Wednesday, Nov. 14, 2007

You get what you pay for, and we’re paying for the wrong things

WHETHER THE government, employers or individuals write the check for medical care, it’s going to cost too much until we transform our sick-care system into a health-care system.

Of course the best way to cut medical costs is to prevent chronic diseases, which eat up 75 cents of every medical dollar. That’s a tough battle to win, but fortunately the war isn’t over just because we fail at prevention.

With proper treatment, some chronic diseases are reversible. And early detection and proper management of diseases not reversed can still save a tremendous amount of money and suffering.

The problem is that we don’t do that, because our insurance system was designed before chronic diseases were our main problem. We didn’t know statins and ACE-inhibitors could lower cholesterol and blood pressure, weren’t able to monitor blood-glucose levels so it was safe to tightly control diabetes. We didn’t have chemo and coronary bypass surgery, kidney and heart transplants.

If you got cancer or had a heart attack, you died, and there weren’t that many bills to pay. Insurance paid for surgery, childbirth, setting broken bones.

It’s still geared to do that.

That’s why an impressive group of public health, medical, business, labor, insurance and civic organizations is working this campaign season to get the public and the presidential candidates focused on The Big Seven chronic diseases. And that’s why the most important proposal from the Partnership to Fight Chronic Disease is to “refocus our health system on preventing, detecting, and managing chronic disease.”

“In an era when we have the knowledge and expertise to prevent disease and to better treat chronic conditions,” the partnership says in a platform released last month, “it simply doesn’t make sense to have a ‘1960s’ model health care system built around episodic and acute care — a system that, for instance, will pay to amputate a leg or perform open-heart surgery, but too often fails to provide preventive care and disease management that could prevent much more costly interventions down the road.”

Mike Huckabee doesn’t need convincing. Bring up medical care, and the former Arkansas governor, who came to national attention when he dropped 110 pounds and led his state on a health crusade, sounds like he could be reading straight out of the partnership’s platform. Actually, he sounds like he could have written it, with such lines as these:

• “We don’t have a health care crisis in America, we have a health crisis.”

• “The challenge is not universal coverage. Frankly we could afford that, if we had a healthier population.”

• “What you’re really doing is building an intervention-based system that intervenes at the catastrophic level, when you should be focusing on a prevention-based system that keeps us from ever getting there.”

Part of Mr. Huckabee’s prescription for a healthier Arkansas was a smarter insurance system for government employees. Reduce their insurance premiums if they’ll take a health assessment. Encourage them to get cancer screenings by eliminating the deductibles and co-payments.

“We found that a lot of people who should be getting those screenings weren’t doing it,” Mr. Huckabee told our editorial board earlier this fall. “So when we asked them why — well if you have a co-pay or deductible ... (and) you don’t present symptoms, you’re not going to go, when that $200, $300 could send your kid to summer camp for a few days. Do I want to go to the gastroenterologist and have him scope me — done that; it’s not very pleasant — or do I want to get rid of my kid for a week? Guess what I choose to do?

“Take the deductibles and the co-pays off, and women get their beast exams, men get their prostate-cancer exams, and you don’t have people waiting until they’re in a significantly advanced stage of cancer before you get the diagnosis and then the treatment becomes extraordinarily expensive, cost-prohibitive, and the costs are passed on to the payers.”

Some employers are beginning to take that approach one step farther, applying it to the drugs people need to manage their diseases and avoid the $30,000 foot amputations and $200,000 bypass surgeries. For the last several years, I’ve had to pay just a single $15 co-pay each month for insulin, syringes and glucose test strips, rather than the $100 to $150 I would have to pay in a more short-sighted insurance plan.

The payoffs mount quickly. When the city of Asheville, N.C., eliminated co-pays for the medications needed to treat chronic diseases if employees signed up for an education and oversight plan, it saved more than $2,000 per year per patient — and reduced absenteeism by 50 percent.

The other component of smart disease-management — physician reimbursement — has been slower coming, perhaps because early attempts by HMOs were so bungled. We pay doctors to perform procedures. That “does not really give them incentives to lower your blood pressure, A1C, hemoglobin and cholesterol,” Mr. Huckabee said. “But the system rewards them for seeing you as often as possible or doing a procedure on you.”

It’s time to start working on that last component — and to work harder on the others.

Reach Ms. Scoppe at(803) 771-8571 or cscoppe@thestate.com. Mr. Huckabee discusses health care on “Brad Warthen’s blog” at www.thestate.com/opinion/.