a kick out of it.

          • Luis Collar, M.D.

            That really is great. It’s funny, and sad, that when you look at it, the costs associated with physicians, nurses, and other practitioners is miniscule compared to the administrative costs in healthcare. That is true in hospitals, biopharmaceutical companies, insurance companies (literally ALL of insurance is administrative cost), and many other organizations involved in healthcare. Unfortunately, it’s slowly becoming the reality for independent physicians as well, either because they are forced to join large, corporate health networks or respond to the growing government and insurance industry administrative burdens placed on their own practices by hiring more administrative help. Very tough situation and one that will only get worse if it isn’t addressed head on. Thanks again for passing on the Administratium piece. lol

          • Deceased MD

            You know that is a whole blog in and of itself Luis. I feel burdened just thinking about it. I feel heavier every day thinking about admins who I see having no solutions but endless weight.

            Really everything today is about reductionism and simplistic answers to complex issues FAST!! And applied to medicine of course it is a disaster. I think admins of all types to medicine will be like the iceberg was to the Titanic.

          • querywoman

            The “good old days of medicine” were really brief, from about 1920 to 1960. The discoveries of insulin and antibiotics swept into the 20th century a new social entity of medicine, as a discipline that could do more than use narcotics, purge you, or bleed you.
            Hospitals before that were dread places where you went to die. Now they can give you aggressive care and often release you.
            And sometime in the 20th century, the beast of health care entered the picture, along with the other beast of student loans. Both third party systems really corrupted medicine.

  • Luis Collar, M.D.

    I respect your opinion. And, more importantly, I respect your right to that opinion. However, I must tell you that direct comparisons to other countries are misguided in this case. In countries where there is a public / private partnership between the federal government and the insurance industry to deliver care, the government sets limits as to how much profit (if any) can be extruded from mandated policies. Additionally, those same governments exert considerable influence on the prices that pharmaceutical companies, hospitals, and others can charge throughout the market for their services. And the government also mandates a certain degree of price transparency. No such price transparency requirements or profit limits (at least not equivalent ones) are in place here (other than for physicians). And so rather than transferring wealth from the “rich” to the “less rich,” we are simply transferring wealth from the “rich” to the “richer,” while simultaneously providing the illusion of universal coverage and arbitrarily picking “winners and losers” amongst the players in healthcare. Insurance companies enjoy much more guaranteed business, but they really take on no additional risk. That is, they manage any additional risk by narrowing networks (not only for the newly insured but also for those that previously had insurance), adjusting benefits, denying claims, withholding payments to physicians, and so on.

    Simply stated, the concept of insurance, the purpose for which it was developed, is not to cover a $100 office visit. That is not what insurance is for. There should be a strong “safety net” for that (e.g. one more robust and less complicated to function within than Medicaid). But the purpose of “insurance” is to effectively manage risk and deal with “unforeseen” or “exorbitantly costly” events. It is absolutely foreseeable that you may have to go to the doctor for the flu shot, or for a checkup, or for a skin rash. I do understand that the prices of many medications / procedures are exorbitantly high. But further relying on insurance will only make that particular reality even worse. In fact, one reason (there are many) that they are currently that high is precisely because we have increasingly relied on third-party payors in healthcare, entities that exacerbate derangements of price and impinge on the rights of physicians and patients to practice medicine and direct their own healthcare, respectively.

  • Lisa

    My husband refers to doctors as medical dieties. As someone who has plenty of experience with health care providers, I do not want to be treated by someone who does not want to be questioned.

    • liz1rn1

      I work with doctors every day, and my bf is a doctor. I’ll be the first one to admit that some are difficult to work with, but, in fairness, most are doing their best to make the best of a bad situation and do the right thing for their patients. Just my opinion, but I think they take the heat for a lot of things they have no control over.

      • Lisa

        My comment was an aside to Vipul Vyas’ comment about the “era of doctor = god” is over.

        While I understand that doctors are under increasing pressure, I don’t think the problem of doctors not wanting to be questioned is a new phenomena. And if a doctor is trying to do the “right thing” for their patient, having their diagnosis or treatment plan questioned should not be a problem.

