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Fixin' Healthcare

Friday, March 24, 2006

The Lifestyle Chronicles - Health Assurance Is Insuring Health

In the not too distant past health insurance was a mundane topic. Now, it is a hot issue with special interest groups, politicians and the media fueling the fire. At the moment the health insurance chorus is singing with a multitude of discordant voices, but at least they have shown up for practice. This may turn into a rehersal and then a show.

To most patients health insurance is simply a payment mechanism. Patients expect bills for health care services to be submitted directly to the insurance company for payment. This procedure has the effect of discounting the value of service in the minds of patients. By the time the bill has made several prolonged round trips and partial payment has been rendered, any residual amount due to the provider is discounted to near zero in the minds of patients.

One straightforward change with the potential for profound impact would be for the patient to render full payment for professional service and submit the bill to the insurance company for reimbursement. It is a more responsible business transaction leading to a reorientation of values. For starters, the patients would be aware of prices. Health care providers and their patients, as well as insurance companies and their customers would be positioned in the proper relationship. Carrying cost and administrative overhead would be allocated to the appropriate parties. And, value for service rendered would be more apparant to the patient/customer.

The basic role of insurance is to share risk. Insurance compensates for predetermined risk by means of differential premiums or denial of coverage but the ultimate, lasting value is to reduce risk. All of us would be remiss if we did not insist that health insurance include mechanisms to manage risk with emphasis upon primary and secondary prevention. Otherwise, it is nothing more than a method to pay for sick care.

Why would someone with a healthy lifestyle want to share risk with those who have unhealthy lifestyles? The answer is they don't unless someone else pays the bill. If not the employers, then the government. In either case, health insurance without effective prevention is a formula for financial disaster.

The $64 (thousand, million, billion) question is how to implement effective primary and secondary prevention. I have always believed in hope and incentives but there appears to be some need for fear, enforcement and guilt. Traffic laws and police enforcement are effectively adjuncts for risk management to automobile insurance. Until we know better, the more effective route is to focus upon children and take a long-term view on salvation. In all likelihood the children will teach the adults. Focusing upon children includes young women before pregnancy and during pregnancy (a very special group in any civilization).

It would be highly productive to retool primary care as a specialty for preventive health care and a value added activity. Primary care "sick call" as it exists today has already been relegated to a low value activity. Redefining community health and creating a structure to manage community health is a component of this system.

If there is to be universal health insurance, let it start with prevention. The improvement of health status that results will change the health care system and the future of society as we know it.

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