Wednesday, August 20, 2008

Fifteen days of blogging for health care reform: Overuse, underuse, barriers, and compliance

Guest post by Skylanda.

There are a few folks out there who overuse the medical system. Every emergency department has its “frequent fliers,” and every clinic has its quota of personality disorders on the rolls that require an individualized level of energy that could otherwise fulfill the needs of ten patients in the same time span. These people are often the bane of primary care and emergent care facilities alike, they are a vortex of resource suckage (and if they were stable enough to stay enrolled in a billable insurance plan, they wouldn’t be causing your practice so much grief). But in all honesty, they are usually people with very large problems. Those problems may be occurring entirely above the brainstem, but nevertheless: large problems. Thus need lots of help.

There is another type of overuser, one that no one takes to task for their affect on the total medical system: the user of boutique clinics, unnecessary specialty services, and excessive cosmetic commodities. These people pay - usually straight out of pocket - for the privilege, so we usually don’t get huffy with them for altering the landscape of medical economics in such a way that the limited number of doctors in the nation get pulled to doing things other than providing general care for actual medical problems. This is a mutual harm for sure - doctors who choose lucrative Botox practices over low-income community clinics certainly have their own free will in sustaining this market - but nevertheless: very easy to blame the mentally ill self-medicating narcotic addict for overusing the ED. Very rare to blame the wrinkle-free six-time Botox patient for their role in the dearth of primary care providers, even though on a market-level scale the relationship is hard to miss.

From an economics perspective, you could say that an “overuser” is someone who draws more on the system than is necessary to accrue the most maximal level of benefits per dollar spent. Put that in yer calculator and smoke it. Something is very inefficient, for example, when a person - any person - hits up the emergency department more than once a month, unless that is one clumsy person. Something is also very maladjusted when a cadre of providers is yanked out of the low-pay business of providing primary care and into the high-pay business of catering to people with an excess of time and money on their hands.

But if there are over-users, does that mean there are people on the other side: under-users? You can ask ten providers and get ten thoughtful answers to this question, but from a social justice perspective, the answer is - without a doubt - yes. From an economics perspective, I would argue that the answer is also an unequivocal yes.

For the sake of simplicity, let’s define an under-user in this manner: an under-user is a person who costs the system more when they fail to utilize health care. This is the homeless person who does not make it to a local clinic to get simple treatment for a foot ulcer from sleeping upright on the street, and thus ends up getting scraped unconscious off the park sidewalk a week later and dumped on the emergency room with a bloodstream infection - at an exorbitant, avoidable cost. This is the poorly controlled diabetic who skimps on insulin to pay the electrical bill, only to end up on dialysis because of the consequences of their years of high blood sugar. This is the uninsured construction worker who ignores that shooting pain because he can’t afford not to work, only to end up on long-term disability from continually re-injuring a wrist that could have been fixed permanently if addressed right away. This is the heroin-addicted street person who was hacking up blood in a shelter for a month before anyone noticed that every cough brought up aerosolized whiffs of tuberculosis bacteria. No matter who ends up footing those bills, the whole lot of us would be better off if the care were done earlier, on the cheap, and to the benefit of the individual in question.

There are a myriad of reasons why people underuse medical resources, but the big ones are obvious: Can’t afford it. Don’t have insurance. Could qualify for public coverage, but don’t have the wherewithal to navigate the system. Don’t speak the language. Don’t have transportation. Don’t feel welcome. Aren’t welcome. Have been turned away before. Can’t take time off work. Have a violent partner that won’t allow it. You have your own imagine - feel free to add your own to that list.

The system as we currently know is designed to throw up as many barriers as possible to the class of folks who we could call “under-users.” We have clinics that are only open during business hours; we make sure that if you don’t fill out this piece of paperwork by that date, you fall off the Medicaid rolls for at least such and said number of months; we place facilities where it convenient for developers and physicians, not where it is most inconvenient for people who need it most (the medical school in Oregon, for example, is so far removed from town - perched on a height aptly known as Pill Hill - that a common reason I saw cited for patients no-showing to appointments was simply that they could afford the bus fare from poorer parts of town).

