I’m taking off my author hat today and replacing it with my health care administrator hat. There’s been so much talk about this all week, I had to add my two cents.
For those of you who are unfamiliar with this topic, I refer you to Ashish Jha’s The Health Care Blog – “Misunderstanding Oregon.” or Mike Mieson’s “Evidence That Health Does Not Equal Healthcare? Early Results From the Oregon Experiment Are In” – or head straight to the New England Journal of Medicine if research details are your thing.
The experiment and the published results are described in these blogs. Essentially a group of uninsured folks were given Medicaid and a control group was not, and the results showed higher utilization, fewer catastrophic medical cost-related bankruptcies, lower rates of depression, and generally healthier quality of life for the insured group. But specific measures like hypertension, cholesterol, and diabetes showed no meaningful improvements. The conclusion that could be drawn from this was that access to health insurance (1) and therefore to health care (2) did not improve health (3).
One plus two doesn’t equal three in the assessment of the experiment’s results because there is at least one missing piece, possibly two.
Dr. Jha says that missing piece is health care QUALITY. That may be true in some cases. Certainly it is important to have an invested primary care physician – without that, a passive patient or those not knowledgeable of what a PCP should assess and recommend, could flounder. But surely an important missing piece is, as one of the responses to Dr. Jha’s posting stated, habits and environment. The average person doesn’t have a lot of control over environmental influences like air quality and pollutants. But everyone (with the possible exception of the most vulnerable – those with limited mental capacity) has or is capable of having control over habits. Two words: personal responsibility.
Genetics play a role in tendencies toward high blood pressure and high cholesterol and even diabetes. But it is personal choices and behaviors that tip the scale (literally and figuratively).
If you are prone to high cholesterol, the most stringent diet probably will fail to get your numbers into ideal ranges. So health care plays a role there, by prescribing appropriate medications. But if you persist in living on a diet of high fat, high sugar and little to no exercise, you’ll probably end up obese with diabetes. Don’t then blame your doctor when you have a heart attack or stroke, or end up on dialysis, or lose your eyesight. Your doctor can provide you with preventive medications and lifestyle advice, but you are the one who has to follow that advice and plan of care.
And don’t get me started on smoking. In NYS, the average one-pack-a-day smoker drops between $250 and $300/month on cigarettes. And die-hard smokers often don’t stop at one pack per day. How anyone can watch the graphic and grotesque anti-smoking ads and still delude themselves that smoking isn’t hurting them is beyond my comprehension. When someone tells me their budget doesn’t permit fresh vegetables, fruits and fish purchases while they exhale smoker’s breath, I’m torn between presenting reality and minding my own business. I’m not a crusader. I just believe people make their own choices in life and for the most part the rest of us should not be held responsible, financially or otherwise, for their choices.
As for quality of health care: A good primary care provider (PCP) pays attention to preventive care and listens to your needs and tailors your “care plan” realistically to your lifestyle and personality while steering you in healthy directions. He/she diagnoses problems and treats or refers you for specialist treatment and then follows up with you. That’s all you really should ask of your doctor.
After a wonderful PCP of mine retired, I went to one who, three years after seeing him twice a year, still asked me every time “who’s your primary?” Only after I reminded him that he was did he, for the duration of that visit, act like a primary. When I returned six months later it was Ground Hog Day all over again.
I gave up finally and tried a female doctor (that wonderful PCP I had was a woman) – and went from the frying pan into the fire. In four office visits I saw her only once. That wouldn’t have bothered me so much if the NP I saw paid attention to my family medical history. Serious heart disease is rampant in our family – yet not once in over a year, including my initial visit, have I had an EKG done. Even without my history, that’s standard for a sixty-something woman. I had to ask for an annual physical. I’ve not been asked when my last colonoscopy or GYN exams have been. I wasn’t asked if I’d had a flu shot or if I’d be interested in the Shingles vaccine. I’m in health care, so I know about these things – but what about the patients who do not? Last December I had a bout of severe muscle burning that kept me up at night. Lab work (which I had to request) showed borderline liver issues that could point to an adverse effect of the simvistatin I was taking for high cholesterol. The doc told me to stop the simvistatin, follow a low fat diet and start getting regular exercise. (If she’d paid attention to my history, she’d know I have run numerous marathons/half marathons in the past several years, mix it up with other exercise and maintain a healthy weight.) Then, she said, get the lipids retested in three months. I had labs done in March and my worst fears were realized – my total cholesterol had shot up nearly 100 points and my LDL was way over the safe range even for people without a family history of heart disease. I had to call for the results and drag the details out of the nurse (who only said it was “up”), and was told, once again, to follow a low fat diet and get more exercise. “Time’s up,” I thought. Time to find a PCP who has my back.
So, yes, quality of care plays a role. But so does personal responsibility. I’m not a doctor, but I pay enough attention to these things to know that cholesterol management is not an all or nothing situation. I also know that genes trump diet every time. I’m on the hunt for a new PCP, but in the meantime I put myself back on simvistatin at a reduced dose – damage control, I rationalized. When I find the right doctor, we will discuss other options for managing my cholesterol safely. And hopefully she will assess and treat the total person that I am, not just whatever symptom I’m presenting at a given visit. If not, the search will continue.
Let’s come full circle back to the Oregon experiment and whether health insurance improves outcomes. The answer depends on what outcomes you are measuring (cost, utilization, depression, financial security, or patient outcomes). There is no doubt in my mind that the cause and effect of insurance on patient outcomes is influenced by other factors that weren’t measured in Oregon: yes, the quality of the care. But as the old saying goes, “You can lead a horse to water, but you can’t make him drink it.” At least as important is the patient’s personal accountability for his/her own health, as reflected in their lifestyle choices.
Okay, I’ll get off my soapbox now.