        • liz1rn1

          I just meant that not all doctors are like that. Many make recommendations based on their experience and then actually do listen to patients and make adjustments when they have concerns. Same thing happens in nursing. Some nurses are good and others aren’t. Many doctors are difficult to deal with, but there are many that listen and are quite pleasant and easy to deal with. Not all doctors don’t “want to be questioned.” That was my point.

          • Lisa

            Yes, there are ‘good’ doctors and there are bad ones, but there are enough ones who can’t or don’t communicate with their patients to generate the quote that I was responding to in Vipul Vyas original comment or my husband’s nickname for doctors.

    • querywoman

      I wrote a letter to a doctor once when I was mad. At the bottom, I included the computer file name, “mdeity.”

  • Luis Collar, M.D.

    On your first point, I agree there is a perception / image problem. And also agree the profession hasn’t dealt with it appropriately. (Not sure how any fair-minded person could question an entire profession’s competence, so I won’t delve into that aspect of your comment.)

    On your second point, I agree that price transparency is clearly necessary. But I would point out that in healthcare, precisely because of the overreliance on third-party payors, price transparency and competition do not always lead to lower prices. Conversely, for elective procedures not covered by insurance (e.g. Lasik surgery and many cosmetic procedures), we do see that, without the presence of third-party payors, increased physician competition does lead to price transparency and decreased prices for consumers.

    On your third point, I would only point out that there is, in fact, such a thing as “bad” technology. In other words, some EMRs are good and some are not so good. The not so good ones do, in fact, make patient care more difficult and can actually lead to patient harm. When someone points that out, it doesn’t necessarily mean he or she believes technology has no place in medicine. It simply means that for technology to be adopted, it must be safe and actually improve the care delivery process. Adopting bad technology just for the sake of doing it is not only silly but ill-advised.

  • Luis Collar, M.D.

    Agree with most of those points, RL. I’m all for increased access, lower costs, and greater price transparency. I just don’t think increasing our reliance on insurance in healthcare accomplishes any of these. In many cases, I think our reliance on third-party payors is what is impeding progress in those areas.

    As far as where doctors are in the discussion, I don’t think we’ve done enough to make our opinions known and to advocate for patients on this front. There are many that do just this (many on this blog, for example), but more needs to be done. Also, I don’t think many of the organizations that are supposed to represent physicians (e.g. AMA) have done enough.

    Out of curiosity, do you think more insurance coverage will fix the problems you raise?

    • ErnieG

      Dear Dr. Collar–
      I have been following your posts for months, and I believe you provide a clear succinct voice that echoes many physician’s concerns. I am also a physician, and I too believe that third party payers, including government and insurance, as well as big pharma/medical device companies have eroded the fundamental concept of medicine as a service provided by physicians, nurses, and ancillary staff to patients. That is not to say they do not have a role– there is risk management, redistribution of wealth, and new advances in meds and procedure– but rather that their interests are so great that the individual importance of diagnosis, management, and treatment of the sick seems to have been lost. Furthermore, I am very upset that the main physician organizations such as the AMA, ACP, and others can’t seem to go beyond the idea that insurance does not equal medical care. Perhaps they are afraid of sounding cruel, but they clearly are not promoting the ideal that a strong physician-patient relationship is key to medical care.

      • Luis Collar, M.D.

        Thank you very much for the kind words. I think your assertions are completely accurate. As for the fear of “sounding cruel,” I think what is being done is precisely what is cruel. Namely, convincing patients that these insurance products can actually make them “healthier” or even deliver on the promise of high-quality care.

  • Martin White

    Hi Dr. Collar,
    Thanks for this post. I believe this is the second time it has appeared on KevinMD. Like I said last time, I think we are brainwashed into thinking we must have insurance and it will take a lot of work to change that mindset.

    • Luis Collar, M.D.

      You are quite welcome. Thank you for taking the time to comment.

  • Martin White

    Will the average American citizen pay out of pocket for routine care? I doubt it. As others have mentioned in this discussion, many people who “can’t afford” healthcare somehow seem to find the money for manicures, cell phones, and nice cars.

    • hawkeyemd1

      Well, people have to have priorities, don’t they? What good is staying alive if you don’t have a nice ride and impeccable nails. Just kidding…sort of.

    • Luis Collar, M.D.

