To limit future pandemics, U.S. must move beyond the medical insurance industry
Our health-care system has struggled to respond to the coronavirus crisis. A population health approach linking public health with health-care providers could better coordinate a range of services, from identification to management of sick patients, and instill the confidence we need in the health care we receive.
This week I received a call from a mother concerned about her child’s fever and vomiting. I went through my standard questions and responses, then braced for the followup questions. Is this coronavirus? Can I take her to be tested? At the time, I couldn’t answer more specifically than to recommend to keep her child at home, avoid sharing utensils, contact their clinician if symptoms persist or go to the emergency room if worse, and call the health department regarding testing.
I don’t know what happened with this child, who likely had a viral infection unrelated to coronavirus, but I can predict what happened if she contacted her doctor, went to the emergency room, or called her health department. Her doctor is scrambling to keep up with changing messages for physicians regarding testing that is further complicated by different standards from state and federal agencies regarding protective gear staff must wear, and the availability of the protective gear itself.
Emergency rooms have access to a broader array of resources, but face all of the same issues as well as questions, such as, do you first screen for other viral infections such as influenza? When patients contact the health department they will likely be directed back to their doctor to determine next steps, or to a lab for testing.
Commercial labs will be happy to process your coronavirus tests, but they won’t collect the specimens themselves. Obtaining a specimen for a coronavirus test requires a nasopharyngeal swab which induces intense coughing and sneezing that sprays droplets potentially containing virus, so individuals collecting samples must be properly trained. Some hospitals and emergency rooms have stepped up with drive-through testing manned with personnel in the proper protective gear, but coordination with doctor offices is still challenging.
As doctor offices, public health departments, and emergency rooms point to each other, one major player in health care is conspicuously absent — the health-care companies we pay astronomic amounts to insure our health care. As a physician who is part of a managed care program providing services to Medicaid and Medicare patients, I am not surprised. Health insurers contract out health-care services while retaining up to 15% of all insurance premiums for what is called the “medical loss ratio” — in short, your health-care costs are the insurers medical loss. If you ask providers who actually give health care whether health insurers help in caring for patients, the vast majority are likely to respond with a wry smile, or worse.
Despite not contributing value to our health-care system, insurers are embedding themselves deeper and deeper into our health-care system, most notably by siphoning off more and more Medicare patients into Medicare Advantage plans. Even in California, we are in the process of turning over critical coordination functions that touch on key services provided by government and community agencies, to health insurers. The California Advancing and Innovating Medi-Cal program, or CalAIM, has the very laudable goal of targeting social determinants of health and reduce health disparities and inequities. Managed care companies will be the recipients of billions of dollars to lead the effort to organize these critical services in each county, even though there are multiple managed care companies competing for patients. Inefficiency and duplication is inevitable.
Our money would be better spent investing in our underfunded and unappreciated public health system. We should expect in return a strong, sustainable infrastructure that bridges the divide between public health and individual health care services. This will support coordination between medical offices and community and government agencies when social determinants are identified. Linking public health and individual health services could also optimize wellness and health maintenance activities, as well as be a conduit for information and coordination of health care services in crises such as we face today.
Instead of the mixed messages we hear now, imagine if the public health system was able to offer lab testing coupled with contact tracing, in locations safe for patients and the workers collecting samples and caring for the patients. This would free up health care providers to do what they do best, focus on caring for those patients who are sick.
The coronavirus issues we face today will be different from the grimmer challenges we will face tomorrow. Reinforcing public health and linking it to health care providers and to the community and governmental agencies that address the social determinants of health will pay dividends long after we have survived the coronavirus crisis.
John Zweifler is a Fresno family doctor with decades of experience in medical director roles, patient care, medical education, and managed care. He is the author of two e-books, “Tipping Health Care in the Right Direction” and “Pop Health.”