Who's Paying For Health Care?

America spent 17.3% of its gross domestic product on health care in 2009 (1). If you break that down on an individual level, we spend $7,129 per person each year on health care...more than any other country in the world (2). With 17 cents of every dollar Americans spent keeping our country healthy, it's no wonder the government is determined to reform the system. Despite the overwhelming attention health care is getting in the media, we know very little about where that money comes from or how it makes its way into the system (and rightfully so...the way we pay for health care is insanely complex, to say the least). This convoluted system is the unfortunate result of a series of programs that attempt to control spending layered on top of one another. What follows is a systematic attempt to peel away those layers, helping you become an informed health care consumer and an incontrovertible debater when discussing "Health Care Reform."

Who's paying the bill?

The "bill payers" fall into three distinct buckets: individuals paying out-of-pocket, private insurance companies, and the government. We can look at these payors in two different ways: 1) How much do they pay and 2) How many people do they pay for?

The majority of individuals in America are insured by private insurance companies via their employers, followed second by the government. These two sources of payment combined account for close to 80% of the funding for health care. The "Out-of-Pocket" payers fall into the uninsured as they have chosen to carry the risk of medical expense independently. When we look at the amount of money each of these groups spends on health care annually, the pie shifts dramatically.

The government currently pays for 46% of national health care expenditures. How is that possible? This will make much more sense when we examine each of the payors individually.

Understanding the Payors

Out-of-Pocket

A select portion of the population chooses to carry the risk of medical expenses themselves rather than buying into an insurance plan. This group tends to be younger and healthier than insured patients and, as such, accesses medical care much less frequently. Because this group has to pay for all incurred costs, they also tend to be much more discriminating in how they access the system. The result is that patients (now more appropriately termed "consumers") comparison shop for tests and elective procedures and wait longer before seeking medical attention. The payment method for this group is simple: the doctors and hospitals charge set fees for their services and the patient pays that amount directly to the doctor/hospital.

Private Insurance

This is where the whole system gets a lot more complicated. Private insurance is purchased either individually or is provided by employers (most people get it through their employer as we mentioned). When it comes to private insurance, there are two main types: Fee-for-Service insurers and Managed Care insurers. These two groups approach paying for care very differently.

Fee-for-Service:

This group makes it relatively simple (believe it or not). The employer or individual buys a health plan from a private insurance company with a defined set of benefits. This benefit package will also have what is called a deductible (an amount the patient/individual must pay for their health care services before their insurance pays anything). Once the deductible amount is met, the health plan pays the fees for services provided throughout the health care system. Often, they will pay a maximum fee for a service (say $100 for an x-ray). The plan will require the individual to pay a copayment (a sharing of the cost between the health plan and the individual). A typical industry standard is an 80/20 split of the payment, so in the case of the $100 x-ray, the health plan would pay $80 and the patient would pay $20...remember those annoying medical bills stating your insurance did not cover all the charges? This is where they come from. Another downside of this model is that health care providers are both financially incentivized and legally bound to perform more tests and procedures as they are paid additional fees for each of these or are held legally accountable for not ordering the tests when things go wrong (called "CYA or "Cover You're A**" medicine). If ordering more tests provided you with more legal protection and more compensation, wouldn't you order anything justifiable? Can we say misalignment of incentives?

Managed Care:

Now it gets crazy. Managed care insurers pay for care while also "managing" the care they pay for (very clever name, right). Managed care is defined as "a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision making through case-by-case assessments of the appropriateness of care prior to its provision" (2). Yep, insurers make medical decisions on your behalf (sound as scary to you as it does to us?). The original idea was driven by a desire by employers, insurance companies, and the public to control soaring health care costs. Doesn't seem to be working quite yet. Managed care groups either provide medical care directly or contract with a select group of health care providers. These insurers are further subdivided based on their own personal management styles. You may be familiar with many of these sub-types as you've had to choose between then when selecting your insurance.

Preferred Provider Organization (PPO) / Exclusive Provider Organization (EPO):This is the closet managed care gets to the Fee-for-Service model with many of the same characteristics as a Fee-for-Service plan like deductibles and copayments. PPO's & EPO's contract with a set list of providers (we're all familiar with these lists) with whom they have negotiated set (read discounted) fees for care. Yes, individual doctors have to charge less for their services if they want to see patients with these insurance plans. An EPO has a smaller and more strictly regulated list of physicians than a PPO but are otherwise the same. PPO's control costs by requiring preauthorization for many services and second opinions for major procedures. All of this aside, many consumers feel that they have the greatest amount of autonomy and flexibility with PPO's.

Health Management Organization (HMO): HMO's combine insurance with health care delivery. This model will not have deductibles but will have copayments. In an HMO, the organization hires doctors to provide care and either builds its own hospital or contracts for the services of a hospital within the community. In this model the doctor works for the insurance provider directly (aka a Staff Model HMO). Kaiser Permanente is an example of a very large HMO that we've heard mentioned frequently during the recent debates. Since the company paying the bill is also providing the care, HMO's heavily emphasize preventive medicine and primary care (enter the Kaiser "Thrive" campaign). The healthier you are, the more money the HMO saves. The HMO's emphasis on keeping patients healthy is commendable as this is the only model to do so, however, with complex, lifelong, or advanced diseases, they are incentivized to provide the minimum amount of care necessary to reduce costs. It is with these conditions that we hear the horror stories of insufficient care. This being said, physicians in HMO settings continue to practice medicine as they feel is needed to best care for their patients despite the incentives to reduce costs inherent in the system (recall that physicians are often salaried in HMO's and have no incentive to order more or less tests).

The Government

The U.S. Government pays for health care in a variety of ways depending on whom they are paying for. The government, through a number of different programs, provides insurance to individuals over 65 years of age, people of any age with permanent kidney failure, certain disabled people under 65, the military, military veterans, federal employees, children of low-income families, and, most interestingly, prisoners. It also has the same characteristics as a Fee-for-Service plan, with deductibles and copayments. As you would imagine, the majority of these populations are very expensive to cover medically. While the government only insures 28% of the American population, they are paying for 46% of all care provided. The populations covered by the government are amongst the sickest and most medically needy in America resulting in this discrepancy between number of individuals insured and cost of care.

The largest and most well-known government programs are Medicare and Medicaid. Let's take a look at these individually:

Medicare:

The Medicare program currently covers 42.5 million Americans. To qualify for Medicare you must meet one of the following criteria:

Over 65 years of age

Permanent kidney failure

Meet certain disability requirements

So you meet the criteria...what do you get? Medicare comes in 4 parts (Part A-D), some of which are free and some of which you have to pay for. You've probably heard of the various parts over the years thanks to CNN (remember the commotion about the Part D drug benefits during the Bush administration?) but we'll give you a quick refresher just in case.

Part A (Hospital Insurance): This part of Medicare is free and covers any inpatient and outpatient hospital care the patient may need (only for a set number of days, however, with the added bonus of copayments and deductibles...apparently there really is no such thing as a free lunch).

Part B (Medical Insurance): This part, which you must purchase, covers physicians' services, and selected other health care services and supplies that are not covered by Part A. What does it cost? The Part B premium for 2009 ranged from $96.40 to $308.30 per month depending on your household income.

