HCCD Report District of Columbia 20008

Summary of Discussion of Health Care Reform

11 people (6 male and 5 female) who are neighbors in the Cleveland Park neighborhood of Washington, D.C. met over dessert and coffee to discuss their personal experiences with the U.S. health care system, and potential solutions to the problems we see with it. The group comes from 7 households, ranging in age from couples with very young children to those on Medicare.

To focus the discussion, each household gave one personal experience of their own of problems with the health care system. Here are those anecdotes.

One person’s older relative lives in a rural area and has multiple health problems that were not properly diagnosed. She moved from doctor to doctor, with multiple hospitalizations, never receiving the proper diagnosis (until coming to D.C. to a specialist). In the meantime, although she had health insurance, she exceeded her lifetime limit. There was little co-ordination among these various health providers. The result is that some tests and treatments were repeated and unnecessary.
Another of us has a relaive with mental health, physical health, and social service needs, and no health insurance. She has not been able to conquer the paper-work necessary to obtain disability benefits or public health insurance, and there seems to be no one available to help with that. It is hard for family members who are very far away to even understand the various systems that could help her. There is a “giant crevasse” between the health and social service systems that are designed to help people with these kinds of needs (eg. the many homeless people on our streets).
One family has a middle-aged relative who was a professional dancer early in her adult life, and now works in a job with a limited insurance plan. She has lost functioning in one kidney, and could loose the other. Her health insurance will not pay for a transplant or dialysis, or other catastrophic health expenses.
Another family has two children who recently graduated from college. When the children were finished with school, they could no longer be on their parents’ good government insurance policy. Since it is very difficult for young adults to immediately get a job with good health insurance benefits, they joined the ranks of the uninsured. (The parents were able to purchase a “catastrophic” insurance plan for them as a bridge until they got a job with insurance.)
One of us has a relative who worked for himself all his adult life and never purchased an individual health insurance policy. Now he has been diagnosed with leukemia, and has no access to health insurance. Because he did not go to the doctor regularly, the leukemia is at an advanced stage and treatment will be extremely expensive.
Another of us works for community health centers and spoke of the experiences of low income people who prefer to use the emergency room for health care. There are many reasons they do so. In order to access alternative sources of care, they have to take days off from work (often many days) without pay. The ER is open around the clock. It is a “one stop shop” with all the specialist advice a person might need, rather than having to go from one provider to another.
The final household told of a harrowing experience after a diagnosis of cancer. The routine referral to the top cancer treatment center would have taken 6 weeks. Only through personal connections was that delay eliminated and the treatment (which worked) obtained on time.

Solutions:

From these anecdotes, we proceeded to try to develop some proposed solutions for you to consider as you turn to developing health care reform proposals.

Cost

We spent a lot of time discussing the reasons for the high cost of medical care in the U.S. and what can be done to reduce it. We felt that any other solutions must incorporate some forms of cost containment (and noted that the Baucus framework does not address this well). From our personal experiences, there seemed to be a lot of reasons that the health costs are higher than necessary.

Families have noticed that doctors often order what appear to be unnecessary tests (for colds, flu, or digestive problems), and sometimes have them go to the emergency room after hours for complaints. However, when doctors order tests, procedures, or prescriptions that they (as the patient) feel might be unnecessary, they are reluctant to question their doctor’s judgment. They are unsure why this happens, but think it may be fears of malpractice claims, or possibly just the desire to “do something” and please the patient. The insurance usually pays for these tests and procedures, so busy doctors may find this solution easier than spending more time with the patients (or parents) either in person or on the phone.

For those whose relatives are experiencing catastrophic health care problems, we saw several sources of excess costs. When patients move from doctor to doctor, their (almost always manual) health records often don’t move or doctors don’t take the time to review them. Thus tests are repeated. In addition when people don’t have health insurance, they delay care. The result is care that is more expensive than necessary, and sometimes in settings that are more expensive than necessary (such as the emergency room).

The solutions to these cost issues that we identified are:

More use of “physician extenders” (eg. nurse practitioners or physicians’ assistants). These individuals should provide more of the education and counseling, routine preventive services, primary care, care management and triage to specialized care for urgent health problems.
More use of electronic medical records (recognizing that this will not be cost-saving in the near future)
More emphasis on coverage of tests and procedures that are known to be cost-effective.
More sharing of the decisions on care and its cost-burden (we were unsure about how to do this without jeopardizing access).
Better access to after-hours care to reduce the use of the emergency room for primary care. We were skeptical of the “minute clinic” approach to most care because of a lack of continuity of care, but—combined with an electronic medical record—it could be useful for some care (eg. flu shots).
Much of the excess health burden in the U.S. is due to behaviorally related problems such as obesity, smoking, or HIV. More community-based education and action is needed.

Access

Many of the problems we had experienced derive from a lack of health insurance. Other problems derive payment that is too low for some types of care (eg. primary after-hours care) and too high for others (eg. some forms of specialty care, tests, drugs or procedures).

Our solutions are:

A universal health insurance system that is based on a model of either Medicare or the federal employees system (both of which are the coverage for several of us, and with which we are very satisfied). This could take the form of a “catastrophic” plan (as is Medicare now), with full coverage for cost-effective preventive services and for catastrophic expenses over a certain limit). The private insurance market through employers would provide “wrap around” coverage, and an “exchange” (such as is proposed in the Baucus plan or exists in Massachusetts) would provide the ability to purchase this wrap-around coverage for others. There would be subsidies for low income people, building on Medicaid.
Everyone should have a “medical home” (primary care doctor or physician-extender).
Greater assistance (more public education) should be provided concerning the health care system, particularly concerning the choice of: (1) health plan; (2) primary care doctor; (3) appropriate services for prevention and different types of illnesses. (Even those in our well-educated group were uncertain of many of their choices).