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Archive for August 2010

A Scientist’s Approach to Health Care Reform

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By K. Shmueli


Just as scientists introduce their papers by giving an overview of previous relevant literature, last month’s health policy speaker began by summarizing the historical background to the current health care system in the USA. Landmarks include the origins of (Blue Cross) Health Insurance when Baylor Hospital in Texas first allowed teachers to prepay for hospitalization in the 1920s-30s. During the salary caps of the Second World War, health benefits enabled employers to compete for workers; what started as an incentive program has evolved into the employer-based health care most Americans rely on today. Medicare and Medicaid, federal programs intended to cover the extremes of the population in age and poverty, were created by 1965 amendments to the Social Security Act. Add to that the State Children’s Health Insurance Program (SCHIP), founded in 1997 to cover uninsured children in families with modest incomes too high to qualify for Medicaid, and we can appreciate why Americans and foreigners alike are confused by this byzantine health care system.

One consequence of this complexity is that physicians have to deal with multiple health insurance companies. This explains why some doctors are increasingly refusing to accept health insurance, leaving patients to negotiate medical claims directly with their insurers. Another ramification of the complex health coverage patchwork is pressure towards further centralization or socialization of health care. Despite socialized health care being disparaged by some American media, the USA has one of the world’s largest socialized health care systems: the Veterans Health Administration (see our previous posting on Gulf War Syndrome ). Fear of socialization of health care could arise from the fact that any health care reform threatens to change the current system which many Americans perceive to combine maximum choice with maximum coverage, even though employers often restrict employee health care choices to a limited number of insurance plans and companies. Clearly there is no simple, single answer to solve the huge conundrum of health care reform.

Can we bring a scientific perspective to bear on health care reform? How do its policy and cost implications intersect with science? A fundamental principle of science is transparency: we must report our methods and findings transparently to allow science to progress. A major problem that the Patient Protection and Affordable Care Act (PPACA) tries to address is the lack of transparency of both health care costs and insurance coverage. Presently, consumers of health care are shielded from its true costs by providers and insurance companies, and this is exacerbated by the diversity of administrative processes followed by different health care providers ranging from social workers to hospitals. Pricing studies have found it very difficult to obtain a single “price” for a given procedure, drug or treatment.

Transparency of costs may be improved by a soon-to-be implemented piece of the PPACA , which involves standardizing how information on cost-sharing and coverage is presented in health insurance documents. The standards, which the PPACA requires HHS to develop by 23rd March 2011, will also determine how health insurance and medical terms are defined. By 23rd March 2012, those uniform definitions will be used by insurers in summary-of-benefits and coverage ex­planation documents. That should improve the transparency of health insurance, making it easier for consumers to compare different policies.

As well as transparency, science values consensus. One of the most widely supported measures in the PPACA, which will come into effect on 23rd September 2010, is theprohibition of insurance companies from rescission (canceling health insurance policies once patients get sick on the basis that the insured had a pre-existing condition that was not disclosed in advance).

Finally, a further aspect of the PPACA that should please scientists: its provision to invest in comparative effectiveness research (CER). However, as with all aspects of the PPACA, this is contentious, with experts fearing that investment in CER will not have an impact unless steps are taken to ensure practical implementation.

Written by sciencepolicyforall

August 10, 2010 at 12:36 pm

Posted in Essays

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