Tuesday, August 13, 2013

Obamacare and the Kaiser Method - The Future of Healthcare

It is a rarely discussed secret, known the doctors, that most medical problems resolve by themselves. In otherwise healthy patients, most medical complaints are self limited, and improve with time with or without intervention. Colds, flu, back pain, headaches, fevers, abdominal pain, and muscle pain usually resolve on their own. Blood tests, X-rays, scans, physical examination, and any treatment given often make no difference at all in the course of the problem.

This simple formula has spawned the entire HMO industry, perfected by Kaiser healthcare. If patients are forced to wait by delaying being evaluated and treated, their symptoms will resolve spontaneously. When I was a radiology resident at Stanford, there was a two week waiting list to get an Upper GI study for abdominal pain. By the time the appointment came around, up to half of the patients canceled their appointments because their symptoms were gone, and another third no longer had symptoms, but came anyway "to make sure". We rarely found anything.

Hence roadblocks to care are very effective in reducing the amount and costs of medical care. Patients get better or simply give up. Kaiser perfected this concept, and used it to dramatically cut the cost of healthcare to its clients, while pretending to use "preventive" care and "efficiency" realize their cost savings. Other HMO's have attempted, with varying degrees of success, to duplicate this strategy.

Techniques such as not answering the phone, delaying appointments, seeing nurse practitioners prior to physician visits, and making specialists hard to see, effectively filter out the self limited problems which frequently fill the schedules of many physicians.

The problem with this method is that it only works on healthy populations. If you include the truly sick, the old, preexisting conditions, the diabetic, or the chronically ill, such delays result in bad outcomes and real problems for the patients and the healthcare system. Kaiser realized this early on, and has successfully marketed to the younger, healthy populations(mainly by offering inexpensive maternity benefits). HMO's that didn't effectively screen out the bad risk patients did not fare as well. It is a joke we used to tell that Kaiser is great healthcare insurance, until you get sick.

So what does this have to do with Obamacare? Obamacare makes its assumptions based upon the Kaiser model, pretending that utilization rates and outcomes can be extrapolated to much sicker cohorts of patients. When these older, sicker, and previously excluded patients are thrown into the medical system, all bets are off. The direct result will be long delays obtaining any kind of care, with people being sicker by the time they receive care.

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