Part C (Managed Care): This part, called Medicare Advantage, is a private insurance plan that provides all of the coverage provided in Parts A and B and must cover medically necessary services. Part C replaces Parts A & B. All private insurers that want to provide Part C coverage must meet certain criteria set forth by the government. Your care will also be managed much like the HMO plans previously discussed.

Part D (Prescription Drug Plans): Part D covers prescription drugs and costs $20 to $40 per month for those who chose to enroll.

Ok, now how does Medicare pay for everything? Hospitals are paid predetermined amounts of money per admission or per outpatient procedure for services provided to Medicare patients. These predetermined amounts are based upon over 470 diagnosis-related groups (DRGs) or Ambulatory Payment Classifications (APC's) rather than the actual cost of the care rendered (interesting way to peg hospital reimbursement...especially when the Harvard economist who developed the DRG system openly disagrees with its use for this purpose). The cherry on top of the irrational reimbursement system is that the amount of money assigned to each DRG is not the same for each hospital. Totally logical (can you sense our sarcasm?). The figure is based on a formula that takes into account the type of service, the type of hospital, and the location of the hospital. This may sound logical but often times this system fails.

Medicaid:

Medicaid is a jointly funded (funded by both federal and state governments) health insurance program for low-income families. Eligibility rules vary from state to state and factors in age, pregnancy, disability, income and resources. Poverty alone does not qualify an individual for Medicaid (there is currently no government-provided insurance for the American poor...despite the fact that almost all first world countries have such a system...enter the current health care debate) but is a significant factor in Medicaid eligibility. Each state operates its own Medicaid program but must adhere to certain federal guidelines to receive matching federal funds (you may be familiar with California's MediCal, Massachusetts' MassHealth and Oregon's Oregon Health Plan due to their recent media coverage). Medicaid payments currently assist nearly 60 percent of all nursing home residents and about 37 percent of all childbirths in the United States.

How are the bills paid?

We now understand who is paying the bill but we have yet to cover how those bills are paid. There are two broad divisions of arrangements for paying for and delivering health care: fee-for-service care and prepaid care.

Fee-for-Service

As we mentioned briefly while discussing PPO's, in a fee-for-service structure, consumers select a provider, receive care (a.k.a. "service") from the provider, and incur expenses (a.k.a. "a fee") for the care. Deductibles and copayments are also required as previously discussed. Pretty simple. The physician is then reimbursed for their services in part by the insurer (i.e. a private insurance company or the government) and in part by the patient, who is responsible for the balance unpaid by the insurer (the return of the unanticipated medical bill despite your overpriced insurance). Again, the major downfall of the fee-for-service approach is that medical professionals are incentivized to provide services (and by this we mean any and all services they can legally request or must request to be protected legally), some of which may be nonessential, to increase their revenue and/or "C.Y.A." (revenue that has steadily decreased as insurance companies continue to lower the amount they pay medical professionals for their services).

Fee Schedule

A fee schedule operates in the same way that Fee-for-Service does with one exception: instead of using the "usual, customary, and reasonable" amount to reimburse medical professionals, states set fees to be paid for specific procedures and services. The reimbursement is very low ($.10-.15 on the dollar) and barely covers the actual direct cost of providing the care. Physicians may chose to opt into the plan or not (starting to see why a doctor might not be so excited about this plan?). Would you sign up to be paid 10 cents for every dollar you charged for your work? Try the insurance reimbursement approach next time you go out to eat. We'll come bail you out of the Big House if things go awry. What happens when the insurance system does this? You get the Wal-Mart approach to medicine (high volume, low quality). Not the kind of heath care we recommend.

Pre-Paid

Pre-paid health care? Like a phone card? Not exactly--but close. The pre-paid system evolved out of the insurance company's desire to share its risk ( a.k.a "pooled risk") with health care providers. Essentially, they wanted the doctors to have some skin in the game. In the pre-paid system, insurers make arrangements with health care providers to provide agreed-upon covered health care services to a given population of consumers for a (usually discounted) set price-the per-person premium fee-over a particular time period. What does that mean? It means that Dr. Bob gets paid, say, $30 per month to take care of Joe the Plumber including his blood work and x-rays. If Dr. Bob spends less than that caring for Joe, he makes money. If Joe is sick every month and needs lots of tests and follow-up visits, Dr. Bob could lose money caring for Joe. The set monthly fee paid to the doctor for taking care of a patient is set up on a per-member, per-month (PMPM) rate called a "capitated fee." The provider receives the capitated fee per enrollee regardless of whether the enrollee uses health care services and regardless of the quality of services provided (not a good thing in our book). Theoretically, providers should become more prudent and subsequently provide services in a more cost effective manner because they are bearing some of the risk. Often times, however, less care is provided than is needed in hopes of saving money and increasing profits. In addition, physicians are incentivized to cherry pick the youngest and healthiest patients because these patients typically require less care (i.e. they are cheaper to keep healthy). We like that doctors are encouraged to keep patients healthy but we have to worry about the ways in which they are being encouraged to reduce costs (as little care as possible?). Again, the incentive system falls short and encourages providers to act unethically.

The Take Home Message:

Health Care in the United States today is complex and messy at best. The layers on top of layers of failed attempts to correct the system continue to encourage the wrong behavior in both patients (out of fear of medical bills) and providers (out of fear of bankruptcy). We have yet to provide every American citizen with medical care (something that goes without saying in most 1st World countries...even Cuba has it!). We spend more money on caring for our citizens than any country in the world yet we continue to lag behind in terms of national health outcomes. We think it's safe to say that we're not getting the best bang for our buck. The ultimate solution? We wish we knew. Only time will tell where the system goes from here. Our goal: to help you better understand the system as it stands today in hopes of developing a more effective, efficient, and comprehensive system for the future. Are you with us?

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Health Care Fraud

The Perfect Storm

Today, health care fraud is all over the news. There undoubtedly is fraud in health care. The same is true for every business or endeavor touched by human hands, e.g. banking, credit, insurance, politics, etc. There is no question that health care providers who abuse their position and our trust to steal are a problem. So are those from other professions who do the same.

Why does health care fraud appear to get the 'lions-share' of attention? Could it be that it is the perfect vehicle to drive agendas for divergent groups where taxpayers, health care consumers and health care providers are dupes in a health care fraud shell-game operated with 'sleight-of-hand' precision?

Take a closer look and one finds this is no game-of-chance. Taxpayers, consumers and providers always lose because the problem with health care fraud is not just the fraud, but it is that our government and insurers use the fraud problem to further agendas while at the same time fail to be accountable and take responsibility for a fraud problem they facilitate and allow to flourish.

1. Astronomical Cost Estimates

What better way to report on fraud then to tout fraud cost estimates, e.g.

- "Fraud perpetrated against both public and private health plans costs between $72 and $220 billion annually, increasing the cost of medical care and health insurance and undermining public trust in our health care system... It is no longer a secret that fraud represents one of the fastest growing and most costly forms of crime in America today... We pay these costs as taxpayers and through higher health insurance premiums... We must be proactive in combating health care fraud and abuse... We must also ensure that law enforcement has the tools that it needs to deter, detect, and punish health care fraud." [Senator Ted Kaufman (D-DE), 10/28/09 press release]

- The General Accounting Office (GAO) estimates that fraud in healthcare ranges from $60 billion to $600 billion per year - or anywhere between 3% and 10% of the $2 trillion health care budget. [Health Care Finance News reports, 10/2/09] The GAO is the investigative arm of Congress.

