It’s not that you couldn’t have a healthcare system composed of private plans that would work almost as well as a single-payer system — but why would you? Most modern countries use some combination of public and private financing, even the Scandinavian nations, and when you factor in Medicaid, Medicare and SCHIP, even the United States. The trouble is, the more insurers you let into the system, the worse the system is going to work. We’re told that having more insurers is competition, and competition leads to greater efficiency, and that’s good. It’s also a serious misrepresentation, and that’s bad — because when it comes to healthcare, inefficiency can be fatal.
The question that should be asked, but somehow never is, is: What are all these companies competing for? If there were some sort of prize for which company’s customers lived the longest, healthiest lives, that would be an inducement for privatization — but they’re competing for profits, and that’s where people get hurt. Profits are a matter of income minus outgo, about collecting premiums and providing nothing in return. It’s in the best interests of insurance companies to say “no,” and they’ve been very good about finding new and creative ways of doing it. In place of the efficiency that competition promises, healthcare providers are faced with a series of stumbling blocks and interruptions, and time that’s spent listening to the endless drone of “your call is very important to us so please stay on the line” has to come from somewhere. It comes from the next patient.
A healthcare provider has to see a certain number of patients in a limited amount of time. In theory, the time is equitably divided, and everybody is taken care of. In practice, some patients take a disproportionate amount of time, and that leads to shortchanging others. The time gets wasted dealing with the idiosyncracies of different insurers — filling out forms, calling for prior approval for tests or drugs, dealing with denials of claims, and all the while trying to stick to a schedule because patients, reasonably, have their own lives and expect to be seen more or less around the time of their appointment. Chain pharmacies have clocks on the wall making promises of what time your prescription will be ready, or at least would be if the various corporate types staffed the store with enough people so that some could be making phone calls while the others are filling prescriptions, while still others are listening to the complaints of those whose prescriptions weren’t ready at the promised time because someone had to call the prescriber or insurer.
The insurance companies make the rules, change them at whim, and everything else grinds to a halt. The next, almost inevitable step is that everybody is in a perpetual rush. Scheduling fewer patients isn’t the answer either, because the insurers determine how much they’ll pay for each service, and they’ve cut that to the bone, so that the provider — physician, laboratory, pharmacy — have to increase their volume just to make expenses.
It’s an invitation to make mistakes, and the invitation is routinely accepted. Only the most dramatic, most tragic cases ever make the news, but a report in the June 2009 issue of Clinica Cimima Acta, an international journal of clinical chemistry, makes the point: “Medical injury is a serious problem, affecting, as multiple studies have now shown, approximately 10% of hospitalized patients, and causing hundreds of thousands of preventable deaths each year. The organizing principle is that the cause is not bad people, it is bad systems.” We’re quick to look at the most immediate areas: work hours per week, understaffing, lack of communications between personnel, acid rock playing on the radio. While Dr. Lucian Leape, the author of the paper, focuses on remaking the model of healthcare from being provider- (doctors) centered to being patient-centered and moving our models of care from reliance on independent, individual performance to interdependent, collaborative, interprofessional teamwork, changes in philosophy come slowly. A good first step would simply be to have the money people take a step back, and not intrude on those who are actively providing care.
The simplest first step would be a universal system, one where everybody follows the same rules, so that everyone knows which tests are covered, which drugs are on formulary, so that there’s no need to argue about pre-existing conditions and coordination of benefits, and whatever forms have to be filled out are sufficiently familiar so that nobody has to make a telephone call to ask what the insurer wants in box B-1. A universal plan would free up time for interprofessional collaboration — which translates out to making sure that the X-ray is right side up, and the drug is supposed to be 0.4 milligrams and not 4 milligrams.
There are lots of economic benefits to a single-payer system, but there’s a health benefit too. If speed limits save lives on the highway, they can save lives in hospitals too, and single payer would help a lot.
Sam Uretsky is a writer and pharmacist living on Long Island, N.Y.
From The Progressive Populist, August 1, 2009
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