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Mar 25 2015

Report from the front lines: Technology, engagement, and killing paternalism

By healthcare industry, politics, technology

I’ve spent a good portion of the last two months on the healthcare equivalent of the political stump – called the “rubber chicken circuit” in political circles. Thankfully, there was no actual rubber chicken served during these sojourns, although there was the incident of the seductive breakfast sausage, followed by my solo re-enactment (off stage) of the bridal salon scenes from the movie “Bridesmaids.” I will draw the veil of charity (and gratitude for travel expense coverage) over the details of that incident, and just advise all of you to stick to fruit, cereal, or bagels at conference breakfasts. ‘Nuff said.

My original editorial calendar plan was to turn this into a series of posts, broken down by focus into technology and clinical categories. However, since a big part of my goal in standing on the barricades at the gates of the healthcare castle, waving my digital pikestaff in service of system transformation, is breaking down silos … well, go grab a sandwich, and a beverage. This is gon’ be a long one.

HIMSS Patient Engagement Summit

In early February, I headed to Orlando for the first Health Information and Management Systems Society (HIMSS) Patient Engagement Summit. I was asked to participate in two panel discussions, one titled “Patient Perspectives: The State of Engagement,” the other “Can We Talk? The Evolving Physician-Patient Relationship.” Both were moderated by Dr. Patricia Salber, the bright mind behind The Doctor Weighs In.

Being a person with no letters after her name (like Elizabeth Holmes [update: she’s trash, so redacted] and Steve Jobs, I’m a college dropout), I’m used to showing up at healthcare industry events and being seen as something of a unicorn fairy princess. That’s how people commonly called “patients” are usually viewed in industry settings outside the actual point of care. Healthcare professionals/executives are so used to seeing us as revenue units, or data points, or out cold on a surgical table, but not as walking/talking/thinking humans, they can do a spit-take when meeting an official “patient” at an industry conference. Which is fun if they have a mouthful of coffee, but I haven’t seen anyone actually get sprayed yet.

All kidding aside, I really have to hand it to HIMSS for their uptake speed on seeing people/patients as valuable voices in the conversation about healthcare IT and quality improvement. In the time since they first noticed (in 2009, I believe) that people like ePatient Dave deBronkart, Regina Holliday, and others might have something to add to the discussion, they’ve made a visible effort to include people/patient voices in their national programs. Of course, had they not invited patients to present at their Patient Engagement Summit, they would have been line for a public [digital] beating … and so there we were: Amy Gleason, Kym Martin, Alicia Staley, and yours truly, ready to grab a mic and speak some truth.

A favorite tweet during the opening keynote by Dr. Kyra Bobinet, a friend of mine via our mutual membership in the Stanford MedX community:

I see patient engagement as healthcare that nourishes the people it serves, and also as a nutrient for the healthcare delivery system itself. Healthcare itself will get better, in its body (clinicians and all other folks who work inside the system) and in its spirit (its culture), with authentic connection – engagement – with the human community who seeks its help in maintaining or regaining good health.

Both panels went well, and the audience seemed to be both awake, and interested in what we had to say. For those of us who have been working the user – PATIENT – side of healthcare transformation, it’s frustrating that we’re still saying the same things to professional audiences that we’ve been saying for (in my case) close to 20 years now. But those of us on the patient side of this change management rodeo can sense a paradigm shift, and are starting to believe that we’re seeing transformation slowly deploy across the healthcare system. As the oft-repeated William Gibson quote goes, “The future is here, it’s just not evenly distributed.”

 

Patients ARE engaged. We’re working our butts off to get medical professionals and healthcare execs on the same page as us. Like the old story goes, when it comes to bacon and eggs, the chicken’s involved, but the pig’s fully committed. In the bacon-and-eggs of healthcare, patients are the bacon. We’re all in, and we know more, in many ways, about how to fix the system than the “professionals” do. Alicia Staley said, again, what she says consistently to healthcare audiences, “You need a Chief Patient Officer on your board.” So … get one. And we all need to be wary of blaring headlines, which can be very misleading when it comes to the real health risks we all face:

HIMSS Privacy + Security Forum

 

In early March, I winged my way out to San Diego, one of my several hometowns (growing up a Navy kid means you get more than one) for the HIMSS Privacy + Security Forum. I was a panelist for the last session of the conference, which I knew meant that many of the attendees would already be in the TSA screening line at Lindbergh Field, but I was going to share my thoughts with whomever stuck around, even if it was just the busboys. Our session was titled “What Matters Most: Patient Perspectives on Privacy & Security,” and what happened at the end of our panel was something I had hoped for – several of the folks who had stuck around come up to us and said, “that panel should have opened this conference!”

When it comes to IT security, the healthcare industry is rightly terrified, given the epic bitch-slap that a HIPAA fine can be ($1.5 million dollars per incident) – and the irony of the Anthem data breach affecting up to 8.8 million of their members making headlines the week before this conference was not lost on me … or any of the other folks at the HIMSS Forum meeting. Yet it’s critical to note that access, by patients and by clinicians, particularly at the point of care, to all the relevant data necessary to deliver the right care at the right time to the right patient, is still an undelivered promise across the health IT landscape. So don’t be Mordac, Dilbert’s Preventer of Information Services – we have enough of him. He’s like a freakin’ virus.

Hilariously, the day before I traveled to San Diego, I had to threaten a HIPAA complaint to get my records transferred from one provider to another. I had been asking for TWO MONTHS for the rads practice where I had gotten my mammograms 2009 through 2011 (twice a year in 2009 and 2010, given my Cancer Year of 2008) to send my scans and reports to my current mammography radiologist, and it took a voicemail with a HIPAA violation threat to get someone to call me back. My records are so damn secure that NO ONE can get them, except for “Robert in the basement” at [rhymes with … Bon Secours]. It felt like I was talking to Central Services in the Terry Gilliam movie “Brazil.” And people wonder why I have a QR code linked to my health history tattooed on my sternum …

 

Lown Institute RightCare conference

Speaking of right care/right time/right patient, two days after the HIMSS Privacy + Security Forum wrapped, the Lown Institute’s RightCare 2015 conference kicked off just down the street.

Dr. Bernard Lown is the cardiologist who invented the cardiac defibrillator in the 1960s, and who won the Nobel Peace Prize in 1985 for his part in creating the International Physicians for the Prevention of Nuclear War. The Lown Institute, founded to continue the work on healthcare and human rights that Dr. Lown has devoted his life to, states as its mission “We seek to catalyze a grassroots movement for transforming healthcare systems and improving the health of communities.”

In short, this event made me feel like I’d taken a trip in the Wayback Machine to my college days 1970-1973 in the Haight Ashbury in San Francisco … without the LSD, but with all the fire of my youth, mixed with the wealth of mature knowledge I’ve managed to velcro on to myself in the decades since. The real beauty part? There were lots of young people in the room, who are the age today that I was 40 years ago (in my early twenties), speaking up for the human rights of the people served by the healthcare system. The ones commonly called “patients.”

I got a chance at a scholarship to #Lown2015 after meeting Shannon Brownlee during our work on the Patient & Family Engagement Roadmap, and our attendance at Dartmouth’s SIIPC14 “informed patient choice” conference last year. She tipped me off that scholarships were available, I applied, and got lucky by snagging one. Doubly lucky, because it put me in the room while some of the leading voices on the clinical side of medicine called out the industry they work in for being slow to fully enfranchise the people they serve – patients – by being too driven by money, and not driven enough by their own humanity. A sampling:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

And, because it just ain’t a movement unless this gets thrown down:

The bedrock message here? The democratization of knowledge that’s been delivered thanks to the Information Age has lifted the scales from the eyes of the early-adopter people/patients who are on to what healthcare is now, and what it must become to remain sustainable, or even relevant. Patients are coming up off their knees. The occupants of the ivory towers of medicine must descend from their aeries, or risk being flung from the parapets. Like winter …

Nov 18 2013

Healthcare.gov and me: I win!