- The National Health Care Anti-Fraud Association (NHCAA) reports over $54 billion is stolen every year in scams designed to stick us and our insurance companies with fraudulent and illegal medical charges. [NHCAA, web-site] NHCAA was created and is funded by health insurance companies.

Unfortunately, the reliability of the purported estimates is dubious at best. Insurers, state and federal agencies, and others may gather fraud data related to their own missions, where the kind, quality and volume of data compiled varies widely. David Hyman, professor of Law, University of Maryland, tells us that the widely-disseminated estimates of the incidence of health care fraud and abuse (assumed to be 10% of total spending) lacks any empirical foundation at all, the little we do know about health care fraud and abuse is dwarfed by what we don't know and what we know that is not so. [The Cato Journal, 3/22/02]

2. Health Care Standards

The laws & rules governing health care - vary from state to state and from payor to payor - are extensive and very confusing for providers and others to understand as they are written in legalese and not plain speak.

Providers use specific codes to report conditions treated (ICD-9) and services rendered (CPT-4 and HCPCS). These codes are used when seeking compensation from payors for services rendered to patients. Although created to universally apply to facilitate accurate reporting to reflect providers' services, many insurers instruct providers to report codes based on what the insurer's computer editing programs recognize - not on what the provider rendered. Further, practice building consultants instruct providers on what codes to report to get paid - in some cases codes that do not accurately reflect the provider's service.

Consumers know what services they receive from their doctor or other provider but may not have a clue as to what those billing codes or service descriptors mean on explanation of benefits received from insurers. This lack of understanding may result in consumers moving on without gaining clarification of what the codes mean, or may result in some believing they were improperly billed. The multitude of insurance plans available today, with varying levels of coverage, ad a wild card to the equation when services are denied for non-coverage - especially if it is Medicare that denotes non-covered services as not medically necessary.

3. Proactively addressing the health care fraud problem

The government and insurers do very little to proactively address the problem with tangible activities that will result in detecting inappropriate claims before they are paid. Indeed, payors of health care claims proclaim to operate a payment system based on trust that providers bill accurately for services rendered, as they can not review every claim before payment is made because the reimbursement system would shut down.

They claim to use sophisticated computer programs to look for errors and patterns in claims, have increased pre- and post-payment audits of selected providers to detect fraud, and have created consortiums and task forces consisting of law enforcers and insurance investigators to study the problem and share fraud information. However, this activity, for the most part, is dealing with activity after the claim is paid and has little bearing on the proactive detection of fraud.

4. Exorcise health care fraud with the creation of new laws

The government's reports on the fraud problem are published in earnest in conjunction with efforts to reform our health care system, and our experience shows us that it ultimately results in the government introducing and enacting new laws - presuming new laws will result in more fraud detected, investigated and prosecuted - without establishing how new laws will accomplish this more effectively than existing laws that were not used to their full potential.

With such efforts in 1996, we got the Health Insurance Portability and Accountability Act (HIPAA). It was enacted by Congress to address insurance portability and accountability for patient privacy and health care fraud and abuse. HIPAA purportedly was to equip federal law enforcers and prosecutors with the tools to attack fraud, and resulted in the creation of a number of new health care fraud statutes, including: Health Care Fraud, Theft or Embezzlement in Health Care, Obstructing Criminal Investigation of Health Care, and False Statements Relating to Health Care Fraud Matters.

In 2009, the Health Care Fraud Enforcement Act appeared on the scene. This act has recently been introduced by Congress with promises that it will build on fraud prevention efforts and strengthen the governments' capacity to investigate and prosecute waste, fraud and abuse in both government and private health insurance by sentencing increases; redefining health care fraud offense; improving whistleblower claims; creating common-sense mental state requirement for health care fraud offenses; and increasing funding in federal antifraud spending.

Undoubtedly, law enforcers and prosecutors MUST have the tools to effectively do their jobs. However, these actions alone, without inclusion of some tangible and significant before-the-claim-is-paid actions, will have little impact on reducing the occurrence of the problem.

What's one person's fraud (insurer alleging medically unnecessary services) is another person's savior (provider administering tests to defend against potential lawsuits from legal sharks). Is tort reform a possibility from those pushing for health care reform? Unfortunately, it is not! Support for legislation placing new and onerous requirements on providers in the name of fighting fraud, however, does not appear to be a problem.

If Congress really wants to use its legislative powers to make a difference on the fraud problem they must think outside-the-box of what has already been done in some form or fashion. Focus on some front-end activity that deals with addressing the fraud before it happens. The following are illustrative of steps that could be taken in an effort to stem-the-tide on fraud and abuse:

- DEMAND all payors and providers, suppliers and others only use approved coding systems, where the codes are clearly defined for ALL to know and understand what the specific code means. Prohibit anyone from deviating from the defined meaning when reporting services rendered (providers, suppliers) and adjudicating claims for payment (payors and others). Make violations a strict liability issue.

- REQUIRE that all submitted claims to public and private insurers be signed or annotated in some fashion by the patient (or appropriate representative) affirming they received the reported and billed services. If such affirmation is not present claim isn't paid. If the claim is later determined to be problematic investigators have the ability to talk with both the provider and the patient...

- REQUIRE that all claims-handlers (especially if they have authority to pay claims), consultants retained by insurers to assist on adjudicating claims, and fraud investigators be certified by a national accrediting company under the purview of the government to exhibit that they have the requisite understanding for recognizing health care fraud, and the knowledge to detect and investigate the fraud in health care claims. If such accreditation is not obtained, then neither the employee nor the consultant would be permitted to touch a health care claim or investigate suspected health care fraud.

- PROHIBIT public and private payors from asserting fraud on claims previously paid where it is established that the payor knew or should have known the claim was improper and should not have been paid. And, in those cases where fraud is established in paid claims any monies collected from providers and suppliers for overpayments be deposited into a national account to fund various fraud and abuse education programs for consumers, insurers, law enforcers, prosecutors, legislators and others; fund front-line investigators for state health care regulatory boards to investigate fraud in their respective jurisdictions; as well as funding other health care related activity.

- PROHIBIT insurers from raising premiums of policyholders based on estimates of the occurrence of fraud. Require insurers to establish a factual basis for purported losses attributed to fraud coupled with showing tangible proof of their efforts to detect and investigate fraud, as well as not paying fraudulent claims.

5. Insurers are victims of health care fraud

Insurers, as a regular course of business, offer reports on fraud to present themselves as victims of fraud by deviant providers and suppliers.

It is disingenuous for insurers to proclaim victim-status when they have the ability to review claims before they are paid, but choose not to because it would impact the flow of the reimbursement system that is under-staffed. Further, for years, insurers have operated within a culture where fraudulent claims were just a part of the cost of doing business. Then, because they were victims of the putative fraud, they pass these losses on to policyholders in the form of higher premiums (despite the duty and ability to review claims before they are paid). Do your premiums continue to rise?

Insurers make a ton of money, and under the cloak of fraud-fighting, are now keeping more of it by alleging fraud in claims to avoid paying legitimate claims, as well as going after monies paid on claims for services performed many years prior from providers too petrified to fight-back. Additionally, many insurers, believing a lack of responsiveness by law enforcers, file civil suits against providers and entities alleging fraud.

