Health Care Anew

In times past there was an approach to planning called Comprehensive Rationality. 

According to an e-learning web page published by Freie University in Berlin, Germany, the approach was “based on instrumental rationality when analysing and making decisions (goal-rational).”  The central assumptions were that: 

The Affordable Care Act (a.k.a. Obamacare) provides for something called Accountable Care Organizations, which combine all elements of care – including doctors and hospitals – into single entities, which are offered financial incentives to improve quality and reduce cost.  Various approaches are offered with provision being made for evaluation to see which ones work best. 

This is Comprehensive Rationality in its pure form.   

I had been given to understand that the planning fraternity had long since concluded that the approach didn’t work.  Modern organizations are complicated and nobody is smart enough to compose a manual that will make them succeed. 

If my impression is correct, the word hasn’t yet penetrated health care.

Our archaic system of paying doctors and hospitals is beginning to cause problems. 

The Boston press recently carried a story about a patient who got a few pre-cancerous skin spots removed in what appeared to be the private office of his Dermatologist.  He got the doctor’s bill in what seemed to be a reasonable amount and was then shocked a few days later to get a bill for $1,525 from a nearby hospital for “operating room and other hospital charges.” 

The February 5 issue of The Boston Globe editorialized against such charges, but without seeming to understand the origins of the problem. 

In recognition of the traditional independence of the medical profession, payments to doctors have been kept separate from payments to hospitals.  Thus we have Blue Cross and Medicare Part A for hospitals and Blue Shield and Medicare Part B for doctors.

Originally, hospital outpatient departments were for poor people. Physician care was provided by interns and residents under the supervision of attending staff who served without pay.  Then Medicare and Medicaid came along and insured many of those people.  But outpatient care was insured on the doctor side and there was no provision for paying the hospital.  Eventually that was changed so that insurance paid both. 

As time went by, hospitals started buying up physician practices, many of which continued to operate in private offices.  Hospitals apparently found that in these circumstances they could make a hospital charge as well as a professional fee charge – something obviously not intended when the dual-billing system was created. 

That is the sort of thing that happens when financial arrangements don’t keep up with the times.

If physicians would manage care, insurance companies wouldn’t have to. 

I’m in the midst of one of the health insurance episodes that drive physicians crazy. The whole thing has been handled in the ham-handed way that is common among large bureaucracies with different parts of the organization telling you different things.   

One of the drugs I’ve been taking for years has recently been identified as being potentially hazardous.  The insurance company’s mail order pharmacy dealt with that by not filling the most recent prescription written by my primary care physician, instead asking her for a justification.  Though annoyed by the request, she responded to it and was then driven into a frenzy when it was rejected.  

The irrationality of the whole procedure was illustrated when I told the mail order pharmacy that my supply was running out.  The person I spoke with suggested that I get a month’s worth at my local drug store. 

One supposes that the pharmacy is concerned that I will get in trouble with the drug and then file a lawsuit claiming that I shouldn’t have been allowed to have it.  If I got it at the local drug store, it took the mail order pharmacy off the hook. 

During all this I saw the physician on a previously scheduled visit and pointed out that since health care providers can’t be counted on to manage such things, insurance companies think they have to. 

It didn’t make her any happier, but she had to agree that I was right.