By healthcare industry, politics, technology

Unless you’ve been living under a rock since October 1, you’ve heard that Healthcare.gov, the site where Americans can shop for health insurance, had a rocky start in life. OK, it was an epic mess.

I was one of the people who was eager to jump on the site on October 1, since I haven’t had health insurance since I completed cancer treatment in 2008. That cancer diagnosis and treatment put me in the pre-existing condition pile, which put renewal insurance premiums for my individual coverage at an eye-popping level. You can read the details on that here. On October 1, I hopped on my Mac, and surfed over to Healthcare.gov … and had the same experience everyone else seemed to be having:

healthcare.gov error message image

image credit: forbes.com

That continued over the following seven days, with me developing a nice little flat spot on my forehead from head/desk-ing my way through many attempts per day at getting past the first step of creating a profile on the site. Even when I had completed that process of creating a profile, every time the site announced “Success! Click here to continue.” I clicked “there” and … got a blank page.

On October 8, I realized that I, and the site’s developers, might have missed something. I was using Google Chrome, my default browser, and the dominant browser across the web. Could it be that the dim bulbs that built the Frankenstein that is the Healthcare.gov site optimized the site only for native browsers? I opened Safari, and discovered that yes, they were indeed that dim, because even though the site loaded at the speed of a slug on Quaaludes, it did load. And “Success!” allowed me to continue the enrollment process. No blank pages.

I re-enacted scenes from 1995, when I would log on to Netscape to download email on my dial-up connection: open the page, hit “go,” and then make coffee. When I returned with a hot cup of joe, I’d repeat the process on each subsequent page, working in another tab while the site loaded the next page in the process. I managed to complete the entire enrollment process, save for the last “pull the trigger” step of hitting the ENROLL button, because I wanted to make sure I had the money for my first month’s premium available. Which turned out to be unnecessary, since when I did hit the ENROLL button, I got a message saying that my selected insurer would be contacting me about billing. That conversation happened a few days ago, and I’ve paid my first month’s premium.

As of January 1, 2014, I’ll have health insurance again for the first time since December 31, 2008. WIN.

Here is the upside of what I saw in my voyage through Healthcare.gov:

  • Even though my state is one that announced it “hated Obamacare, would not be building its own marketplace, and we hate Obamacare,” there was a wide array of plans offered to me.
  • I could compare plans side-by-side.
  • Premiums were a wide range, with some surprises: the lowest-premium Bronze Plan had 0% co-insurance (I wasn’t on the hook for a percentage of cost on covered services), with higher premium plans tagged with 25% co-insurance.

Here’s the thing that made me go “WTF?”:

  • Only the Bronze Plans are HSA-friendly. HSA=Health Savings Account, essentially 401(k)s for healthcare. Individuals can sock away $3,300/year (in 2014) of pre-tax money in a dedicated savings account for healthcare costs, with people over 55 allowed to sock away an additional $1,000 for a total of $4,300 in 2014. Since all the Bronze Plans I was offered had deductibles of $5,500 or more, with the plan I selected carrying a $6,350 deductible, it would seem reasonable – fairer? – to allow consumers to fund their HSAs annually to match the level of their deductible.

On the whole, this is a big win for me, and other uninsured people who fell into the “pre-existing condition” bucket. By the way, just being female was considered a pre-existing condition until the Affordable Care Act passed. In spite of the views of Fox News talking heads (all male, of course), gender equality needs to exist in all phases of public life, including health insurance.

Bottom line? I win.

Jun 23 2013

Stetho-Snopes: Time for some rigorous myth-busting in healthcare?

By healthcare industry, politics, technology

It was recently revealed that an Excel error contributed to the European fiscal crisis, and a continuing global economic recession/depression. Paul Krugman called the revelation the Excel Depression in the NY Times.  Certainly lives are at stake when the success or failure of large economies are at risk, but not nearly as many lives as are at stake every day given the lack of transparency (and even, in some cases, plain truth) in bioscience research and medical outcomes reporting.

