Thursday, June 14, 2012

Health Insurance is Sick Insurance: It's not on our list

© Raimond Spekking / CC-BY-SA-3.0 (via Wikimedia Commons)
Many years ago, I traveled to Köln, Germany. My wife and I had read some guidebooks and we knew which hotel we wanted to stay at.  So we went to the Tourist Office and asked them to contact our hotel of choice.  We don't speak German after all.

"It's not on our list.", he said.
"I just want to know if there are rooms available." I replied.
"It's not on our list.", he said.
"Can you please call them?" I asked.
"It's not on our list.", he said. 

And that was as far as the conversation went.  He booked us into a hotel that was 'on his list'.

This is how our insurance companies pay for medical treatments.  By the list.  If it's not on the list, they don't pay for it.

If you are diagnosed with a disease, and you are treated and the treatment FAILS - if the treatment is on the list, the insurance company pays.

But, if you are diagnosed with a disease, and you are treated and the treatment succeeds - the insurance company refuses to pay, if it's not on the list.

What might happen if insurance companies paid for results?

A proposal.

1. Conventional doctors diagnose.  That's their area of expertise, diagnosis.

Conventional medicines are very good at treating some illnesses, infectious diseases for example.  And very good at treating fractures and other wounds. However, conventional medicines are not effective in treatment of chronic health issues like arthritis, Multiple Sclerosis, and even cancers.

2. Patient chooses the treatment and the treatment practitioner. It's their body.  It should be their freedom to choose.  Of course the diagnosing physician can recommend, and the insurance company might also list recommended treatment for specific conditions - but the patient should be allowed to choose.

3. Treatment is undertaken by the chosen practitioner.

4. An conventional doctor, not the one giving the treatment - evaluates the results.

5. The insurance company pays the practitioner for the treatment - based on the cost, and the level of success.

Insurance companies need to pay for treatments that work.  What increases healthiness, not 'treatments'. What counts is results.  We need to count, and pay for, results.

Insurance company statistics might provide information that is more valuable than thousands of clinicical studies - if they agree to pay more for treatments that work, and pay less for treatments that work less effectively, or less often.

I would like to see us take this one step further.  I would like an additional measurement of healthiness

1. A patient goes to a conventional doctor with a medical problem and receives a medical diagnosis (as above).  In addition to the diagnosis, the patient also receives a comprehensive health assessment. We would need to develop a comprehensive health assessment tool- none exists today.  One could be developed and refined as we learn more from this process.

2. Patient chooses treatment and practitioner.

3. Treatment is undertaken by a the chose practitioner.

4. A conventional doctor, not the one providing treatment, evaluates the results. Based on the initial diagnosis and the initial health assessment, compared to the health assessment and diagnosis after the treatment.  Did the treatment improve the disease?  Did the treatment improve or decrease the health of the patient?

5. The insurance company pays the practitioner for the treatment - based on the cost, and the level of success.

I don't think we could take the leap to this system today, or tomorrow.  But I believe we can make the transition over time.

The first step is to have insurance companies agree to pay for results.  Is that so strange?  If a diagnosis is made, and the patient gets treatment, and a follow-up diagnosis indicates that the treatment worked - the insurance company should pay.

Unfortunately, that's not how the system works today.  The insurance companies pay for treatments 'on their list'.  If it's not on their list, they don't pay.

And the result?  We don't have health insurance.  We have sick insurance.  Health insurance doesn't help you get healthier, although sometimes it helps you get 'less sick'.  Sometimes, the treatments paid for by health insurance can make you 'more sick' but no-one keeps track.

It's sick insurance.

Everyone has a right to life, liberty, and the pursuit of healthiness.
to your health, tracy

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Tracy is the author of two book about healthicine: