Health Care Community Discussion Group 12/29/08

Cafe Spinoza – Virtual World of Second Life

This report contains the questions provided by the transition team with summary conclusions based on the discussion held on 12/29/08 in Second Life. The pages immediately following the questions contain the text chat available from that discussion. Participant introductions and personal stories can be found in that section. Audio files with related video shot on machinima will be available on January 9, 2009.

1. What does the group perceive as the biggest problem in the
health care system?

Equitable access to quality care is perceived to be the overriding problem with the current system. Access is hindered by a variety of factors such as poverty, chronic disability and loss of employment in a system with no built in portability of insurance.
Escalating costs of care for both the insured and uninsured leave people with little choice but to sacrifice other family needs or in absence of resources, foregoing not just preventative care but acutely needed care.

The discussion turned to the current system of employer based health insurance coverage. Costs to the employer, passed on to the employee are escalating at an alarming rate and some perceive consideration of costs to be a factor in hiring and retention decisions when dealing with employees who may have health related issues or have a family member that requires expensive care. There is concern over the pressure exerted by insurance companies via escalated premiums that the system is inherently set up to cherry pick only the healthy for coverage leaving the rest relegated to inadequate or non-existent access to quality care. The issue of cost escalation passed on to health care consumers by doctors due to their expenditures on malpractice insurance was also raised as a contributing factor to prohibitive costs.

The current system is set up to incentivize care restrictions. As long as the focus remains on increased profitability, insurance companies will continue to implement policies which restrict or deny care to those that need it most. Health care as a profit based industry run by insurance companies rather than health care providers does not seem to be a system that is viable if the goal is to provide equitable access to quality care.

As aptly stated by Kara Timtam and agreed to by many attendees; "Who let the bean counters practice medicine anyway"?

2. How do attendees choose a doctor or hospital? Where do attendees get information in making that decision? How should public policy promote quality health care providers?

The primary criteria for choosing a doctor or hospital are location, coverage pool and any substantive discoverable information on quality of care, personal referrals being the most trusted source of information. Many of the attendees utilize resources made available through their insurance carriers though they agree it is lacking in substance. When coverage is limited (medicaid/medicare) or disability is an issue, attendees report having to simply call around to find a physician that can treat
them. Online resources are utilized to the extent that they are available. However, there is great concern over the accuracy of the information provided. Much of the data available through simple searches is outdated or from sources that could be questionable. Some recommended resources which came up during the discussion were:

• Angie's List: www.angieslist.com,
• MedlinePlus: http://www.medlineplus.gov and
• Healithfinder: http://healthfinder.gov.

It was mentioned that the paid subscription services may pose a barrier to some regardless how nominal the cost may be.

It is extremely difficult for the typical end user to navigate the maze of currently available resources. Policy could drive an effort to consolidate information in a comprehensive, standardized searchable database that provided information related to certification status, insurance accepted and other objective measures. Policy driven standardization of IT record would facilitate capturing that information. It was agreed that qualitative measures should remain separate as their subjective nature necessitates the availability of multiple resources in order to keep all information freely available for evaluation by the end user. Efforts are currently being made to provide unbiased qualitative measure by sites like www.qualitynet.org. Public policy could focus on educating consumers on how to utilize the resources currently available. It was suggested that information
consultants could be made available as part of a community resource pool and health care team.

3. Have attendees or their families experienced difficulty paying medical bills? How can policy makers address this problem?

The majority of attendees knew someone or personally had difficulty covering medical bills. A cancer survivor in our group had received a $30,000 bill for chemotherapy. Another attendee faces $40,000 a year in therapy costs for a special needs child. Astronomical costs coupled with confusion over what expenses are covered by coverage providers sometimes leads to delays in payment to the service providers. This can result in the doubling of some bills due to collection fees. A substantial contributing factor is the length of time is takes for the coverage providers to pay service providers resulting in confusion over what portion is the responsibility of the patient.

Often late payments and denials of coverage by insurance companies have resulted in physicians denying care or refusing to provide referrals to specialists. One attendee knew a cancer patient who was denied a referral to a pain clinic and subsequently died. There was a consensus that these stories are not uncommon in our current profit driven coverage system.

Pharmaceutical costs are also a huge problem. Examples were cited of those that forego medical treatment altogether because they know they cannot afford the prescriptions. There is a sense that doctors push higher cost pharmaceuticals versus cheaper medications because of their affiliations with the drug companies.

Again, an industry that regularly posts record profits is responsible for setting price points which are out of reach for a large segment of the population thereby denying them equitable access to life saving medications.

