Health Care Anew

Recent articles in the hospital literature about Emergency Medical Technicians (EMT’s) remind me of a personal experience that may be instructive for health care in the future. 

Some years ago, when I was still in the process of learning how to manage my diabetes, I had an episode of severe hypoglycemia.  Noting that I was behaving strangely in the night, wife Marilyn tried to wake me up but was unable to do so.  She called 911 and within minutes the local emergency response team arrived.  The senior technician quickly sized up the situation and tested my blood sugar level.  Finding it dangerously low, she gave me an infusion of sugar and, after a few seconds, commanded me to wake up, which I did. 

I believe that qualifies as a life-threatening experience.  Had I not been given the sugar, I presume I would have died. 

But I was saved by a health care provider who was not a physician.  It was an EMT who made the diagnosis, decided on a treatment, and administered it.  Had she personally charged and collected a fee, I believe what she did would qualify as the practice of medicine.   

I have had other experiences with EMTs, all fully satisfactory. 

It reminds me that in all the discussion about the quality of health care, I have heard no questions raised about the quality of care provided by EMTs. 

I know that there are an ever increasing number of Physician’s Assistants and Nurse Practitioners involved in health care.  But my experience with EMTs causes me to wonder how much more of what doctors do might be done equally well – or even better - by people who have much less training and command much lower incomes.  Maybe that could be part of the solution to the cost problem and also provide jobs for the middle class. 

I am a regular reader of the columns of David Brooks, house conservative of the New York Times editorial pages. 

A recent Brooks piece was devoted to the Republican alternative to Obamacare, a key element of which was the need for patients to have skin in the game.  In Brooks’ words,“If they are going to request endless tests or elaborate procedures, they should bear a real share of the cost.” 

I think there is a case to be made here, but one a little more subtle than that.  The way I would put it is this:  Providers are not likely to work very hard at improving efficiency unless they are under economic pressure to do so.  During the managed care era of the 1990s, economic pressure was applied by insurance companies and while it worked, patients did not like the restrictions involved and revolted against it.  So it appears that if effective economic pressure is to be applied, the cooperation of patients is required; i.e., they will need to have skin in the game. 

The so-called tiered health insurance policy now being sold in Massachusetts is one way of doing that.  That policy is offered at reduced rates and offers patients complete free choice of providers.  But if they use designated expensive ones, their co-pays and deductibles are substantially higher. 

Predictably, there have been a few complaints by patients who found themselves wanting to use the expensive providers but didn’t want to pay the higher amounts.  But as a general matter, the tiered policy experiment seems to be working. 

Clever minds can probably come up with other acceptable ways to give patients skin in the game.  They ought to be encouraged to do so.