6. Increased investigations and prosecutions of health care fraud

Purportedly, the government (and insurers) have assigned more people to investigate fraud, are conducting more investigations, and are prosecuting more fraud offenders.

With the increase in the numbers of investigators, it is not uncommon for law enforcers assigned to work fraud cases to lack the knowledge and understanding for working these types of cases. It is also not uncommon that law enforcers from multiple agencies expend their investigative efforts and numerous man-hours by working on the same fraud case.

Law enforcers, especially at the federal level, may not actively investigate fraud cases unless they have the tacit approval of a prosecutor. Some law enforcers who do not want to work a case, no matter how good it may be, seek out a prosecutor for a declination on cases presented in the most negative light.

Health Care Regulatory Boards are often not seen as a viable member of the investigative team. Boards regularly investigate complaints of inappropriate conduct by licensees under their purview. The major consistency of these boards are licensed providers, typically in active practice, that have the pulse of what is going on in their state.

Insurers, at the insistence of state insurance regulators, created special investigative units to address suspicious claims to facilitate the payment of legitimate claims. Many insurers have recruited ex-law enforcers who have little or no experience on health care matters and/or nurses with no investigative experience to comprise these units.

Reliance is critical for establishing fraud, and often a major hindrance for law enforcers and prosecutors on moving fraud cases forward. Reliance refers to payors relying on information received from providers to be an accurate representation of what was provided in their determination to pay claims. Fraud issues arise when providers misrepresent material facts in submitted claims, e.g. services not rendered, misrepresenting the service provider, etc.

Increased fraud prosecutions and financial recoveries? In the various (federal) prosecutorial jurisdictions in the United States, there are differing loss- thresholds that must be exceeded before the (illegal) activity will be considered for prosecution, e.g. $200,000.00, $1 million. What does this tell fraudsters - steal up to a certain amount, stop and change jurisdictions?

In the end, the health care fraud shell-game is perfect for fringe care-givers and deviant providers and suppliers who jockey for unfettered-access to health care dollars from a payment system incapable or unwilling to employ necessary mechanisms to appropriately address fraud - on the front-end before the claims are paid! These deviant providers and suppliers know that every claim is not looked at before it is paid, and operate knowing that it is then impossible to detect, investigate and prosecute everyone who is committing fraud!

Lucky for us, there are countless experienced and dedicated professionals working in the trenches to combat fraud that persevere in the face of adversity, making a difference one claim/case at a time! These professionals include, but are not limited to: Providers of all disciplines; Regulatory Boards (Insurance and Health Care); Insurance Company Claims Handlers and Special Investigators; Local, State and Federal Law Enforcers; State and Federal Prosecutors; and others.

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Hiring a Home Health Care Employee

Providing the primary care for an elder loved one can be difficult. When you cannot deliver all the elder care yourself and support from friends, family, and community organizations is not enough, it may be useful to hire a home health care worker. He or she can offer care from a few hours a week to 24 hours a day, and can provide many other helpful services. Types of in-home health care services include:

General Health Management like administration of medication or other medical treatments

Personal care such as bathing, oral hygiene, dressing, and shaving

Nutrition help like preparing meals, assisting eating, and grocery shopping

Homemaking services including laundry, dishwashing, and light housework

Companionship for example reading to the senior or taking them on walks

Recruiting and Interviewing Applicants

There are many avenues for hiring a home health care employee. Generally, home health care workers can be hired directly or through an agency. Home health care agencies often have a staff that includes social workers and nurses that will manage your care. However hiring an independent home health care worker is generally more cost effective, it will also give you more control over the type of care you receive.

Senior home care workers should be carefully screened for proper training, qualifications, and temperament. Fully discuss the needs of the elder care recipient during an interview with a prospective home health care employee. There should be a written copy the job description and the type of experience you are looking for.

References

Have applicants fill out an employment form that includes the following information:

Full name

Address

Phone number

Date of birth

Social Security number

Educational background

Work history

Before hiring, you should ask to see the senior home care worker's licenses and certificates, if applicable, and personal identification including their social security card, driver's license, or photo ID.

References should be checked out thoroughly. Prospective employees should provide the employer with names, dates of employment, and phone numbers of previous employers and how to contact them. It is best to talk directly to previous employers, rather than just to accept letters of recommendations. Also ask the applicant to provide or sign off on conducting a criminal background check

Special Points to Consider

Make sure the person you are considering hiring knows how to carry out the tasks the elder care recipient requires, such as transferring the senior to and from a wheelchair or bed. Training may be available, but make sure the worker completes the training successfully before hiring him or her.

No one should be hired on a seven-day-a-week basis. Even the most dedicated employee will soon burn out. All employees need some time to take care of their personal needs. No worker should be on call 24-hours a day. If the elder care recipient needs frequent supervision or care during the night, a family member or second home health care worker should be able to help out or fill in.

Live-in assistance may seem to be more convenient and economic than hourly or per-day employees but there can be drawbacks. Food and lodging costs must be calculated into the total cost of care, and it could be difficult to dismiss someone without immediate housing alternatives. If you decide to utilize a live-in arrangement, the employee should have his own living quarters, free time, and ample sleep.

Job Expectations and Considerations

Before hiring a senior home health care worker, you should go over the tasks you expect them to perform and other issues, such as promptness, benefits, pay scale, holidays, vacations, absences, and notification time needed for either employer or employee before employment is terminated. If you work and are heavily dependent on the home health care worker, emphasize the importance of being informed as soon as possible if he or she is going to be late or absent so that you can make alternative arrangements. Be clear about notification needed for time off, or what to do in the case the home health care worker experiences a personal emergency that requires them to abruptly leave work. It is important to have a backup list of friends, family, other home care workers, or a home health care agency you can call on.

Be clear about issues concerning salary, payment schedule, and reimbursement or petty cash funds for out of pocket expenses.

You should spend the day with the home health care worker on his first day to make sure you are both in agreement over how to carry out daily tasks. It would also be helpful to supply the home health care worker with a list of information on the elder care recipient such as: special diets, likes, dislikes, mobility problems, health issues, danger signs to monitor, possible behavior problems and accompanying coping strategies, medication schedule, therapeutic exercises, eye glasses, dentures, and any prosthetics.

You should also provide the following information to your home health care worker: your contact information, emergency contacts, security precautions and access to keys, clothing, and locations of washing/cleaning supplies, medical supplies, light bulbs, flashlights, fuse box, and other important household items.

Transportation

Another big consideration in hiring a senior home care worker is how he or she is going to get to work. If they do not have a reliable car or access to public transit, then you might want to consider hiring someone to drive him or her, which might be more economical than using taxis. Inform your insurance company if the home health care worker is going to drive your car when caring for the senior. Your insurance company will perform the necessary driving background checks. If the home health care worker is using his or her car to drive the elder care recipient, then discuss use of her or his car, and conduct a driving background check.

Insurance and Payroll

Check with an insurance company about the proper coverage for a worker in your home.

Make sure all the proper taxes are being drawn from the employee's check by contacting the Internal Revenue Service, state treasury department, social security, and the labor department. If you do not want to deal with the complexities of the payroll withholdings yourself, than you can hire a payroll company for a fee.

Even if your home health care worker is working as a contractor, you are still obligated to report the earnings to the IRS. Talk to your accountant or financial adviser about making sure you are following IRS rules.