We have come to a point where those with profit driven motives are allowed to make final decisions on appropriate care often with catastrophic consequences. We have allowed a system to unfold which denies or delays needed care in the name of fraud prevention and cost control. Perhaps policy could drive a standardization of the definition of "reasonable care" and lend it's efforts toward devising methods of cost control that do not put the burden on the end user, who is often sick and suffering, to prove they are not guilty of perpetuating a fraud before they receive care. A standardization of medical bills allowing for transparency in charges and eliminating inequities in allowable charges would allow for the clarity necessary to truly manage costs.

4) In addition to employer-based coverage, would the group like the option to purchase a private plan through an insurance-exchange or a public plan like Medicare?

Those that are employed with good insurance coverage are not struggling with this issue personally but understand the urgent need to address the issue in light of escalating unemployment. The current economic climate is bringing this issue home to many. Those in the disabled community are struggling with 70% unemployment rates and little or no options as to how to pay for health care. If employer based health insurance remains the primary vehicle to coverage, unemployment has to be urgently addressed or there will be a health care catastrophe in this country as COBRA costs are simply too prohibitive for those that have lost employment.

A policy creating incentives for private insurers to cover the currently uninsured and/or a public plan that is portable and covers pre-existing conditions would address this issue. A small business owner in the group expressed a desire to more fully concentrate on his core business rather than spend time negotiating with insurance companies. A single payer system with one or two private options would help eliminate the layers of bureaucracy which add to the complexity of the current system, drive up costs and drain resources from actual health "care". A blend of options with incentivized inclusion would provide access to coverage for most if not all Americans.

5. Did attendees know how much they or their employer pays for heath insurance? What should employers role be in a reformed health care system?

Most attendees were not aware of the actual expenditure on their health insurance by their employers but the sense was it is too much. This is evidenced by what has become the common of practice of laying people off and bringing them back as independent contractors or forcing people to work just under the legal threshold of hours to be considered full time with benefits. Mandated access to the health care package of benefits for all employees regardless of full or part time status would eliminate some of these abuses. Attendees have not only experienced an escalation of premiums but also the share of the premium they must pay. Inequities in insurance rates paid by corporations with large numbers of insured employees vs. small businesses need to be addressed. A single payer system could level the playing field in terms of costs.

There were two schools of thought expressed. One expected employers to recognize their vested interest in keeping employees healthy. Mandating employer-based basic coverage while also having a national plan offering extended benefits to those that need them could be implemented in this scenario. Another proposes that the employer role should pay the employee for their work and the employee should be able to afford and obtain their own health care.

6. Were attendees familiar with the types of preventive services Americans should receive? Had attendees gotten the recommended prevention? If not, how can public policy help?

Yes, the attendees were familiar with the preventative services listed and most that had insurance coverage and good access had followed through with their preventative care though some confessed to not always doing screenings on schedule.

Those that did not receive this care gave reasons related to accessibility and transportation. Disabled attendees state that facilities in their area require you to walk or stand for mammograms. Wheelchair accessible machines simply are not available. Trips to primary care physicians for flu shots were postponed due to lack of transportation. It was mentioned that if we are giving everyone $40 for HDTV receivers why can't we provide flu shots? As a matter of public health, hospitals could provide this kind of service through some kind of similar subsidy.

Public policy could push for discounted premiums or other incentives for those that follow through on regular screenings and offer support for those facing access obstacles. Screenings should be available in more areas with transportation being made available to clinics in rural areas. Public policy should require that facilities be accessible and that municipalities provide accessible transportation. A public education effort on the importance of preventative care coupled with the necessary support structure would vastly improve the current numbers of people accessing these basic services.

7. How can public policy promote healthier lifestyles?

Public policy goals should begin with a focus on education then promotion of personal responsibility. The principles of healthy living need to be understood by everyone. Education on proper nutrition and exercise should be provided beginning in early childhood.

Promotion of healthy lifestyle can be achieved with municipalities providing safe environments for people to walk, bike and exercise. Facilities should be accessible to the disabled as well. Fostering environments/atmospheres where healthy lifestyles are modeled will encourage others to participate. Support existing programs in communities with advertising and sponsorship.

Nutritionally, beyond an educational effort on healthy diet, policy should discourage if not ban unhealthy food additives. There should be support for buying local food and sustainable food sources within communities.

Subsidies should be provided for programs offering a holistic approach to health; mental, physical and spiritual. A recognition or reward system should be in place for insurers/employers/health care providers that make preventative care accessible and affordable. An added focus should be mental health and stress management. Promoting access to mental health care can only improve the potential for better self care. Mandated vacation time such as exists in Europe should be considered. Stress management tools and other relevant information could be made available on a national health database.

Since the top causes of death in this country are preventable, education, access to information and access to care should be key goals in any policy proposal.