The brave new world of medicine started innocently enough with the HMO health care delivery model, pioneered by Kaiser Permanente. The essential features of the model are now all too well known: A self contained, hospital-anchored system of linked physicians and support personnel, not portable, a system where bureaucratic cost management operates in the background. When funding is limited (hint – funding is always limited), the pressure is felt in delays, especially in access to specialists, in long waits and abbreviated visits with the frontline physicians. The Kaiser model, which began as a sort of company town health care-for-employees model, was emulated by the fee-for-services insurers as a way to keep costs within margins acceptable to employers and the unions.
The typical HMO is a virtual Kaiser, one tied together by contractual agreements where the former general practitioner/family doctor mutated into a services-gatekeeper (the “primary care physician”) who was placed under relentless fiscal pressures to see more patients a day, utilizing fewer and fewer minutes of “face time” per each. Over time, a new pattern emerged: physicians jumped ship with burned out specialists leading the way. Shorter visits with “family doctors” and delayed access to specialists inevitably followed.
In the mean time, insurance providers were placed in an intolerable cost squeeze. They were contractually required to cover everyone in the assigned groups (typically negotiated between employers and employee representatives) at fixed costs – impossible in an environment where new life-saving technologies were constantly emerging and being demanded by patients. As any insurer knows, the primary duty is to the existing pool of insured. This included the absolute obligation to secure sufficient funds to full cover that group. Is it a surprise that insurers caught in the vise of conflicting obligations might be reluctant to take on new patients outside the required group unless they were (a) healthy and (b) otherwise a low risk of catching something expensive?
Because of the employer-employee vise, fewer and fewer individuals have been able to break out of the bureaucracy to obtain care outside the HMO trap.
All of the complaints about this country’s over-bureaucratized health care delivery system can be traced back to this dynamic. Even before the specter of health care reform, the ghost of a Darwinian life-death struggle had entered the picture. This is why we spend hours researching our own health care issues on the web; we insist on having a friend or loved one as a guardian in the hospital whenever possible; and we are starting (when possible) to save up a little money to break out of the system for a reality check. This is Darwin at work: the smart, proactive patients survive and the dull, passive ones die. I do not exaggerate here …by much.
Cutting through the fog of rhetoric, political spin and legal jargon, the huge difficulty with the liberal health care reform juggernaut (now opposed by a durable majority of the American people) is that it will accelerate the Darwinian trend, while closing most of the private Exit pathways.
The most promising model (about which I’ve written earlier – see, < http://www.jaygaskill.com/HeathCareTrainWreck.htm >) is one that gradually moves Americans back to a customer-driven model where patients are given cost transparency and empowered to select treatment modalities on a personally determined cost-benefit basis. This is a much less bureaucratic system wherein insured groups are folded into much large ones to spread the risk as widely as possible, participation made available to individuals, with selected subsidies for indigent patients, using a voucher format, so as not to distort the cost-containing pressures of a market-based model. That will never happen if Americans are allowed to become addicted to the top-down Darwinism of “liberal” health care. We need – desperately need – an intelligent, not-crisis-driven national conversation about this.
As I’ve already argued (see < http://www.jaygaskill.com/HEALTHCAREIsItReallyTimeToSayNO.htm > ) the best REAL conversations usually start after a definitive NO.