Ensuring Security

You should protect your private papers and valuables in a locked file cabinet, safe deposit box, or safe. If you are unable to pick up your mail on a daily basis, have someone you trust do it, or have it sent to a post box. You should check the phone bill for unusual items or unauthorized calls. You should put a block on your phone for 900 numbers, collect calls, and long-distance calls.

Keep checkbooks and credit cards locked up. Review credit card and bank statements on a monthly basis, and periodically request credit reports from credit reporting agencies. Lock up valuable possessions or keep an inventory of items accessible to people working in the house.

You can help to prevent elder abuse to your loved one by:

Make sure the home health care worker thoroughly understands his or her responsibilities, the elder care recipient's medical problems and limitations, and how to cope with stressful situations.

Do not overburden the home health care worker.

Encourage openness over potential problems.

The following are possible signs of elder abuse or neglect:

Personality changes

Crying, whimpering, or refusing to talk

Sloppy appearance

Poor personal hygiene

Disorganized or dirty living conditions

Signs of inappropriate sedation, such as confusion, or excessive sleeping

Mysterious bruises, pressure sores, fractures, or burns

Weight loss

If you suspect abuse, act immediately. Do not wait until the situation turns tragic. Investigate the situation by talking to the elder care recipient in a safe situation, or install monitoring equipment. Examples of abusive behavior include yelling, threatening, or over controlling behavior that could involve isolating the senior from others. If the situation is serious, you should replace the home health care worker as quickly as possible. If you fear the elder care recipient is in danger, he or she should be separated from the home health care worker as soon as possible. Place the elder care recipient with a trusted relative or in a respite care facility. Make sure your loved one is safe before confronting the home health care worker, especially if there is concern about retaliation.

Report the situation to Adult Protective Services after ensuring the safety of the elder care recipient. The police should be contacted in the case of serious neglect, such as sexual abuse, physical injury, or misuse of funds.

Supervising a Home Health Care Worker

The most important thing to remember after hiring a home health care worker is to keep the lines of communication open. You should explain the job responsibilities clearly, and your responsibilities to the home health care worker. Do not forget that the home health care worker is there for the elder care recipient and not the rest of the family. For live-in arrangements, the maximum amount of privacy should be set up for the home health care worker's living quarters. Meetings should be set up on a regular basis to assure that problems are nipped in the bud. If conflicts cannot be resolved after repeated attempts, than it is best to terminate the employee. In such a case, you may have to either place the elder care recipient in a nursing home temporarily or hire a home health care worker through an agency. Reserve funds should be kept on hand in the case of such an emergency.

General Eligibility Requirements for Home Care Benefits

Hiring a home health care worker directly is usually less expensive than hiring through a home health care agency; but if the elder care recipient is eligible and you wish to use assistance from Medicare, you must hire someone through a certified home health care agency. For the senior patient to be eligible, three or more services must be ordered by a physician. Other factors or eligibility are the required need for skilled nursing assistance, or one of the following therapies: physical, speech or occupational. The elder care recipient's medical needs will determine asset and income requirements.

Hiring Home Health Care Workers through Home Health Care Agencies versus Independently

Different health professionals can assess the elder care recipient's needs. A nurse or social worker can help with design and coordination of a home care plan. Your care manager, doctor, or discharge planner can help with services being covered by Medicare. They generally help make the arrangements with a home care agency.

You should ask the home health care agency how they supervise their employees, and what kind of training their employees receive. Find out the procedures for when an employee does not show up. Also ask about the fee schedule and what it covers, there may be a sliding fee schedule. Furthermore, find out if they have a policy for minimum or maximum hours. Ask the agency if there are any limitations on the types of tasks performed.

Especially if you have to pay for the care services yourself, find out if there are any hidden costs such as transportation. If all the costs for hiring a care worker through an agency become too much, you may want to consider hiring directly.

Hiring independent home health care workers is not only more economical than using an agency, but it also allows more direct control over the elder care.

More about → Hiring a Home Health Care Employee

Volunteers Needed

NEEDING VOLUNTEERS - We are seeking people who can volunteer to help me feed / rug and unrug 16 ponies in the mornings and nights. Carol is going in for surgery and I work full time so we need some help. 

Mornings 5am - 7am
Nights 5pm -7pm
MUST BE RELIABLE AND COMMITTED.
ALSO - Volunteers needed to help clean paddocks on the weekends. Teenagers welcome and will exchange help for horse riding :-)
Please call 0405053740 or text if you cant get through. Please note that I work from 8am - 5pm and it can be hard for me the answer my phone.

More about → Volunteers Needed

A Prescription For the Health Care Crisis

With all the shouting going on about America's health care crisis, many are probably finding it difficult to concentrate, much less understand the cause of the problems confronting us. I find myself dismayed at the tone of the discussion (though I understand it---people are scared) as well as bemused that anyone would presume themselves sufficiently qualified to know how to best improve our health care system simply because they've encountered it, when people who've spent entire careers studying it (and I don't mean politicians) aren't sure what to do themselves.

Albert Einstein is reputed to have said that if he had an hour to save the world he'd spend 55 minutes defining the problem and only 5 minutes solving it. Our health care system is far more complex than most who are offering solutions admit or recognize, and unless we focus most of our efforts on defining its problems and thoroughly understanding their causes, any changes we make are just likely to make them worse as they are better.

Though I've worked in the American health care system as a physician since 1992 and have seven year's worth of experience as an administrative director of primary care, I don't consider myself qualified to thoroughly evaluate the viability of most of the suggestions I've heard for improving our health care system. I do think, however, I can at least contribute to the discussion by describing some of its troubles, taking reasonable guesses at their causes, and outlining some general principles that should be applied in attempting to solve them.

THE PROBLEM OF COST

No one disputes that health care spending in the U.S. has been rising dramatically. According to the Centers for Medicare and Medicaid Services (CMS), health care spending is projected to reach $8,160 per person per year by the end of 2009 compared to the $356 per person per year it was in 1970. This increase occurred roughly 2.4% faster than the increase in GDP over the same period. Though GDP varies from year-to-year and is therefore an imperfect way to assess a rise in health care costs in comparison to other expenditures from one year to the next, we can still conclude from this data that over the last 40 years the percentage of our national income (personal, business, and governmental) we've spent on health care has been rising.

Despite what most assume, this may or may not be bad. It all depends on two things: the reasons why spending on health care has been increasing relative to our GDP and how much value we've been getting for each dollar we spend.

WHY HAS HEALTH CARE BECOME SO COSTLY?

This is a harder question to answer than many would believe. The rise in the cost of health care (on average 8.1% per year from 1970 to 2009, calculated from the data above) has exceeded the rise in inflation (4.4% on average over that same period), so we can't attribute the increased cost to inflation alone. Health care expenditures are known to be closely associated with a country's GDP (the wealthier the nation, the more it spends on health care), yet even in this the United States remains an outlier (figure 3).

Is it because of spending on health care for people over the age of 75 (five times what we spend on people between the ages of 25 and 34)? In a word, no. Studies show this demographic trend explains only a small percentage of health expenditure growth.

