Health Care Reform or Sickness Care Financing Reform?   (March 5, 2009)

As of today, Google has about 4,710,000 webpages discussing "health care reform," but none for "sickness care financing reform." One example, a headline in today's news: Obama Hosts Health Care Reform Meeting at White House. The story starts "U.S. President Barack Obama is launching an effort to reform the nation's health care system with a much-anticipated forum at the White House Thursday."

Reform the health care system? What health care system? I think we are caught up with jargon -- the United States does not have a "health care system" to be reformed! No way. The U.S. has a series of sickness-care systems, some of them pretty good, some of them pretty awful, but almost all of them were designed primarily to pay doctors and hospitals to care for people's acute illnesses and accidents. There's the Medicare system, the VA system, about 50 different Medicaid systems, and hundreds if not thousands of private insurance systems.

Although the headline writers and the politicians and indeed the general public have latched onto the concept that the U.S. needs health care reform, I'd make the point that part of what is needed is reform of these multiple systems that pay for the financing of sickness care.

Overall, I think that the medical care that is provided to patients in the United States, whether for diabetes or other diseases or accidents, is probably about as good (and perhaps better) as it is anywhere else in the world. It's the reimbursement for this care that's all screwed up. Example: When I was in private practice, I routinely encouraged all of my diabetic patients to have a flu shot every autumn. For some reimbursement systems, my staff could give the shot, and we would be reimbursed. But for other reimbursement systems (the acronym HMO comes to mind), if we gave the shot, we would not be reimbursed, and hence we were actively discouraged from providing appropriate medical care. For these patients with HMO coverage, we were supposed to advise the patient to go to their HMO primary-care physician to get their shot -- with the full knowledge that it would take extra time, extra paperwork, extra gasoline, and a fair likelihood that the patient would never get the flu shot. This is not a problem with medical care -- I could give the flu shot -- but with the payment mechanisms -- if it were an HMO patient, and I authorized the nurse to give the shot, I simply wouldn't get reimbursed. (And if that same patient didn't go to their HMO PCP for their flu shot, but subsequently got the flu and required hospitalization, the HMO would pay for that huge expense. Go figure.)

And if we want to call it a health care system (rather than a sickness-care-financing-system), we need to insist that besides paying for acute care of sick people, that prevention of sickness and maintenance of health must be a necessary component of whatever is developed. We all know examples: dietitian visits should be covered, blood glucose strips should be covered, diabetes education visits should be covered; the list goes on. Prevention is just as important as any other aspect of health care, and must be part of a health care system.

Yes, the U.S. really does need a health care system. It's time for reform of the present Sickness Care Financing Systems.