By Jay Segel, DPM
In my podiatric practice, I have found that health insurance can impede patient care, by adding layers of complication and burden to all involved, particularly the patient and the provider. Private-sector insurance companies have profits to make, buildings to build, shareholders to satisfy, and overhead costs to pay. Government-run plans have costs, exclusionary policies, bureaucratic oversight, and a changing landscape as administrations change. Subsidized insurance plans often are associated with seemingly unreasonable regulations, narrow coverage, burdensome documentation requirements, and are, in my opinion, complicated by policies written by bureaucrats who might never have seen a patient. In my experience, health insurance often stands in the way of a doctor doing his (her) job reasonably, compassionately, and efficiently.
The concept of insurance originated from the needs of the shipping industry, to pool risk in the transport of goods. People, however, are not goods, and patient care risk cannot be pooled without compromising treatment for some (perhaps many) through delays and rationing care. Further, health insurance requires healthier people — often young people who are just starting out and living paycheck-to -paycheck — to shoulder a large portion of the burden. Yet most of us fear going without it.
A way forward to making quality medical care available to more people in need is, in my opinion, achievable by, 1) reducing costs by eliminating redundancy, overregulation, and bureaucratic red tape, and 2) making greater use of low-cost tele-triage systems. Such systems might be staffed by retired physicians and other clinicians. In such a system, patients seek advice sooner, obtain an opinion on the severity of the problem, and the patient is directed to skilled care. Such a tele-triage system could relieve the burden on face-to-face care, and help patients overcome the inclination to wait until minor problems progress to more complex issues before seeking help—this might help improve outcomes and reduce health care costs.
I’ve been exploring the concept of truly cooperative medicine; put simply, insurance-free, fee-for-service, live, multidisciplinary, patient-focused evaluation and management. This structure might also be performed in the setting of health insurance, but interdisciplinary diagnosis and treatment is sufficiently complicated without it. Further, by eliminating the insurance-driven administrative bureaucratic costs such as claims creation, claim submission, third-party billing companies, collection agencies and professional liability safeguards, we could reduce the cost of healthcare that can pass on to the patient.
Consider the treatment of neuromuscular and musculoskeletal disorders, which can be complex and often require a multidisciplinary approach. Under the current care model we encounter obstacles in the way of smoothly transitioning care in referral follow through, lack of a cohesive plan, specialty jargon, time elapsed between patient visits, ethnocentricity among disciplines, and uncertainty in the patient’s mind regarding how to reconcile, prioritize, and implement all of the information from the various professionals on their care team. Add to these impediments the burdens of insurance referrals and establishing “medical necessity.”
My dream scenario of an insurance-free cooperative care scheme goes something like this: A patient with multifocal musculoskeletal problems involving the kinetic chain has a specific chief complaint of joint pain in the rear foot, medial ankle, knee, hip and low back. The care team includes a physical therapist, podiatrist, chiropractor, orthopedic surgeon, and exercise physiologist. Medical history is obtained, followed by an appropriate multifocal review of systems and physical exam. Each member of the care team benefits from questions asked by other members, leading to fresh lines of inquiry based on newly uncovered subjective knowledge and objective findings. Together, the team agrees on additional testing and imaging, such as radiography, magnetic resonance imaging, diagnostic ultrasonography, computer-aided gait analysis, and laboratory studies. Waiting for the test results, the team discusses the possible diagnosis and formulates an interim care plan. The team reconvenes to discuss test results, evaluate the interim plan, and agree on a long-term care plan. The patient can follow up as needed with the clinician most directly associated with the patient’s chief complaint.
Perhaps soon, we will realize a care model that will work for all who need care. Stay tuned.
Jay Segel, DPM, is in private podiatry practice, Martha’s Vineyard, Massachusetts, and is Director of Applied Podiatric Biomechanics at Noraxon USA, as well as a podiatric advisor and member of the medical education staff at Orthotic Holdings Inc.