      I don’t think any drastic changes would be well tolerated, or even needed. The important thing is to first stop increasing the role of insurance in healthcare and cease the ongoing transfer of authority over care decisions and allocation of resources to insurance company bureaucracies. Then, we can gradually pull back our reliance on insurance in small increments. As prices begin to decline (as they have for services that aren’t typically covered by insurance like cosmetic surgery and Lasik procedures), we can pull back more. Doing so might let us eventually return insurance to its rightful place in healthcare, to the role it was designed to play and is actually effective in–risk management and protection against catastrophic or unforeseen events. Thanks for contributing.

    • liz1rn1

      I see this all the time too. Patients won’t spend 100 dollars on a visit, but they’ll spend that much on all sorts of useless things and much more on insurance that doesn’t cover what they need in the first place. And then many blame the doctors / nurses / other staff.

  • hawkeyemd1

    Great post. Agree 100% that we rely too heavily on insurance, but the powers that be are unlikely to let that change. Insurance / pharma / corp med / PBMs / govt…The status quo means they all continue to profit handsomely and wield considerable power. BIg Insurance is what keeps it all together administratively.

    Besides, people don’t really believe they’re financially responsible for their own health care anymore. Hard to change the entitlement mentality that as well.

    • Luis Collar, M.D.

      Thank you for the feedback. Hopefully, increased public awareness and pressure will lead the “powers that be” to pursue a more thoughtful, fiscally responsible, and effective policy approach to healthcare financing.

      • hawkeyemd1

        Not sure my outlook is as positive as yours, but I do think we need more docs like you in the public eye. Keep it up.

  • hawkeyemd1

    Hey, I spend a lot of time in my hospital’s ED. It’s in a pretty rough neighborhood, so “asshole” is by no means the worst name I’ve been called. lol.

    But on a serious note, is there really any comparison between what doctors do and what investment bankers do? The formal education required? Their value to society? The repercussions of their mistakes? The implications of their successes? Were the people you talked to really saying investment bankers are somehow nicer or more altruistic than doctors? Really? Doctors may not = god, but the vast majority are definitely much more altruistic, consequential and valuable than investment bankers (especially if you’re dealing with real things like life and death and not just wall street’s “paper reality” and fancy financial double-talk or marketing-speak).

  • hawkeyemd1

    Physicians might need to speak up more, but they also need to stop paying dues to organizations that do absolutely nothing to represent their interests, even when that’s exactly what they are supposed to be doing. It really is disgraceful how ineffective the AMA and others like them are.

    • Luis Collar, M.D.

      Agreed.

  • liz1rn1

    “Engaging it for routine activities, including all but the most costly
    drug therapies and procedures, serves only to dilute valuable resources
    and relinquish essential control.”

    As a nurse, I see this all the time. Common scenario: doctors and patient want one thing, insurance company disagrees, doctors and patient spend hours filling out forms, making phone calls, talking to ins. co. personnel, trying to prove medication or procedure is necessary. In the end, so much money and other resources are wasted while the patient suffers, and sometimes the insurance company gives in, sometimes they don’t. Even when they do give in, all the administrative costs and wasted time involved makes it much more expensive than it otherwise would be. But all the insurance commercials make it seem like getting coverage with their company is all about having choices, having a health “partner,” and getting you the best care possible., Very sad situation.

    • Luis Collar, M.D.

      Very common scenario indeed. Thank you for contributing.

  • Lisa

    What you are suggesting is a return to pre-ACA days, where only the very well off had access to medical care if they did have insurance covered by their job. The folks I knew who didn’t have insurance coverage through their job either went without insurance (and without medical treatment for the most part) or they had expensive, high deductible insurance. All of these people accepted the situation because they were relatively healthy. They also avoided going to the doctor like the plague because of the costs.

    Medical debt is the single biggest reason people in the US file for bankruptcy. Much of what I have seen in the responses to this article are bashing people with lower incomes for their irresponsibility; paying for cell phones, drugs, TV, alcohol, tickets to sporting events, and so on over medical care. Even if lower or mid income people gave up all of these things, which I truly doubt they spend that much money on, given the cost of food, housing and transportation, they couldn’t afford to pay for anything other than the occasional doctor visit.

    More health insurance may not be better, but doing away with it isn’t the answer unless we go to some form of universal coverage. Remove the profit motive and we (except for insurance companies) would be better off.

    • Luis Collar, M.D.

