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March 13, 2014 at 8:00 AMComments: 0 Faves: 0

Population Health Care: Two Sides of the Story

By Jeffrey VanWingen M.D. More Blogs by This Author

This time of year means different things to different people. Some throng to McDonalds for a shamrock shake. Some start filling out their March Madness brackets and prepare for a steady diet of basketball. Some head to the southern beaches for spring break. In my office, it means that we will be inundated with insurance forms that need personal data - hopefully within a prescribed set of guidelines.

If you are one of the many Americans who need to collect this medical data from your doctor, you may question the logic in this process. It seems that the medical community and the insurance companies stand at odds when it comes to these forms, but let's look at both sides of the story.

Treating Populations

Insurance companies, by and large, are businesses. These businesses leave as little to chance as possible and their highly paid mathematicians called actuaries make sure of this. Actuaries look at any trend and statistic they can get their hands on to help set rates and project the healthcare expenses the insurance company they're working for will need to pay.  It's really quite simple after this - project how much a certain population will cost in healthcare dollars, factor in the cost of running the company and then add some for profit.  Here are some examples:

  • Mayo clinic researchers found that obese expend on average $1850 per year on healthcare than normal weight counterparts.
  • According to the National Institute of Health, smokers expend on average $1275 per year on healthcare than nonsmokers.
  • The Center for Disease Control recommends screening for chlamydia (a sexually transmitted illness) for all women aged 15-25 even if not engaging in high-risk sexual behavior.

Putting People into Boxes

Based on general guidelines, many health insurance guidelines set bars for physicians to get their customers to conform. Both financial incentives and penalties are put in place for doctors and clients to accomplish their two fold goals.

First, according to the statistics, getting better statistics will likely mean less cost. For instance, getting more customers to quit smoking will save them money and charging smokers more for their insurance will cover projected costs. Second, better conforming to standards gives the insurance company a better HEDIS score.

Healthcare Effectiveness Data and Information Set and is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service.  Put simply, better scores are used for bragging rights and marketing to prospective customers.  So, basically, this type of "health herding" is commonplace and used extensively (and successfully) to improve the bottom line for insurance companies. Theoretically,  it should also improve the health of their clients.

Don't Box Me In!

Of course, this type of practice also has plenty of critics. Telling an American how to live their life with threats of financial penalties is a sure way to make an enemy and doctors don't like being told how practice.

Personally, knowing there is always an exception to every rule, I take issue with this type of healthcare for the fact that it leaves very little room concession or flexibility. It also leaves many in healthcare questioning who they work for - patient or insurance company. In other words, it strains the doctor-patient relationship. So, as a doctor, I tend to dread this time of year, meeting with patients and filling out these forms.

Though I do see how it stimulates a discussion and perhaps some action on a serious health factor, it's tough telling a patient that their body mass index is high and they will be forced to choose between enrolling in a insurance sponsored weight loss program or pay more for their insurance. Testing patient's blood for nicotine because their insurance company doesn't take their word for it is likewise difficult, though it does flush out those using tobacco and may tip the scales to helping them break free of the nasty habit. And it's difficult explaining that even though my 15 year old patient has never had sex, I am still urged by guidelines from the government and health insurance company to screen for chlamydia.  But for that one patient with no symptoms who tests positive, fertility may be preserved and further spread of the disease can easily be contained.  There are two sides to the issue.

My Take:

Population medicine prescribed by insurance companies is commonplace and seems to be gaining ground. Bucking this system can increase personal costs for insurance. Though it strains the relationship between doctors and their patients the inconvenience is relatively minor.  Plus, underneath all the fuss, benefits may exist not only for the herd but for us as individuals. 

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