Several years ago, in another state, I watched a debate rage over five dollars. Five dollars per month: the amount that the state suggested asking of every enrolled Medicaid member to maintain their status with the program. Its intent was to force the Medicaid enrollees to buck up and contribute to their care. Indeed, there is a fair amount of evidence that having patients pay for part of their care - even a nominal sum like five dollars - contributes positively to how seriously they take the advice they get, how likely they are to comply with physician recommendations. After all, if you paid for it, you’re more likely to pursue your money’s worth. But the behavior of rational, middle-class consumers in regards to a nominal fee has no bearing on the effect of attaching fees to people who simply cannot pay those fees or do not have the wherewithal to locate the local bureaucracy to whom they must be paid, monthly and on time.

When the policy passed and a five-dollar monthly “premium” was attached to Medicaid enrollees, the net immediate effect was to boot the poorest and most vulnerable patients - those already most likely to be under-users - right off the rolls. In the short term, it cut costs by cutting coverage to a whole sector of the population; in the long term, those cut off the Medicaid rolls will cost the state (and the local hospitals that swallow the cost of charity care) eons more in time, money, and human health by putting up one more barrier between the most vulnerable people and the one source of coverage they qualify for. All for five bucks a month.

The right wing, wouldn’t you know it, likes to put a morality spin on this issue. The rhetoric at the time was all bootstrap and welfare queen: If these people can’t even bother to come up with five bucks a month - and who can’t come up with that - why should we bother to keep giving them free healthcare handouts? An ounce of imagination and a droplet of empathy should put that question to rest, but in case that is lacking, let’s go back to good, sound finances: because it costs us more in the long-term to deny coverage over five bucks a month, that’s why. Medical problems do not go away unless the person who has them ups and dies on you; they merely get worse - and more expensive - until they are treated or debilitating or fatal. And if those medical problems happen to be contagious? All the more reason to get on them now rather than wait until they spin out of the margins of society and into the core of people that actually seem to matter.

It is for these reasons that any comprehensive health care reform must have built into the system a means of reducing barriers to care for the people most prone to getting locked out of the system. First and foremost, this means nixing this morality rhetoric out of the debate; whether or not you believe in bootstrapping has zero regard on whether a homeless man with TB should have to come up with five bucks before someone figures out what he’s got and makes damn well sure he doesn’t pass it on. Whether or not you believe in scapegoating welfare queens has nothing to do with the financial difference between treating a simmering case of diabetes and letting that case go until the body it is developing in loses its kidney function and ends up on the public dollar for dialysis three times a week.

Second, this means that the characteristics and demographics of people most likely to get locked out of the system need to be identified, and those people need to be exempted from the sorts of petty penny-grabbing fees and bureaucratic hoop-jumping that form barriers to care. These barriers include but are not limited to: nominal monthly premiums to stay on the Medicaid rolls; copays at the point of service; inflexible paperwork and deadlines that cause people to be booted off Medicaid if they turn in a signature a couple days late or can’t provide proof of address when indeed have no address. These demographics include but are not limited to: homeless individuals and families, unemployed heads of household and their children, people undergoing treatment for chemical addiction (or heck, throw in those who merely should be undergoing treatment but aren’t yet), the disabled and chronically ill who have trouble accessing the bureaucratic arm of the health care infrastructure due to transportation issues, the developmentally disabled, those with profound mental illness, women and children living in shelters to escape violent partners, and other groups with similar impairments to full access. These are people who you do not want falling off the Medicaid rolls and losing their only access to care, who are prone to becoming the expensive sorts of under-users that eventually cost the system dollars on pennies further down the line. Sanctimonious rhetoric about bootstrapping and personal responsibility aside, regular unfettered access to care is a necessary (though not adequate) safeguard against pointless and costly delays and medical care for these demographic groups.

Paul Farmer - the demi-god of international medicine - has said some inflammatory things in his time, and this may be one of the more calmly understated of those quotes:

"Throughout the world," he writes, "those least likely to comply are those least able to comply."

If we want to demand compliance from the people that we like to label as social problems - that addicts attend treatment, that the mentally ill take their antipsychotics, that the homeless quit with that annoying habit of slumping over on the street and dying while we with homes and shoes and places to be are trying to walk where they lie across the sidewalk - the absolute minimal obligation from those in power is to remove all unnecessary barriers to accessing care.

The five-dollar Medicaid premium? Piece of cake, swipe of the bureaucratic pen and it‘s gone - cheaper in fact to eradicate it than to pay a cadre of bureaucrats to push the paperwork required to collect it. Now then, establishing trust between these individuals and a system that has routinely failed them such that they actually access that care when necessary and appropriate? That, my friends, is what is known as a challenge.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.