      Hi Lisa,

      I definitely see your point, and I do believe all your concerns are valid. To be clear, I don’t believe in drawing a simple distinction between “pre-ACA days” and “post-ACA days,” nor do I believe that most people that can’t afford healthcare are drug addicts. I’m well aware that things weren’t that great “pre-ACA” either. And despite considerable problems with many of the individual components of the law, this isn’t a political issue for me. I actually applaud the administration for wanting to do something to improve our healthcare system, something others have either avoided doing or been unable to do for decades.

      My problem simply has to do with entrusting so much of our healthcare to the insurance industry. I generally believe in free markets, and I would welcome any system that would leave more care and resource allocation decisions in the hands of patients and physicians, without the intrusive presence of third-party payors that add no value to the process. But I do recognize that due to what borders on collusion and lack of oversight, we didn’t have a free market in healthcare even before ACA. So rather than reminisce about better times that never really existed, I want us to find ways to drive prices down for many of the most common healthcare services while regaining some of the control and resources we’ve unwisely relinquished.

      My goal it to have more people get real medical care, the care they need, not some administrator’s interpretation of what a patient’s care should look like. Again, I think insurance is critical if used appropriately (as a matter of policy), but relying on it more and more will only cause prices to continue to rise and premiums will continue to rise, networks will continue to narrow, formularies will continue to shrink, and so on.

      Not getting the care you need because you can’t afford it is unacceptable in our society. But not getting the care you need even when you are paying for insurance (or have a subsidy providing assistance) is just as bad and, in some ways, worse. I hope we can focus on driving down prices for most services, providing strict oversight (not intervention) over companies providing affordable catastrophic coverage, and returning the authority to decide what medical care is appropriate and necessary to patients and physicians. Thanks for taking the time to respond. I do appreciate the feedback.

      • Lisa

        I would like to hear how you propose people who are poor or even middle class get health care. I would be fine under such a system of self pay and catastrophic coverage (more than likely) because I have resources. But many people I know really live pay check to pay check. They would be hard pressed to come up with 10K (I am presuming that might be a deductible on a catastrophic coverage policy based on the high deductible insurance plans I have looked at in the past.

        • Luis Collar, M.D.

          With any system, the poor would need to be covered by a strong safety net, Ideally, a more robust version of what we currently refer to as medicaid.

          • Lisa

            I am glad you recognize that need.

          • Luis Collar, M.D.

            I absolutely do, Lisa. The poor, the elderly, children…we, as a society, need to make sure that we provide a strong, but more effective, safety net that addresses their needs and is streamlined to ensure that physicians are incentivized to care for those populations. Specifically, those systems need to be much less administratively burdensome (e.g. less or no preauthorizations, less complicated reimbursement, etc…)

            To me, though, simply adding more “coverage” without addressing the underlying issues of cost / price / socioeconomic determinants of health in healthcare only masks the problem, leaves many (even those that are “insured”) without the care they need, and will be fiscally unsustainable in the long run.

          • Lisa

            Addressing cost does involve getting into issues of what will be covered when you are talking about insurance or safety net programs. From my point of view as a patient and consumer of medicine, I see a lot of unnecessary treatment and testing happening. Who will dedicde what is necessary? Now the political lobbies, those who make money from the business of medicine heavily influence those rules. That is why I think a single payer system is better – medicine will be a mess as long as the profit motive is involved.

          • Luis Collar, M.D.

            I think patients should be the ones making decisions (with physician advice, of course, for those issues they don’t have the knowledge or training to fully understand on their own). To your point, though, forcing insurance companies to administer the system only serves to add profit motive (insurance) on top of profit motive (hospitals and large health systems) on top of profit motive (biopharmaceutical companies and PBMs). on top of profit motive (physicians). It just adds another to the long line of profit motives in healthcare, but, in this case, one that adds no real value to the process.

            I do think that we can use rational free market approaches, implemented gradually, to address many of the problems we currently have. But, with regard to your comment, I sincerely believe that a single-payor approach would be more effective than the hybrid system we currently have that doesn’t really improve health and arbitrarily picks financial “winners” and “losers” amongst the players in healthcare.