Is it because of monstrous profits the health insurance companies are raking in? Probably not. It's admittedly difficult to know for certain as not all insurance companies are publicly traded and therefore have balance sheets available for public review. But Aetna, one of the largest publicly traded health insurance companies in North America, reported a 2009 second quarter profit of $346.7 million, which, if projected out, predicts a yearly profit of around $1.3 billion from the approximately 19 million people they insure. If we assume their profit margin is average for their industry (even if untrue, it's unlikely to be orders of magnitude different from the average), the total profit for all private health insurance companies in America, which insured 202 million people (2nd bullet point) in 2007, would come to approximately $13 billion per year. Total health care expenditures in 2007 were $2.2 trillion (see Table 1, page 3), which yields a private health care industry profit approximately 0.6% of total health care costs (though this analysis mixes data from different years, it can perhaps be permitted as the numbers aren't likely different by any order of magnitude).

Is it because of health care fraud? Estimates of losses due to fraud range as high as 10% of all health care expenditures, but it's hard to find hard data to back this up. Though some percentage of fraud almost certainly goes undetected, perhaps the best way to estimate how much money is lost due to fraud is by looking at how much the government actually recovers. In 2006, this was $2.2 billion, only 0.1% of $2.1 trillion (see Table 1, page 3) in total health care expenditures for that year.

Is it due to pharmaceutical costs? In 2006, total expenditures on prescription drugs was approximately $216 billion (see Table 2, page 4). Though this amounted to 10% of the $2.1 trillion (see Table 1, page 3) in total health care expenditures for that year and must therefore be considered significant, it still remains only a small percentage of total health care costs.

Is it from administrative costs? In 1999, total administrative costs were estimated to be $294 billion, a full 25% of the $1.2 trillion (Table 1) in total health care expenditures that year. This was a significant percentage in 1999 and it's hard to imagine it's shrunk to any significant degree since then.

In the end, though, what probably has contributed the greatest amount to the increase in health care spending in the U.S. are two things:

1. Technological innovation.

2. Overutilization of health care resources by both patients and health care providers themselves.

Technological innovation. Data that proves increasing health care costs are due mostly to technological innovation is surprisingly difficult to obtain, but estimates of the contribution to the rise in health care costs due to technological innovation range anywhere from 40% to 65% (Table 2, page 8). Though we mostly only have empirical data for this, several examples illustrate the principle. Heart attacks used to be treated with aspirin and prayer. Now they're treated with drugs to control shock, pulmonary edema, and arrhythmias as well as thrombolytic therapy, cardiac catheterization with angioplasty or stenting, and coronary artery bypass grafting. You don't have to be an economist to figure out which scenario ends up being more expensive. We may learn to perform these same procedures more cheaply over time (the same way we've figured out how to make computers cheaper) but as the cost per procedure decreases, the total amount spent on each procedure goes up because the number of procedures performed goes up. Laparoscopic cholecystectomy is 25% less than the price of an open cholecystectomy, but the rates of both have increased by 60%. As technological advances become more widely available they become more widely used, and one thing we're great at doing in the United States is making technology available.

Overutilization of health care resources by both patients and health care providers themselves. We can easily define overutilization as the unnecessary consumption of health care resources. What's not so easy is recognizing it. Every year from October through February the majority of patients who come into the Urgent Care Clinic at my hospital are, in my view, doing so unnecessarily. What are they coming in for? Colds. I can offer support, reassurance that nothing is seriously wrong, and advice about over-the-counter remedies---but none of these things will make them better faster (though I often am able to reduce their level of concern). Further, patients have a hard time believing the key to arriving at a correct diagnosis lies in history gathering and careful physical examination rather than technologically-based testing (not that the latter isn't important---just less so than most patients believe). Just how much patient-driven overutilization costs the health care system is hard to pin down as we have mostly only anecdotal evidence as above.

Further, doctors often disagree among themselves about what constitutes unnecessary health care consumption. In his excellent article, "The Cost Conundrum," Atul Gawande argues that regional variation in overutilization of health care resources by doctors best accounts for the regional variation in Medicare spending per person. He goes on to argue that if doctors could be motivated to rein in their overutilization in high-cost areas of the country, it would save Medicare enough money to keep it solvent for 50 years.

A reasonable approach. To get that to happen, however, we need to understand why doctors are overutilizing health care resources in the first place:

1. Judgment varies in cases where the medical literature is vague or unhelpful. When faced with diagnostic dilemmas or diseases for which standard treatments haven't been established, a variation in practice invariably occurs. If a primary care doctor suspects her patient has an ulcer, does she treat herself empirically or refer to a gastroenterologist for an endoscopy? If certain "red flag" symptoms are present, most doctors would refer. If not, some would and some wouldn't depending on their training and the intangible exercise of judgment.

2. Inexperience or poor judgment. More experienced physicians tend to rely on histories and physicals more than less experienced physicians and consequently order fewer and less expensive tests. Studies suggest primary care physicians spend less money on tests and procedures than their sub-specialty colleagues but obtain similar and sometimes even better outcomes.

3. Fear of being sued. This is especially common in Emergency Room settings, but extends to almost every area of medicine.

4. Patients tend to demand more testing rather than less. As noted above. And physicians often have difficulty refusing patient requests for many reasons (eg, wanting to please them, fear of missing a diagnosis and being sued, etc).

5. In many settings, overutilization makes doctors more money. There exists no reliable incentive for doctors to limit their spending unless their pay is capitated or they're receiving a straight salary.

Gawande's article implies there exists some level of utilization of health care resources that's optimal: use too little and you get mistakes and missed diagnoses; use too much and excess money gets spent without improving outcomes, paradoxically sometimes resulting in outcomes that are actually worse (likely as a result of complications from all the extra testing and treatments).

How then can we get doctors to employ uniformly good judgment to order the right number of tests and treatments for each patient---the "sweet spot"---in order to yield the best outcomes with the lowest risk of complications? Not easily. There is, fortunately or unfortunately, an art to good health care resource utilization. Some doctors are more gifted at it than others. Some are more diligent about keeping current. Some care more about their patients. An explosion of studies of medical tests and treatments has occurred in the last several decades to help guide doctors in choosing the most effective, safest, and even cheapest ways to practice medicine, but the diffusion of this evidence-based medicine is a tricky business. Just because beta blockers, for example, have been shown to improve survival after heart attacks doesn't mean every physician knows it or provides them. Data clearly show many don't. How information spreads from the medical literature into medical practice is a subject worthy of an entire post unto itself. Getting it to happen uniformly has proven extremely difficult.

In summary, then, most of the increase in spending on health care seems to have come from technological innovation coupled with its overuse by doctors working in systems that motivate them to practice more medicine rather than better medicine, as well as patients who demand the former thinking it yields the latter.

But even if we could snap our fingers and magically eliminate all overutilization today, health care in the U.S. would still remain among the most expensive in the world, requiring us to ask next---

WHAT VALUE ARE WE GETTING FOR THE DOLLARS WE SPEND?

According to an article in the New England Journal of Medicine titled The Burden of Health Care Costs for Working Families---Implications for Reform, growth in health care spending "can be defined as affordable as long as the rising percentage of income devoted to health care does not reduce standards of living. When absolute increases in income cannot keep up with absolute increases in health care spending, health care growth can be paid for only by sacrificing consumption of goods and services not related to health care." When would this ever be an acceptable state of affairs? Only when the incremental cost of health care buys equal or greater incremental value. If, for example, you were told that in the near future you'd be spending 60% of your income on health care but that as a result you'd enjoy, say, a 30% chance of living to the age of 250, perhaps you'd judge that 60% a small price to pay.