Ben Goldacre gave a barn-burning TED talk, “Battling Bad Science,” in 2011. He gave another one in 2012 in which he called the data manipulation in scientific research the “cancer at the core of evidence-based medicine.” His point? We cannot make a meaningful decision in the absence of ALL the data.

Tim Berners-Lee, the man who invented the actually-useful-to-humans WWW part of the Internet, has consistently called for raw data – ALL the raw data – NOW.

Paul Levy, the former CEO of Beth Israel Deaconess Hospital, recently blogged about the failure of the Journal of Pediatric Surgery to reveal, in a report on a surgery for sunken-chest deformity, a widely-reported death of a teenage boy after said surgery, even though that boy’s case is used as an example of avoidable medical error in safety bootcamps for medical interns and residents. Boggles the mind, doesn’t it?

Even if the data is fully reported, the PR geeks who write up the announcement of results might get that report 100% wrong. Witness the recent contretemps over a University of Chicago study on patient engagement, shared decision-making, and healthcare cost control. A full outline of that mess, by ePatient Dave deBronkart in Forbes, will give you 411 on that story. The Cliff’s Notes: it was a post-discharge survey, not a full study; it measured attitudes, not outcomes; and the press release was sent out on a holiday weekend, ensuring both pick up (slow news cycle) and lack of follow up.

Given the general public’s lack of understanding of science, the scarcity of journos who can interpret same for said general public, and the scale-thumbing going on in bioscience research, what’s to be done to reverse this disease-mongering and full-on prevarication (look it up) trend?

stetho-snopes image

Stetho-Snopes

How about a Snopes.com for medicine? We could call it … Stetho-Snopes. There’s certainly enough interest in the subject on the part of people and organizations. The challenge is to take all the small villages of interest across the globe and give them a repository for what they find, and what they can debunk.

Ben Goldacre is walking his own talk with an effort called AllTrials, a petition that’s demanding open data from all sources of medical research. Organizations like the Robert Wood Johnson Foundation are working on making medicine and healthcare more transparent and accessible for patients. The Society for Participatory Medicine‘s membership is committed to the same mission: transparency and collaboration across the continuum of care.

How about we all band together and make RAW DATA NOW a reality in medicine? GIMME MY DaM DATA. Now.

Jun 11 2013

Did someone say “palooza”?

By healthcare industry, politics, technology

I’m still recovering from the month of May. I was all up in the healthcare, pretty much 24/7, which differs not-much from my usual roll, other than that in the period of three weeks, I was in DC for eight of 21 days, May 14 through June 5, attending HM13 (the annual meeting of the Society of Hospital Medicine, which I covered for The Hospitalist magazine podcasts) and Health Data Palooza IV as just-me on a Consumer Circle scholarship.

What I saw and heard at both conferences made me hopeful for the future of healthcare … sort of. As inspiring as both of them were, I found the SHM conference more of a hope engine for just-e-patient me than the rah-rah tech-fest that was #hdpalooza. Granted, HM13 was organized and run by the medical society that has a big upward swing on its membership, and on the income of said members, which means that there was a breadth and depth of content that wouldn’t be available at non-clinical conferences.

hm13 logo

I got plenty of mental floss out of both of them. Here are the high (and low) lights:

  • Hands-on practicum at HM13 featuring portable ultrasound guided bedside procedures for the hospitalist. You have not lived until you’ve seen a hospitalist put a central line in a Costco chicken that’s tricked out with liquid-filled tubes serving as major blood vessels. Training that is both fun and practical transmits sticky knowledge. And I’m not taking the grape juice that was cast in the role of blood for this session.
  • Dr. Alberto Puig’s History of the Physical Exam HM13 breakout session offered laughter (imagine doing a pelvic exam on a standing patient fully garbed in Victorian bustle-wear), horror (doctors assessed health status for centuries by *tasting* patients’ urine; and let’s not forget those lovely leeches), and a whole lot of thought-provoking questions about what a physical exam means, and how important touch is to the practice of medicine.
  • Cognitive Diagnostic Error workshop, where a team of patient safety experts from UPenn demonstrated the risks of thinking too fast in clinical situations. Slower thinking is harder, but it will prevent mis-diagnosing and other medical errors.
  • Meeting Dr. Gordon Guyatt, the man who coined the phrase Evidence Based Medicine, and watching him shred study after study using funnel plots of the study’s data. Eye-opening doesn’t begin to describe that particular HM13 experience.
  • A cost transparency workshop! At a hospital medicine conference! Led by Dr. Chris Moriates from UCSF, this session showed the power of shared decision-making across the clinical team *and* included the patient/caregiver in the equation. We’re winning!
  • health data palooza iv logoBest of the Best at Health Data Palooza? AthenaHealth CEO Jonathan Bush’s keynote, where he was by turns hilarious, pointed, inspiring, and infuriating – all good things, as far as I’m concerned. His best line? “Obama was right. There, I said it.” After which he went on to again call the feds on the carpet for lack of testicular fortitude when it comes to setting up a national health data system. He has a great post on The Health Care Blog about his time on the platform, and his message.
  • Biggest disappointment of #hdpalooza? Atul Gawande moderated a panel on the new payment models emerging from Obamacare. Given his writing on healthcare costs, I hoped for a vibrant discussion on how health IT systems are enabling better cost visibility and management, for both the system (providers/payers) and users (patients). Twas not to be. What the session amounted to was a single visual involving CME credits for clinical folks in the audience being at risk if any panelist wound up mouthing commercial messages, accompanied by a round-robin of words into microphones from a sausage party of dude-panelists. Even for an IT geek, this was a snooze-fest of epic proportions. Huge disappointment.
  • Channeling the late Richard Dawson in a game show session called Family Feud’n, where providers and payers battled over what patients said they wanted as value from the healthcare system … well, it was eye-catching. It was funny, in parts. Mostly, I wondered what the hell they were trying to accomplish. Healthcare providers and healthcare payers are forever set in opposition? Patients are just objects, the “product,” and don’t get a voice other than in surveys? I call #fail on that one …
  • Illuminating Disease at the Speed of Light session was a highlight, with researchers and data modelers teaming up to show how data visualization can accelerate progress in clinical studies of disease. I was riveted, and I’m not even a full-on big-data geek.
  • Worst part of both conferences? The running from pillar to post to attend the sessions I most wanted to see, followed by sitting in said session for up to two hours. Seriously, what is up with healthcare conferences that make us sit on our keesters when getting up and moving around would feel so darn good? Conference organizers should start figuring out how to do “walking sessions” that mirror the rise of walking meetings and standing/walking workstations.

Still glaringly missing from all of this rah-rah is the actual, real-world voice of the patient – HM13 can be (somewhat) forgiven for that, since it’s a medical society annual conference. I will note that, in all my interviews for HM13 podcasts, the question, “How can patients help?” was warmly welcomed by everyone asked, and answered with enthusiasm and insight. Figuring out how to break the walls down between clinicians and patients – “gimme my damn data,” two-way edition – using health IT systems as the wedge seems to be a place to start. But letting patients help there is utterly crucial.

Speaking of sitting too long … time for a bike ride to my polling place to vote in today’s off-year election primary in my state. I’m voting for a guy who’s worked on opening up health data. Win/win … ?

Feb 12 2013

Medical Monopoly: Medicine has a major image problem

By healthcare industry, media commentary, politics, technology
image credit: Alec

When you hear the word “monopoly,” does it fill you with a warm and fuzzy feeling? (Unless you’re Hasbro, you really should say no, unless you’re a cyborg.)

