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By Robert B. Teague, MD

August 31, 2005

Between struggling to grasp the significance of Hurricane Katrina and feeling very sad looking at the pictures of a destroyed New Orleans and the suffering inflicted upon her people, I spotted something else.

It was like spotting a lion downwind from a herd of wildebeests. Nose in the air and visualizing the next meal. I'm thinking there must be an election coming soon. USA Today gave almost the same amount of coverage to healthcare as to the hurricane. So what's up?

Since USA Today is known for its sound-bite-sized articles, this is a relatively massive report describing the results of a nationwide survey of adults performed by the paper, the Kaiser Family Foundation, and the Harvard School of Public Health. The thrust was that a significant number of people have difficulty affording healthcare both with and without employer sponsored insurance.

Individual stories, also featured, can be heart rending to be sure. The findings were grouped into six types. About 46% of Americans are either healthy or classified as willing and able to pay and say they don't have a problem. Another 11% have significant health problems but also do not have difficulty affording their care. The rest of the groups have high prevalence of chronic disease and difficulty affording care. As one might expect, the lowest income group has the highest prevalence of chronic disease burden.

One of the findings that was revisited several times in the article was that many people in the marginal groups who have a high prevalence of chronic illnesses also skip treatments or recommended tests or visits to a physician.

The article seems to imply that this behavior invariably results in a negative or worse outcome than if the person had been able to comply with recommendations. Of course, in a survey like this there is no way to know if skipping recommended testing or therapy from a physician resulted in better, worse, or the same outcome as if the recommendations had been followed. There is an assumption, largely challengeable, that physicians give recommendations that invariably result in good outcomes.

The fact is that even in managing chronic illnesses with so-called evidence based guidelines, inappropriate care is still rendered to large numbers of patients. Errors occur both ways. Either appropriate and helpful care is omitted or recommended care may be given in inappropriate circumstances.

Near the end of the article the reporter does touch on the problem of controlled capacity and thus limitation of access. But they never do stumble upon wage and price controls as a cause of unattainable pricing for healthcare. The government has worked for decades with professional and trade groups to control the capacity of the healthcare finance and delivery systems. This approach has also brought us the indirect system of finance.

A patient visiting a physician thinks that they are the physician's customer. Well, sort of they are. The whole truth is more complex. If they were truly the physician's customer, at the end of the visit they would pay for the service. And before agreeing to partake of the service they might discuss the service level and the price and actually make an affirmative decision to proceed or not. This seldom happens. There is almost always at least one third party in the transaction.

The healthcare system can never be fixed until the service transaction and the financial transaction occur between the same two people.

Preventing movement toward the implementation of this axiom is a pervasive view, promulgated by those same government agencies and professional and trade groups, that people are just not smart enough to manage their own health. Third parties and central planning and control are necessary. I reject this view out of hand.

A part of the answer is to unbundle the delivery of healthcare from the financing of healthcare. Put the products of financing of healthcare into the hands of individuals. The government could and should play a constructive role here, just as they did at one time in the mortgage financing system leading to the highest home ownership rate in history. But they should allow individuals to make direct arrangements both for the service and the payment. Health Savings Accounts also are a step in supporting this critical function.

A second part of the answer is the increasing availability of intelligent support tools that allow individuals who have access to their personal health information to make informed judgments about what they want for their own healthcare.

The truth is no one else cares as much about your health as you do. So manage it. Everyone else, get out of the way, especially the lions with their noses raised in expectation.

Robert B. Teague is a pulmonologist and business consultant who is based in Houston, Texas. E-mail him.

Read other blogs in this series.