If you have have worked in healthcare for more than a week, you have entertained this question, "What if it were covered by insurance?"
Health insurers will pay for a patient's opiate prescriptions month after month, pay for the unintended consequences (multiple office visits for constipation, an ED visit after an accidental overdose, a hospital admission for intractable pain). When the patient wants to get off the meds, insurers won't pay for the three-day In Patient rapid detox admission. So the patient continues down the same path, never getting the care really needed to get well, yet still costing the system a bit here and a bit there, day after day. (Maybe the patient will lose their coverage before the insurer has to make that one-time big payment?)
What if health insurers had to include basic dental care - preventative cleanings, simple fillings, and necessary extractions? How many ED and office visits would this prevent? How much patient suffering would this alleviate? How about covering adult shingles vaccines, tetanus & pertussis boosters, and other immunizations?
Well, the overall cost of delivering care to the population might go down, but the cost to the insurer paying for that one patient might go up a bit in the current fiscal year.
What if? What if the insurance companies had to pay for services with a demonstrated positive return on investment at the population level - even if that ROI was longterm? We would then have a healthcare system with coverage of reasonable services aimed at preventing (or limiting) longterm morbidity costs. Isn't that what we want? Well, it is what consumers and healthcare advocates are requesting. Aside from the lower profit margins for insurance companies (which would still be enviable in almost any market), who would argue against such improvement? Once the argument is put aside, how do we get there?
Two solutions which dovetail:
1) ACOs - improve care, improve access, and share the savings. Win-win!
2) Green Mountain Care Board - finally, consumer advocates can create a sustainable model for healthcare delivery aimed at (drum roll) delivering healthcare (rather than aimed at profit-sharing). If insurance companies want to make a profit in Vermont, they should cover a core set of services determined by a group of bright people with no financial interest in the outcome. Wow. It took two thousand years to find that model?
Both models - or one with elements of each - will need to be the flesh on a backbone of healthcare information technology (#HIT), including electronic health records and their respective patient portals, plus the health information exchange (#HIE) that will link our medical communities across VT (#VITL) into a network of patient data. We are on the verge of moving from medical information to medical knowledge.
I am not naive enough to think that change is easy or painless. Uncertainty creates anxiety. Anxiety breeds discontent. New systems (insurance and technology) will bring changes better for some and worse for others.
The road that we have travelled in healthcare cannot survive. Our own "success" is our demise. We may not like the future, but the past course surely is self-limiting.