Healthcare is a monopoly. We can’t DIY cancer treatment, or surgically repair a broken hip for ourselves, so we have to go to the medical-industrial complex to regain our health if we wander into the weeds, health-wise. We also have deep difficulty accessing pricing information. I’ve talked about that here over the last few years. Maybe not a monopoly in the financial-reg sense of the word, but it sure is mighty like a game of Monopoly.

This “chaos behind a veil of secrecy” (all credit for that phrase belongs to healthcare economist Uwe Reinhart) has created the impression in healthcare customers that there’s no way to tell what something will cost before you buy it. You checks the box and takes yer chances. No Get Out of the Hospital Free cards. No pass-the-admissions-counter-collect-$200 option. That’s a rotten way to run a railroad (one of the original monopoly industries in US history), and an even worse way to run a hospital.

Dan Munro wrote about this, and the star-chamber cabal that actually sets the prices in healthcare, the RUC, on Forbes.com yesterday. I’ve talked about the RUC myself. And the search for price transparency, which seemed such an outlier activity just a couple of years ago, is now popping up in the Well blog on the New York Times site, as well as on Reuters. The Reuters piece has the addition bonus of quotes from my buddy Jeanne Pinder, founder of ClearHealthCosts.com. (Yesterday was a big day in medical price transparency.)

This is the central reason I registered the hashtag #howmuchisthat with Symplur, the healthcare hashtag registry. We all have to start demanding that prices be visible, and that the RUC stop cabal-ing around with our lives and our wallets. As more and more people are finding themselves with high-deductible health insurance, asking how much things cost before you make a healthcare decision will become the norm. If a healthcare provider can’t answer that question, s/he will find that s/he’s seeing the patient panel sinking fast, along with practice revenue.

Get with it, medicine. Remake your image, and your brand, to be clear as glass and user-friendly. Outcome metrics along with pricing would be really nice, too.

Jun 13 2012

The black box that caused the crash (of healthcare)

By healthcare industry, politics
healthcare money image

This week, NPR’s Marketplace aired a piece on what I have taken to calling the “black box of healthcare” – pricing. There is a committee, called the RUC, set up and run by the American Medical Association, that reports to CMS (the federal unit that runs Medicare and Medicaid) on relative value numbers for the thousands of medical procedures that wind up as billing codes in Medicare and your health insurer.

Those relative value numbers = PRICES. This isn’t considered price-fixing under anti-trust rules because the RUC reports to CMS, which then publishes the numbers on the Medicare reimbursement rate schedule. So the AMA isn’t publishing the prices, CMS is.

Fox, meet henhouse. Or, stated in another way: airplane, meet the black box that is making you crash and burn. The Marketplace page linked in the 1st graf has plenty of linkage to additional context for this issue. Read them, and weep.

How is it that an industry whose aggregate cost is now at close to 20% of US GDP gets to set its own prices, and then have them published by the federal government as The Official Price List?

It’s called effective lobbying, and it’s so effective that it’s essentially kept access to the pricing committee process a secret for decades. Which makes it pretty clear why so much of our GDP goes to healthcare, doesn’t it?

The sound bite in the story that I found the most hilarious was from Charlie Baker, the former CEO of the Harvard Pilgrim health plan in Massachusetts. His quote:

By having a process that for all intensive [sic] purposes isn’t a public process, and doesn’t appear to actually be accountable to much of anybody, I think that’s kind of un-American!

I find this hilarious because Harvard Pilgrim is a member of America’s Health Insurance Plans, the industry group that advocates (translation: lobbies) for health insurers, who also have their hands on the levers of healthcare pricing via reimbursement rates (granted, based on CMS’s published rates, which are based on the RUC’s relative value numbers). Which means that the very-American health insurance industry is a co-conspirator in this price-setting (-fixing?) game.

Healthcare pricing is such a black box that if a patient attempts to find out what something will cost before s/he has a medical procedure, s/he will be met with a blank stare, “I don’t know”, “nobody knows how to figure that out”, or some other version of “what?” that gets you no answer.

e-Patient Dave deBronkart has a terrific example of how shopping for healthcare can be done, even in the face of “what?” – click the link for the full story there. Patients acting on their own behalf to determine their economic exposure before they get medical care might begin to bend the healthcare cost curve IF they can get the price information.

