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Making Health Care Affordable From The Bottom Up

Health care’s most important problem (and repeat ad nauseam) is the cost. How do we make health care affordable, cost less, and not inflate three times faster than the background economy?  While politicians and insurance companies rant and rave about saving health care from the top down, there is a nascent movement of doctors who are approaching the same puzzle from the bottom up.

What I mean by the bottom up is that doctors and patients are working together to build an independent system whereby they solve the typical day-to-day, or primary care, problems of health care without anyone else’s help or permission. From the bottom up also means that patients expect to be in control of their day-to-day care. This means paying for the service directly, which is the only real way to gain control. It means doctors are employed by the client, have transparent pricing, look the patient in the eye to explain the charge, and are better able to justify the cost. For the bottom-up means competition and a drive towards quality improvement and pricing that will cost a lot less than having ten people between you and getting what you need.

Here’s a simple example. You have a bladder infection. You had these exact symptoms a year ago so you know what’s wrong and what you need. Yet you’re held hostage by the health care “system” and are unable to get the medicine that has worked in the past.  You’re not alone: these type of infections account for 8.3 million doctors visits a year, primarily among women of reproductive age.

Here are three potential ways that this common problem could be handled:

1. The Existing Model: Your symptoms of burning and frequent urination coupled with barely being able to leave the bathroom are funneled though the appropriate gauntlet: receptionist, scheduler, in window, nurse, doctor, out window, billing specialist, insurance company, payment administrator, adjustor, and finally paperwork mailed to you acknowledging  payment.  Along the way you’re likely to get a urinalysis and several urine cultures.

Since you’re not paying for these tests, under insurance you don’t mind and consider this “good care.”  Your co-pay is $20. The insurance company pays $60 for the visit and the lab tests add another $30. You’re given three days of antibiotics and the problem’s resolved. The cost is $110.00 and 5 hours of your time assuming no major delays in getting into the office.

2. The Reformed Model: This would look very similar to the above system, but might include layers of oversight, fraud detection, pay-for-performance measurers, and “quality” assessment reviews, if one is to believe the rhetoric of people talking about “fixing” health care. Universal coverage likely will delay the wait time to be seen. The current delay for seeing a family practice physician in Massachusetts (the closest thing we have to Universal Coverage) is 63 days.

It’s difficult to believe that this added oversight can reduce costs but let’s pretend it pays for itself  by eliminating the unnecessary labs that evidence based standards repeatedly say provide no added benefit to outcome for simple bladder infections. Cost: at minimum $110.00 and your time: at least 5 hours for a three day treatment of antibiotics.

3. The Bottom-Up Model: Patient calls her doctor who answers the phone and listens to the story. This diagnosis repetitively has been shown to be most accurately diagnosed through history alone. Exam without other contributing factors is not helpful. Urine and cultures are not more sensitive or specific than the history.  The antibiotics are called to the pharmacy. Because you and your doctor know each other and work together to get you the best health care at the best price … and you care about the price …  your doctor might say “By the way I’ll call in a ten-day supply of antibiotics so you can keep a reserve treatment in the future whenever you get this again. This would give you two additional treatments in the future.

Before the conversation with your doctor, he sends you a follow-up email offering an overview of the diagnosis and complications when you should contact him. Cost: $45. Time from call until taking the first pill:  1 hour.

Do the math. Eight million cases times $110.00/ UTI infection case/year. Don’t forget the human toll of  40 million human hours/year wasted in the funnel (link).  The lawyers will want to add a value for pain and suffering too.

Compare this to a direct pay system — innovation wave one from the bottom-up, where you can reach your doctor day or night or even a weekend, take your dose of a prescription within an hour of calling, and have a reserve treatment for the future when inevitably you get the infection again. Imagine being treated like an adult. Frankly, $45 for the convenience is a steal compared to what’s being subsidized now.

Not all cases of bladder infection are cured through this simple formula, but seeing them in the office doesn’t reduce this chance either.  Conservatively, more than half of the cases could be done this way, meaning hundreds of millions of dollars saved  each year on this diagnosis alone. Don’t forget the guesstimated 20 million hours of lost productivity, plus the lost opportunities of railing about how someone else should “fix my health care.”

Going forward, we’ll see what the bottom up has to say about upper respiratory illness, poison ivy, low back pain or tick bites.

Until next week, I remain yours in bottoms-up primary care,

Alan Dappen MD

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