          • Lisa

            While you can apply free market approaches to medical care that is strictly elective (mainly cosmetic procedures), I don’t think you can apply free market approaches to much of medical care. That is because demand is inelastic to a fair degree. I still think the only solution is single provider or a system of manadatory, heavily regulated by a government negotiates prices, ala Switzerland.

          • Luis Collar, M.D.

            Urgent / emergent services are indeed inelastic, as are some drugs / interventions. But much of primary care / preventive services / many drugs / minor procedures / and much more could be handled with a free market approach. On Switzerland’s system, I do agree at least they had the fortitude to make more of a real “choice” in their policy direction (e.g. by capping / eliminating insurance company profits on mandated policies, etc.) We seem to have opted for more of a middle ground that I don’t think is good for anyone involved, except possibly the largest corporations (which is neither a “free-market” or “single-payor” solution.)

  • Sharon

    I am humbled when I see the true cost of the medication I take. I would never be able to afford it without insurance coverage, but I don’t think I would be here today, without it. Maybe that would be looked upon favorably in today’s economic market…. sure…. take yourself out…. one less aging person to potentially suck up more resources down the road.

    • Luis Collar, M.D.

      I personally believe we need to strengthen, not weaken, our care of the elderly population. Part of that would include finding ways to drive the prices of most prescription drugs down. Incidentally, I would point out that, though it thankfully hasn’t been your personal experience, there are many insured individuals who can’t get the medications they and their physicians deem necessary because the drugs are not part of the approved formulary for a given insurance company. That is tantamount to not being able to afford them. But in those cases, the person is, in fact, paying for some sort of coverage, they are still told they can’t get the medications they need, and they have to pay out of pocket for those medications anyway. This is why addressing “coverage” without addressing the underlying cost / price problems yields less than ideal results.

      • Sharon

        Good point.

        • Luis Collar, M.D.

          Thanks, Sharon. And than you for contributing.

  • Ava Marie Wensko George

    Unbelievably ignorant argument. So, insurance does not impact health and there are no studies to reflect this? Then I must presume that you did not take the time to even look at relevant reliable studies like this one: http://news.harvard.edu/gazette/story/2009/09/new-study-finds-45000-deaths-annually-linked-to-lack-of-health-coverage/

    Talk to the families who have lost loved ones due to lack of insurance and perhaps you will have a different view. Growing beyond the anger (and rightly so) you have considering the adversarial relationship physicians have with insurance companies will help you to understand the other side – Poor people without insurance die because it limits their access to healthcare, both preventative and emergent.

    • Luis Collar, M.D.

      The study you cite is a retrospective study of health outcomes based on analysis of surveys, one of the least scientifically rigorous forms of analysis. Much more rigorous studies have shown quite the opposite. Consider, for example, the results of the Oregon study published in the New England Journal of Medicine: (http://www.nejm.org/doi/full/10.1056/NEJMsa1212321) — “This randomized, controlled study showed that Medicaid coverage
      generated no significant improvements in measured physical health
      outcomes in the first 2 years,…” And this was part of a randomized, controlled trial which tends to produce much more reliable data.

      A more thorough look at all of the data available (there are other studies) allows one to see that, politics aside, health insurance, in and of itself, makes little to no difference in a person’s physical health (except in certain isolated groups, such as young children, which I believe should be universally covered). This is because simply looking to more “coverage” as an answer, without addressing the underlying issues of cost, price, true access, and socioeconomic determinants of health only masks problems and does little to improve real health.

      As a physician, I would also point out that not only have I cared for the ill and dying without insurance but also held and cared for the ill and dying that were insured at the time of death. Allowing insurance companies to determine how scarce healthcare resources are allocated is what is truly absurd. Many people with insurance routinely have their claims denied. Many of them cannot get the medications they need, as determined by patients and physicians, because they don’t appear on an approved formulary. Many patients have to wait and suffer while physicians spend days, sometimes weeks, arguing with insurance administrators in order to get them much needed treatment. What many people don’t realize is that the for-profit insurance company “risk pool” is an imperfect science. And when these pools break down, for every claim approved, there is a claim denied. For every needed drug on a formulary, there is another that is left out out. Networks become narrower. Payments to physicians are withheld. And all the while, profit is extracted by organizations that add absolutely no value to the process.