This, it seems to me, is what the debate on health care spending really needs to be about. Certainly we should work on ways to eliminate overutilization. But the real question isn't what absolute amount of money is too much to spend on health care. The real question is what are we getting for the money we spend and is it worth what we have to give up?

People alarmed by the notion that as health care costs increase policymakers may decide to ration health care don't realize that we're already rationing at least some of it. It just doesn't appear as if we are because we're rationing it on a first-come-first-serve basis---leaving it at least partially up to chance rather than to policy, which we're uncomfortable defining and enforcing. Thus we don't realize the reason our 90 year-old father in Illinois can't have the liver he needs is because a 14 year-old girl in Alaska got in line first (or maybe our father was in line first and gets it while the 14 year-old girl doesn't). Given that most of us remain uncomfortable with the notion of rationing health care based on criteria like age or utility to society, as technological innovation continues to drive up health care spending, we very well may at some point have to make critical judgments about which medical innovations are worth our entire society sacrificing access to other goods and services (unless we're so foolish as to repeat the critical mistake of believing we can keep borrowing money forever without ever having to pay it back).

So what value are we getting? It varies. The risk of dying from a heart attack has declined by 66% since 1950 as a result of technological innovation. Because cardiovascular disease ranks as the number one cause of death in the U.S. this would seem to rank high on the scale of value as it benefits a huge proportion of the population in an important way. As a result of advances in pharmacology, we can now treat depression, anxiety, and even psychosis far better than anyone could have imagined even as recently as the mid-1980's (when Prozac was first released). Clearly, then, some increases in health care costs have yielded enormous value we wouldn't want to give up.

But how do we decide whether we're getting good value from new innovations? Scientific studies must prove the innovation (whether a new test or treatment) actually provides clinically significant benefit (Aricept is a good example of a drug that works but doesn't provide great clinical benefit---demented patients score higher on tests of cognitive ability while on it but probably aren't significantly more functional or significantly better able to remember their children compared to when they're not). But comparative effectiveness studies are extremely costly, take a long time to complete, and can never be perfectly applied to every individual patient, all of which means some health care provider always has to apply good medical judgment to every patient problem.

Who's best positioned to judge the value to society of the benefit of an innovation---that is, to decide if an innovation's benefit justifies its cost? I would argue the group that ultimately pays for it: the American public. How the public's views could be reconciled and then effectively communicated to policy makers efficiently enough to affect actual policy, however, lies far beyond the scope of this post (and perhaps anyone's imagination).

THE PROBLEM OF ACCESS

A significant proportion of the population is uninsured or underinsured, limiting or eliminating their access to health care. As a result, this group finds the path of least (and cheapest) resistance---emergency rooms---which has significantly impaired the ability of our nation's ER physicians to actually render timely emergency care. In addition, surveys suggest a looming primary care physician shortage relative to the demand for their services. In my view, this imbalance between supply and demand explains most of the poor customer service patients face in our system every day: long wait times for doctors' appointments, long wait times in doctors' offices once their appointment day arrives, then short times spent with doctors inside exam rooms, followed by difficulty reaching their doctors in between office visits, and finally delays in getting test results. This imbalance would likely only partially be alleviated by less health care overutilization by patients.

GUIDELINES FOR SOLUTIONS

As Freaknomics authors Steven Levitt and Stephen Dubner state, "If morality represents how people would like the world to work, then economics represents how it actually does work." Capitalism is based on the principle of enlightened self-interest, a system that creates incentives to yield behavior that benefits both suppliers and consumers and thus society as a whole. But when incentives get out of whack, people begin to behave in ways that continue to benefit them often at the expense of others or even at their own expense down the road. Whatever changes we make to our health care system (and there's always more than one way to skin a cat), we must be sure to align incentives so that the behavior that results in each part of the system contributes to its sustainability rather than its ruin.

Here then is a summary of what I consider the best recommendations I've come across to address the problems I've outlined above:

1. Change the way insurance companies think about doing business. Insurance companies have the same goal as all other businesses: maximize profits. And if a health insurance company is publicly traded and in your 401k portfolio, you want them to maximize profits, too. Unfortunately, the best way for them to do this is to deny their services to the very customers who pay for them. It's harder for them to spread risk (the function of any insurance company) relative to say, a car insurance company, because far more people make health insurance claims than car insurance claims. It would seem, therefore, from a consumer perspective, the private health insurance model is fundamentally flawed. We need to create a disincentive for health insurance companies to deny claims (or, conversely, an extra incentive for them to pay them). Allowing and encouraging aross-state insurance competition would at least partially engage free market forces to drive down insurance premiums as well as open up new markets to local insurance companies, benefiting both insurance consumers and providers. With their customers now armed with the all-important power to go elsewhere, health insurance companies might come to view the quality with which they actually provide service to their customers (ie, the paying out of claims) as a way to retain and grow their business. For this to work, monopolies or near-monopolies must be disbanded or at the very least discouraged. Even if it does work, however, government will probably still have to tighten regulation of the health insurance industry to ensure some of the heinous abuses that are going on now stop (for example, insurance companies shouldn't be allowed to stratify consumers into sub-groups based on age and increase premiums based on an older group's higher average risk of illness because healthy older consumers then end up being penalized for their age rather than their behaviors). Karl Denninger suggests some intriguing ideas in a post on his blog about requiring insurance companies to offer identical rates to businesses and individuals as well as creating a mandatory "open enrollment" period in which participants could only opt in or out of a plan on a yearly basis. This would prevent individuals from only buying insurance when they got sick, eliminating the adverse selection problem that's driven insurance companies to deny payment for pre-existing conditions. I would add that, however reimbursement rates to health care providers are determined in the future (again, an entire post unto itself), all health insurance plans, whether private or public, must reimburse health care providers by an equal percentage to eliminate the existence of "good" and "bad" insurance that's currently responsible for motivating hospitals and doctors to limit or even deny service to the poor and which may be responsible for the same thing occurring to the elderly in the future (Medicare reimburses only slightly better than Medicaid). Finally, regarding the idea of a "public option" insurance plan open to all, I worry that if it's significantly cheaper than private options while providing near-equal benefits the entire country will rush to it en masse, driving private insurance companies out of business and forcing us all to subsidize one another's health care with higher taxes and fewer choices; yet at the same time if the cost to the consumer of a "public option" remains comparable to private options, the very people it's meant to help won't be able to afford it.

2. Motivate the population to engage in healthier lifestyles that have been proven to prevent disease. Prevention of disease probably saves money, though some have argued that living longer increases the likelihood of developing diseases that wouldn't have otherwise occurred, leading to the overall consumption of more health care dollars (though even if that's true, those extra years of life would be judged by most valuable enough to justify the extra cost. After all, the whole purpose of health care is to improve the quality and quantity of life, not save society money. Let's not put the cart before the horse). However, the idea of preventing a potentially bad outcome sometime in the future is only weakly motivating psychologically, explaining why so many people have so much trouble getting themselves to exercise, eat right, lose weight, stop smoking, etc. The idea of financially rewarding desirable behavior and/or financially punishing undesirable behavior is highly controversial. Though I worry this kind of strategy risks the enacting of policies that may impinge on basic freedoms if taken too far, I'm not against thinking creatively about how we could leverage stronger motivational forces to help people achieve health goals they themselves want to achieve. After all, most obese people want to lose weight. Most smokers want to quit. They might be more successful if they could find more powerful motivation.