Dave isn’t the only customer of the healthcare industry who’s looking for pricing, and answers to the variance in said pricing depending on who you ask. The LA Times had a piece in their May 27, 2012 business pages on how patients could negotiate cash prices at the hospital or in the doctor’s office that were far below insurance reimbursement rates IF they didn’t use their insurance.

As an industry, healthcare is deeply broken. Since the industry has been supported for decades by an economic model that hides pricing from its consumers – employer-based health insurance – the end users, patients, have no clear path to making informed choices based on quality and cost.

If you ran your business that way, you’d be out of business pretty quickly. It’s time to break the healthcare industry’s economic model – if ever there was a sector ripe for creative economic destruction, healthcare is that sector.

Feb 16 2010

A Modest Proposal (on Health Insurance Reform)

By healthcare industry, healthcare price transparency, politics

~ Casey Quinlan © 2010 [originally posted on the now-defunct Disruptive Women in Health Care blog, posted here for posterity.]

I will admit to a bias on the subject of health insurance, and healthcare reform: I’m one of the millions of America’s uninsured. I’m female, over 50 (I told you, now I’ll have to kill you), and I was diagnosed with cancer in December of 2007.

The first of those facts – being female – is the biggest dinger of the three when it comes to health insurance premiums. The reasoning there: women use more health services, starting in their teens and 20s and continuing through menopause. The second – my age – could signal a better rate, since women typically tail off in their use of healthcare in their mid-50s. However, the third fact – cancer within the last 10 years – gets me insurance coverage quotes of $2,000 per month, with a deductible between at $3,000 to $6,000 a year.

For the math-challenged, that’s between $27,000 and $30,000 out of my pocket per year before insurance covers Dollar One. Since that amounts to much of my annual pre-tax income in each of the two years since Cancer Year – 2008 was the last year I had health insurance coverage – I’ve remained on the uninsured list. And developed some fierce opinions about the future of healthcare and health insurance in the US.

The Patient Protection and Affordable Care Act, a/k/a “health care reform,” passed earlier this year includes some help for my situation…in 2014. Meanwhile, I’m managing to get the oral chemo meds I’ll be taking until 2013 (which cost $500 a month) with the help of a community clinic. And I’m keeping my fingers crossed that I stay as healthy as I was before the cancer diagnosis, and as I have been since I finished radiation treatment in 2008.

That’s my current health insurance policy: crossed fingers.

There are two things that I think have to happen to bring about meaningful change in the healthcare cost/payment/insurance conundrum, for me and everyone else:

  1. Tort reform*
  2. Severing health insurance from employment

I realize that the tort bar, the health insurance industry, and pretty much everybody with a job-related health benefits package will take out a hit on me for making those suggestions. But the system has fallen, it can’t get up, and until major changes – not the chipping-away-at-the-edges approach of the current iteration of “health care reform” – are made in both the US legal system and how health insurance is marketed and sold, meaningful change doesn’t have a prayer.

How would tort reform help? Defensive medicine – practicing medicine with one eye over your shoulder looking for lawyers – adds as much as $45.6Billion-with-a-b annually to US spending on healthcare, according to a Harvard study published in September. That may seem like a drop in the bucket when the total annual spend on healthcare in this country is $2.3Trillion-with-a-t, but those dollars are all coming out of our pockets one way or another. Whether it’s in higher health insurance premiums, deductibles, fee increases to help providers cover those who can’t pay, fee increases to help defray the costs of malpractice insurance, or tax dollars for Medicaid and Medicare, we pay for it.

Reducing the dollar impact of medical liability would start to address some of those costs. Tort reform would give providers a defined worst-case scenario for liability, and would reduce the sue-the-bastards incentive for patients (and their lawyers) who don’t get the outcome they want from treatment. There are no guarantees in medicine, other than that there are no guarantees in medicine. Patients who are harmed by doctors that are unfit to practice wouldn’t be left without recourse, but the dollar amount of settlements would be capped.