      I want people to receive the care they need and enjoy improved health, real health. And as long as our only answer is to provide more “coverage,” the real problems in healthcare will go unaddressed, at least until the system becomes fiscally unsustainable and “crashes”. We must look beyond coverage if we truly want to improve our nation’s health.

      Thank you for contributing to the discussion.

  • Jerry Segers

    I find your comments some of the most sane pronouncements I have recently encountered. I am not sure of your age, but I am old enough to remember how we got into this mess. There was a time in the 40′s when the Government froze wages and instituted a systems of rationing. This was done for the announced purpose of holding down the price of these goods and services so everyone could fairly purchase them. There were several unintended consequences one of which was that as the emergency wained and companies started hiring, they could not attract qualified workers. Since they were not allowed to offer higher salaries, they chose to offer benefits. One of these benefits was health insurance for the individual, then the family. Suddenly every company had to offer these benefits and we were off to the races. Even into the 60′s, however, the insurance was primarily for the catastrophic problems and people paid for their own maintenance. Now add into the mix the government creation called medicare, and medicaid. These were mandated as the insurance of choice for people over 65 and the less affluent. Thus the government became the largest purchaser of medical services in the country and by law were not allowed to negotiate rates. Later the insurance companies and the government discovered it was easier and less expensive to collect clam data from the provider instead of waiting for forms to be filed by the insured. Thus the stage was set for the insurance companies to refuse payment to the provider. Before this “innovation” individuals payed the bill and filed for insurance reimbursement. Refusing claims resulted in unhappy customers and there were millions of them. With the new system, refused claims and the resultant hassle were rarely seen by the insurance customer only by the medical provider. Today we have complete isolation between the provider and consumer of medical service established primarily, as i have shown, by government intervention in the marketplace. This separation means that for older people like me with Medicare and a secondary provider, we never see a bill no matter what after the first $250 or so deductible is paid. The money for the insurance is taken out of our retirement before we see the check so we never consider it’s cost. As a result all medical care seems free and therefore any and all procedures are requested. Now we are back to the rationing. While no one can stop paying for my care no matter what I demand, the insurance companies or the government can prevent the provider from performing the service by refusing payment. As a result I must have two doctors. One I see when I am ill, paid for by insurance that I mostly don’t need, and another doctor that refuses to take insurance to help with wellness issues that are not covered by insurance since insurance will not cover many tests and other activities I believe are helpful. While I see the problem clearly as you do, I do not see a way out but I am fairly sure adding more insurance rules and more governmental control is only going to make things worse. I can only hope the old saying “Nothing Gets Done until Nothing Gets Done” is true and we are getting close to a solution.

    • Luis Collar, M.D.

      Thank you very much for the kind words, Jerry. I really appreciate the feedback.

      Wow… You truly have a wealth of knowledge on this topic. I can only hope that you share that knowledge and experience as often as possible with others. I think, as a society, we do a poor job of learning from those that have actually lived through much of what younger policy makers and practitioners can only read or hypothesize about.

      I think your assertions are spot on and your “two-physician approach” is quite common with aging patients. And we also see this with patients that are veterans. They have one VA physician and one private physician in order to address some of the very challenges you point out.

      I’d be interested in your opinions on how we can address the issue of drug prices and the costs of imaging / diagnostic testing. As a physician, I believe there are many ways we could more effectively deal with the delivery of healthcare services by physicians and hospitals (many of which I didn’t cover in this piece), but the issue of drug prices and the costs of imaging / diagnostic testing is a bit more difficult to crack since it involves the costly development of technology and huge corporate / government interests.

      Thanks again for the thoughtful comments and insight.

      • Dorothygreen

        I have scanned through much of this conversation and would just like to add my dime’s worth (inflation you know). Jerry say “Thus the government became the largest purchaser of medical services in the country and by law were not allowed to negotiate rates”. Who made this law? I don’t recall reading about such a law in Paul Starr’s 1984 Pulitzer Prize book – The Social Transformation of American Medicine – the rise of a sovereign profession and the making of a vast industry.

        Rather, to my recollection what happened was a deal to placate the AMA at the time because they were so opposed to universal health care and physicians were ready to boycott. So President Johnson allowed physicians and hospitals to set their own prices and fill as many beds as they wanted. There’s another book in that era In Sickness and in Wealth by Rosemary Stevens.

