| The New York Times/CBS News poll is out today. 72% of all Americans favour a public option. The breakout is 50% Republicans, 87% of Democrats, and 73% of Independents. This was a phone poll, and therefore there is a reasonable probability that those people who have no health insurance are under-represented in the respondents. Still, the numbers are pretty striking. I'm still working my way through the legislation, but already there are some things I didn't expect to see, but am very pleased are included. First, bundling. This is currently accomplished by Geisinger Health Services in Pennsylvania for a number of cardiac procedures. Bundling says that doctors and facilities will be paid by the case, instead of by the procedure. This is one of the best approaches to cost-containment relative to unnecessary over-utilization, and it leads to better patient outcomes. Here's a way to look at it: someone has a heart attack, goes to the emergency room, is evaluated, and then needs a surgical procedure. Under the current insurance systems, private or public, the bills are generated for the ER visit, the blood work, the MRI, the surgical work-up, the TPA, the surgery (with separate bills from the hospital, cardiologist, anesthesiologist, OR suite, etc.) the hospital room, the follow-up care over the week the person is in the hospital, follow-up care after the person leaves the hospital, and the cost of any re-admission. "Follow-up care" would also include any complications or hospital-acquired infections. With bundling, there is one flat fee. To make sure that complications and re-admissions are severely curtailed, Geisinger works off a checklist. No one goes to surgery unless all the steps are checked before anyone scrubs. No one leaves the operating room until the checklist is likewise complete. Think is sounds like overkill? On the first set of surgical types Geisinger implemented with this procedure, in-hospital post-surgical deaths fell to ZERO. Meanwhile, they were able to cut the cost of the procedures by 15%. Second, ratings. Currently, premiums are determined by underwriting. The idea here is based on the insurance company being able to set premium rates that will bring in more money than they pay out in claims. One of the ways they do this is to charge higher premiums (or deny coverage either outright or through rescission) to people with pre-existing conditions whom the insurers believe will cost them more. This affects not only individual policies, but also small businesses. (In general, large employers are able to spread risk amoungst enough people to avoid the full brunt of ratings.) The House legislation only allows ratings for geography, family size and age (2:1 max). In addition, it prohibits denials of coverage for pre-existing conditions and does away with lifetime caps. Basic coverage: right now, if you are denied coverage you can get "minimal insurance" - the kind advertised on television as "for just a few pennies a day". And yes, it's cheap, but it also excludes all sorts of coverages, and therefore, once you try to use it, you'll find out that things aren't covered. For example, it's usually a drug discount plan, not a drug insurance plan. The new mandated basic coverage will apply not only to the public plan, but will be required of all insurers. It includes preventive services with no cost sharing, mental health services, dental and vision for children, and annual caps. Starting on current page 730 of the draft is a section on Community Health Centers - something that may actually get me to go back to active practice. The idea is to support primary care, both by setting up centers, and to help new primary care physicians by helping to repay student loans. It even has funding allocations. These centers are to be dedicated to prevention and wellness programs. It is part of the "inverting the triangle" system that can actually help to decrease mortality and morbidity, increase life expectancy and decrease pain and suffering. Tomorrow, the things I'm not all that thrilled with. |