3. Decrease overutilization of health care resources by doctors. I'm in agreement with Gawande that finding ways to get doctors to stop overutilizing health care resources is a worthy goal that will significantly rein in costs, that it will require a willingness to experiment, and that it will take time. Further, I agree that focusing only on who pays for our health care (whether the public or private sectors) will fail to address the issue adequately. But how exactly can we motivate doctors, whose pens are responsible for most of the money spent on health care in this country, to focus on what's truly best for their patients? The idea that external bodies---whether insurance companies or government panels---could be used to set standards of care doctors must follow in order to control costs strikes me as ludicrous. Such bodies have neither the training nor overriding concern for patients' welfare to be trusted to make those judgments. Why else do we have doctors if not to employ their expertise to apply nuanced approaches to complex situations? As long as they work in a system free of incentives that compete with their duty to their patients, they remain in the best position to make decisions about what tests and treatments are worth a given patient's consideration, as long as they're careful to avoid overconfident paternalism (refusing to obtain a head CT for a headache might be overconfidently paternalistic; refusing to offer chemotherapy for a cold isn't). So perhaps we should eliminate any financial incentive doctors have to care about anything but their patients' welfare, meaning doctors' salaries should be disconnected from the number of surgeries they perform and the number of tests they order, and should instead be set by market forces. This model already exists in academic health care centers and hasn't seemed to promote shoddy care when doctors feel they're being paid fairly. Doctors need to earn a good living to compensate for the years of training and massive amounts of debt they amass, but no financial incentive for practicing more medicine should be allowed to attach itself to that good living.

4. Decrease overutilization of health care resources by patients. This, it seems to me, requires at least three interventions:

* Making available the right resources for the right problems (so that patients aren't going to the ER for colds, for example, but rather to their primary care physicians). This would require hitting the "sweet spot" with respect to the number of primary care physicians, best at front-line gatekeeping, not of health care spending as in the old HMO model, but of triage and treatment. It would also require a recalculating of reimbursement levels for primary care services relative to specialty services to encourage more medical students to go into primary care (the reverse of the alarming trend we've been seeing for the last decade).

* A massive effort to increase the health literacy of the general public to improve its ability to triage its own complaints (so patients don't actually go anywhere for colds or demand MRIs of their backs when their trusted physicians tells them it's just a strain). This might be best accomplished through a series of educational programs (though given that no one in the private sector has an incentive to fund such programs, it might actually be one of the few things the government should---we'd just need to study and compare different educational programs and methods to see which, if any, reduce unnecessary patient utilization without worsening outcomes and result in more health care savings than they cost).

* Redesigning insurance plans to make patients in some way more financially liable for their health care choices. We can't have people going bankrupt due to illness, nor do we want people to underutilize health care resources (avoiding the ER when they have chest pain, for example), but neither can we continue to support a system in which patients are actually motivated to overutilize resources, as the current "pre-pay for everything" model does.

CONCLUSION

Given the enormous complexity of the health care system, no single post could possibly address every problem that needs to be fixed. Significant issues not raised in this article include the challenges associated with rising drug costs, direct-to-consumer marketing of drugs, end-of-life care, sky-rocketing malpractice insurance costs, the lack of cost transparency that enables hospitals to paradoxically charge the uninsured more than the insured for the same care, extending health care insurance coverage to those who still don't have it, improving administrative efficiency to reduce costs, the implementation of electronic medical records to reduce medical error, the financial burden of businesses being required to provide their employees with health insurance, and tort reform. All are profoundly interdependent, standing together like the proverbial house of cards. To attend to any one is to affect them all, which is why rushing through health care reform without careful contemplation risks unintended and potentially devastating consequences. Change does need to come, but if we don't allow ourselves time to think through the problems clearly and cleverly and to implement solutions in a measured fashion, we risk bringing down that house of cards rather than cementing it.

More about → A Prescription For the Health Care Crisis

Google Health

Online Health Management Technologies

Google Health

There are a number of online tools available to help you keep track of your health records. Google offers a great one in its arsenal of online applications. It is called Google Health and offers a number of applications for users interested in keeping online records of their health.

Google Health

Google Health

The interface here looks strikingly similar to the popular gmail. Signing up for a free account here is quite similar as well. A left-hand talk bar is the place to begin entering your information and customizing this tool to your needs. There are a number of items to input, such as: gender, ethnicity, blood type, age, etc. An extensive list of medical conditions and symptoms follows this. You can search through an alphabetical list or begin typing a condition and Google Health will make suggestions as you go. The same goes for medications, allergies, medical procedures, test results, and immunizations.

Google Health

Google Health

Google Health

Various health organizations can be linked to the profile created here. These include, hospitals, pharmacies, and medical associations. By linking, medical records can be imported. For example, you can link with your local pharmacy to get all prescription information imported to the Google Health profile.

Google Health

Google Health

Google Health

There is also an application to help find health services on the Internet. Various services can be found and can be linked to the profile much like the medical associations previously mentioned. The Cleveland Clinic offers a "MyConsult" service that can be linked to the profile. This enables a person to send their personal information to the physicians at the Clinic for second opinions, treatment options, and more. This service comes at a premium, however there are options for more budget-conscious users as well. DestinationRx offers options on "lower-cost alternative medication options" according to Google Health. This is an excellent tool for those having trouble affording prescription drug costs.

Google Health

Google Health

Google Health

Searches for medical professionals can be done from this site as well. This works similar to the ubiquitous Google search engine. The user is prompted to input keywords about the professional they are looking for and have the option to select a specialty such as bariatric surgery or family practice. A list is populated with the results with a name, address, phone number, and website when available. Results that prove useful can be saved for future reference. Not sure where one of the doctors you found are located? Google Health makes it easy to figure this out when a map is just a click away.

Google Health

Google Health

This online application has a number of interesting effects. Of course, safety and security of your personal information is tantamount. Google treats user information here the same as with any other of the services it provides which collect information. It takes care to ensure the safety and integrity of personal information.

Google Health

Google Health

Having medical information online has a number of benefits. Digital records can be stored conveniently and without taking up any physical space with everything in one location. A search bar makes finding the documents you're looking for quick. There is also the convenience of having your personal information available to you whenever the Internet is. This can be extremely handy if you have to travel for medical care and you need access to your medical records. Medical tourists may find this very useful as well. International health care providers cannot freely access the medical records of Americans thanks to legislation such as HIPAA. A medical tourist can use Google Health to get access to all of their medical records while abroad.

Google Health

Google Health

There is a survey to take for sending feedback to Google for continued satisfaction. This is a clear delineation of the dedication to providing quality products. It consists of a few questions about the survey taker, how they use Google Health, and if there are any suggestions to offer.

Google Health

Google has successfully integrated yet another tool to its Internet spanning array of applications. Google Health is highly intuitive and helpful to anyone interested in managing health records online. This tool empowers patients to do some research on their own and put their health in their own hands. Google utilizes not only its own resources, Google maps and the popular search engine, but has created partnerships with many other health care providers and information services. All of these resources come together to allow patients to get a little more help with what they're concerned with: their health.

Google Health

More about → Google Health