        Both books describe the bonanza that put the greed machine in gear and like a defective car accelerator it has been unstoppable. We are headed for a crash because of unsustainable health care costs, it is clear to even the casual observer. I think it is the responsibility of the AMA to initiate the move to right this wrong. The ACA is the right path but falls short of having a fair affordable health care system.

        I urge you to look closely at the Swiss system. I appreciate we have much larger and more diverse population but the principles are what is important – the mandate, outlawing private insurance for basic services, a reasonable capped deductible, some up front payment from the patient, and the same negotiated prices for all – there is no such thing as medicaid that separates basic care to the poor.

        In the meantime, the media and lawyers are are having a bonanza – digging into the continued milking of Medicare by some physicians, Big pharma, and hospitals clinging to their cryptic master charge – in this vast industry. And many folks still cannot afford the so-called affordable health care premiums and deductibles. Some will go bankrupt and some will die because of the cost.

        • Luis Collar, M.D.

          Great points. Thanks for sharing your perspective. I definitely agree that there are considerable differences between our system and the Swiss system, particularly with regard to controlling costs / profits. As I’ve written in the past, I think part of the problem is that we haven’t made a clear philosophical choice in our society and moved toward either a true free-market solution to healthcare or true universal coverage: http://www.kevinmd.com/blog/2013/12/health-care-business-time-choice.html

          Until we make that choice, and until our policies are true to the underlying philosophy chosen, I think we’ll be stuck with a hybrid solution that isn’t aligned with either school of thought and isn’t very good for anyone involved (except the select few that profit from the status quo).

    • querywoman

      If you are on traditional Medicare, doctors are supposed to collect 20% after you meet your annual deductible. Many don’t bother to pursue, which is actually illegal. Since the practice is so common, and of course the government knows about it, it would probably never be litigated.

  • Luis Collar, M.D.

    Hi Karen,

    First, I’m sorry to hear that you’ve been dealing with health problems. I hope you’ve been able to get the care you need and are feeling better.

    Thank you for the thoughtful comments. You bring up some great points, and I definitely understand your concerns. What you describe is precisely what insurance was meant to deal with–unforeseen problems that escalate quickly and can lead to considerable financial stress. That is why I don’t advocate getting rid of insurance altogether. It can and should play a significant role in healthcare.

    My argument is that, as a matter of policy, simply focusing on coverage without addressing the underlying issues of price, cost, true access, and socioeconomic determinants of health is ill-advised and ineffective. Furthermore, the more control we turn over to insurance companies, the less autonomy patients and physicians have in deciding what care is needed. And finally, insurance, by definition, adds considerable administrative costs to the system, adds little value at the bedside, and plays a considerable role in keeping the prices of healthcare products and services high.

    I’ve mentioned it in other comments, but I’ll repeat it here: If one looks at certain services that are not covered by insurance–Lasik surgery, many cosmetic procedures, and many dental procedures, for example–one sees that the prices of these services have dropped considerably faster than others of comparable complexity typically covered by third-party payors. Similarly, we routinely see that concierge or direct-pay practices are able to provide better healthcare services at significantly lower prices simply by removing the administrative burden that third-party payors bring to the table.

    I believe that by prudently pulling back our reliance on third-party payors in healthcare, we can gradually bring prices down and improve access without sacrificing patient autonomy or relinquishing the limited healthcare resources extracted from the system as insurance company profit. We will always need to provide a strong safety net for at-risk groups that include the poor, the elderly, children, and others, but, overall, we need to remove the unnecessary layers of administration that exist between patients and physicians.

    Most primary care services and even some specialist services could be provided directly without the need for insurance (again, this would need to happen gradually to ensure that prices are given the opportunity to decrease as they have in the aforementioned examples). And insurance would then ultimately be used as a risk management tool, the purpose for which it was originally designed, Of course, this would require time and careful planning, as well as considerable attention to other factors that include drug prices, hospital care, and closely related socioeconomic policies, but I think we need to have those difficult discussions in order to really improve our nation’s health. More coverage, in and of itself, is not the answer.

    Also, just out of curiosity, could you explain what you meant by this portion of your comment:

    “And in my opinion, paying doctors directly would create a very sticky situation when dealing with second opinions or having doctors address others doctor’s mistakes.”

    Thanks again for contributing.

  • Luis Collar, M.D.