Now, on to my really controversial suggestion: severing the link between health insurance and employment. Employer-paid health insurance benefits weren’t common in the US until World War II, when stiff wage controls made defense plants and other employers get creative to attract and keep good employees. They came up with offering to pay for workers’ health insurance. Thus was employer-sponsored group health insurance born, and the individual health insurance market stamped with an expiration date.

If you’re selling something, wouldn’t you rather package and sell it to as large a group as possible? Insurers, helped along by federal labor laws, have had a great revenue model: sell to large employers, keeping their annual premium-per-employee at an acceptable level because of the size of the risk pool. Cherry-pick the individual market, and put a high price tag on coverage for individuals who look like they might get sick – like women.

I’m actually quite pleased with one of the provisions in the health care reform bill fines employers with 50 or more employees $2,000 for each worker if they don’t provide health benefits. Why? Because the largest US employers – Walmart 1,000,000+ US employees, Verizon 200,000+, UPS 350,000+ in the US, to name a few – will look at that figure, do the math, and discover that the fine will save them money.

Again, for the math challenged: 1,000,000 employees would cost Walmart $2Billion-with-a-b in fines. Sounds like a whacking huge amount of money…until you calculate the cost health insurance benefits for those 1,000,000 employees using the average premium, which runs between $4,000 (single coverage) and $10,000 (family) per year. The fine would save Walmart $4-10Billion a year. They could even offer their employees help buying coverage, and still save some serious money.

And break the tie between group coverage and employment.

What would happen then? I think the American people can get together and drive the market as one big coast-to-coast group, using consumer-driven health plans** (CDHPs) combined with health savings accounts (HSAs). I believe that one of the causes of the healthcare cost conundrum in the US is the passive attitude most Americans have about their health, and healthcare. Decades of coverage paid for with “other people’s money” (employer-sponsored plans) have turned us into a nation of mindless medical consumers. We want cutting-edge care, we want second, even third, opinions, we bitch about $100 co-pays, we want to never have a bad outcome. Oh, and by the way, we don’t want to pay for it.

CDHPs would help make us mindful again: about the costs of healthcare, about the impact of our choices and behavior on our health, about how to get the most value for our healthcare dollar. A consumer-driven plan – also called a high-deductible plan – has a lower premium than traditional PPO or HMO plans due to that higher deductible. It also has no co-pays. You pay for care until you max out your annual deductible – between $1,000 and $5,000 per year – and are fully covered after that. Some CDHPs cover preventive and screening care, like annual physicals and mammograms, outside the deductible.

To be truly effective, CDHPs must be tied to HSAs, both to help consumers pay their deductible costs and to encourage them to save money for future healthcare costs. Making HSA contributions with pre-tax money makes HSAs “IRAs for healthcare,” with tax penalties for non-healthcare withdrawals. Since consumers – patients – will be paying for healthcare out of their HSAs, they’ll have an incentive to both ask what a procedure or prescription costs, and to ask questions about the cost of treatment options.

We’re a consumer nation. We shop for deals on flat screen TVs, cars, iPods, and breakfast cereals. Isn’t it time we did the same thing for prescriptions and hospital costs? I for one would jump at the chance to enroll in a CHDP – unfortunately, they’re not offered to individuals in the state where I live.

Don’t get me started on state insurance commissions…

  • [2021] I no longer subscribe to this idea – not that tort reform is a terrible idea, just don’t think it would help move the needle, or the mind-set, of what I call dinosaur docs (MDs over 60 years old who have “we’ve always done it this way” syndrome)

** [2021] CDHPs have proved to be a trash fire, since too few employers have elected to fund HSAs, and individuals who have bought insurance on the Affordable Care Act exchanges have found that CDHPs are basically just catastrophic care coverage. Their out of pocket expenses are high enough that many are now foregoing care rather than seeking medical care and paying out of pocket until their deductible is met.

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