OCR Text |
Show illness. This ability to "do good things" focused the health care system on the provision of acute care to intervene with the course of disease or illness and away from the role of the health care provider as a facilitator of natural processes such as childbirth, or as a consoler and appeaser of pain for illnesses which could not be treated or cured. A new focus on doing things with the development and utilization of technology that allowed providers to do them better, more quickly, and more extensively, not only shifted medicine toward acute care, it also began to increase the costs of health care delivery. The dilemma thus arose that as long as one remained healthy, means to pay for health care was not a problem. If one became ill, however, to seek acute care meant assuming the obligation to pay the increasing costs associated with that care. Thus, individuals faced a small and unpredictable risk over time of incurring a large economic loss. Health insurance developed to allow pooling of that individual small risk of a large loss, into a predictable and budgetable small loss (i.e. insurance premium). Further laying the ground work for rapidly increasing costs of today was business's response to wage freezes during World War II to incorporate this small predictable loss of the health insurance premium as an employee benefit. Individuals now became insulated not only from the unpredictable risk of high cost health care service needs but even from the predictable risk of paying the premium for an insurance risk pool. These two directions, focusing on acute care and moving responsibility for cost of care from individuals to employers, have continued to compound cost problems in recent decades. The focus on and assurance of payment for acute care provides powerful incentives to develop technology that provides more and more complex acute care, and to increase public expectations that it can and will be provided. Providers have incentives to become adept and competent at providing and developing the technology necessary to provide acute care. Simultaneously, there is ongoing pressure from employee organizations on employers or state legislatures to add additional benefits to the health care insurance plans. Thus most health insurance is now "pre-payment" of not just high and unpredictable health care expenditures, but also of low to moderate but highly predictable expenditures, such as routine checkups, vaccinations, etc. This adds a large administrative overhead to process claims and make payments for all health care services, which then in turn adds to premium costs and overall health care system costs. This also further insulates the individual patient from the true costs of their care, and leads increasingly more employers to not provide health coverage at all. As the costs of insurance have risen for the employer/payer community, they have put pressure on the insurance companies to gain control over those costs. Insurance companies have responded with attempts to control costs either through limiting utilization of services or by eliminating coverage of high risk populations. Thus the incentives now for the insurance companies are to avoid covering individuals or businesses who are more likely to have high health care needs, and to identify businesses and populations where the employees are more likely to be healthy and not need medical services. We have thus come full circle to the point that those citizens who are most in need of health insurance coverage are the least likely to be able to get it. One means of judging our health reform proposal, then, might be to ask two questions: what will reform do to restore fairness to the provision of health insurance and restore the original purpose of health insurance to spread risk appropriately among a large population; and what will reform do to restore some direct responsibility for the cost of seeking health care to those doing the seeking. A second major intertwined area of evolution over the last several decades involves the role of the individual physician. The popular and historic image of physicians is that of the "old time family doctor" who knew not only the health problems of each patient, but also knew their families and everything about their life in general. The family doctor made house calls, provided health advice, or comfort and solace in the presence of death or major disability, and provided relief from pain and suffering when there was no way to achieve cure. This image was perpetuated by the television character Marcus Welby, MD, at the same time that the ability to positively intervene with acute illness was switching the incentives of the health care provider to focus more on the development and improvement of technology and the increases in cost that go along with acute care emphasis. These incentives led physicians to focus on more and more highly specialized care delivery, and fewer physicians were either interested in or able to provide the comfort and personal type of care associated with Dr. Welby. In the 1990s, 70% of the physician providers in the U.S. are specialists or sub-specialists, and only 30% are considered to be "primary care" providers. Worse yet, the number of graduates of medical schools intending to go on in post-graduate training for primary care specialties is progressively declining as well, to a level now of 15-20% (U.S. Dept. of Health and Human Services, 1992). Although other types of providers are stepping up to help fill in the gaps, we are facing a health care delivery system Utah's Health: An Annual Review 1994 113 |