    Okay, I misunderstood that part of the original comment. I do, though, think that process wouldn’t change much. On the contrary, I think independent physicians practicing in a direct-pay environment would be even more likely to take patients like that on. Here’s why:

    Complicated patients are more time consuming to deal with, but insurance companies don’t really compensate physicians for all of the additional work they entail anyway. Moreover, practicing in a more corporate, payor-driven environment means having to worry about arbitrary, biased quality measures. Specifically, doctors are increasingly judged, and paid, based on how much they cost the insurance company / hospital as well as arbitrary “indicators” of disease that serve as surrogates for real outcomes.

    So, for example, if a patient has many complicated illnesses (say, a couple of failed surgeries, heart disease, diabetes, COPD, etc.), then physicians become increasingly averse to dealing with them. Why? Because in addition to the unattractive financial cost / benefit ratio, they have to worry that their “quality numbers” or “utilization costs” will look bad and lead to even less pay, or withheld reimbursements, or administrative “discipline.” For example, if insurance companies or corporate health system administrators say that a diabetic patient’s HbA1C must be at 6.5 to enjoy full payment and job security, then physicians will increasingly avoid older, more complicated patients, or patients that have difficulty controlling their diet or adhering to therapy, or patients that are poor and have difficulty affording medications or healthier foods, etc…

    With a direct-pay model, though those patients would still be more complicated and require more work than a young, healthy patient, at least the physician only has to worry about doing what is right for the patient, not meeting administrative goals that having nothing to do with health or real outcomes.

    And you’re very welcome. And thank you for sharing your thoughts. I really enjoy hearing from patients or anyone interested in improving our healthcare system. All voices need to be heard, all opinions respected, regardless of political or economic ideology, if we are going to continually improve the delivery of care in this country. Unfortunately, sometimes it seems that patients and physicians are the ones least often consulted when developing healthcare policy.

  • Luis Collar, M.D.

    Similar studies have also shown that coverage increases use of the ED, a very expensive, short-term fix at best. Unfortunately, it is also one that won’t be fiscally sustainable in the long run.

    I do agree insurance is one of many different ways to improve access. My problem is with the increasing reliance on it as the only way to achieve access or improve health.

    As I say in the essay, and as you allude to in your comment, socioeconomic phenomena not addressed by insurance or current policy are responsible for the majority of chronic illness in this country. Ignoring that from a policy perspective and simply focusing on insurance is ineffective and considerably more costly than comprehensively addressing upstream issues head on.

  • Luis Collar, M.D.

    Really interesting ideas, Jerry. Thank you so much for contributing. Hopefully, feedback from more well-informed people like you will be sought by policy makers in the future. Unfortunately, I think physicians and patients are seen as increasingly irrelevant and are practically excluded from, or ignored in, policy discussions: http://www.kevinmd.com/blog/2014/04/relevance-physicians-dwindling-rapidly.html

  • querywoman

    I never went to a doctor who posted his or her fees. I know what I pay and what Medicare pays.

  • querywoman

    Dr. Luis touched on the unthinkable here! I don’t think more and more insurance makes people healthier under the present system. Does more insurance lead to a bunch of costly stuff like preventive screenings?
    The poor can already get free mammograms and other preventive screenings. Why? Because the medical schools will use the ones who flunk the tests to study on.
    No one needs health insurance. Most people need some kind of medical care. Regrettably, health insurance has corrupted the medical profession. Scams and Mafia-type schemes come and go. Remember Teapot Dome? My father said when he use young liquor was the biggest scheming industry.
    Now it’s health insurance and the drug companies. Health insurance is here to stay.
    There are so many sides to arguments. The hospitals have to treat the uninsured in emergencies. Do they fail to do as many tests on the uninsured? Or do the insured just get too many tests?
    I really hate tests. I need a certain amount of blood work and occasional spirometer readings. Anything more than those scares me!

    • Luis Collar, M.D.

      Hi QW… Great to hear from you again, it’s been a while! Hope you are doing well. You make great points, as usual. It isn’t the insurance, it’s the actual care / outcomes that need to be a focus. And insurance also makes physicians and patients less relevant in our society / healthcare system. That’s exactly what my new post is about: http://www.kevinmd.com/blog/2014/04/relevance-physicians-dwindling-rapidly.html

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