‘Holes’ – the Baldacci health plan version

A moose with a big bulls-eye tattooed on its side should be the mascot of the state health plan recently proposed by Gov. John Baldacci, because shooting holes in the plan has become a state sport. One of the holes in the plan, however, is one that it came with; it includes few ideas to put effective limits on what patients and malpractice lawsuits do to drive up health care costs. Joe Bornstein and I could drive a pulp truck through a hole that big.

The lack of any specific proposals that would effectively reduce patient demand for health care services, and malpractice suits, in the short term, is surprising. After all, the Baldacci plan is plan to control health care costs and make sure everyone has health insurance. It includes specific proposals to limit increases in hospital prices, health insurance premium prices and doctor fees. It freezes hospital expansions for at least a year. But it is short on ideas to encourage Mainers and Mainiacs to rein in our part of the problem.

The Baldacci plan does speak of promoting healthy lifestyles, and assumes that getting people insured will encourage them to get more preventive health care. That may help lower health care costs in the future, but in the short term people get more health care and spend more health care dollars once they get health insurance. The plan also dedicates all tobacco settlement money to public health, prescription drugs for the poor elderly, home health visits for new parents and pregnant women, etc. All of that is important, but will not save lots of money soon. It’s a kiss on the cheek, not a date to the prom on the issue of decreasing patient demand for health care.

Here is a scenario that shows the hole. A guy gets drunk on coffee brandy – Maine’s state drink – slips on his pile of Down East magazines, and twists his ankle. He goes to the emergency department (ED) looking for an X-ray, but the ED doctor tells him he has a sprain and does not need an X-ray. (The so-called Ottawa Ankle Rules, developed after a study of thousands of ankle sprain patients, identify by injury history and exam which patients do not need ankle X-rays.)

The patient is irate, but goes home on crutches, splinted, and sees his personal physician in follow-up. That doc orders an X-ray, which shows a small fracture, and the patient sues the ED doctor. The patient suffers no permanent injury, the initial treatment was no different (small fractures get crutches and splinting), but the fracture was not found in the ED so the suit is settled for $5,000. The ED doctor vows in the future to X-ray everything that limps, costs be damned.

The scenario illustrates several points, none of which are addressed in the Baldacci health plan as currently described. First, health insurance largely protects patients from financial responsibility for their own poor decisions about their health, unless it comes with deductibles and co-payments. Second, insured patients often have little incentive not to pressure the doctor to do an X-ray because the patient does not have to pay for the X-ray. Third, our system allows doctors to get sued even when they practice state-of-the-art medicine, and encourages settling such suits out of court to avoid court costs and the risk of bigger settlements.

The proposed Baldacci plan is desperately in need of concrete proposals that will effectively decrease unnecessary health care utilization driven by such patient behavior, patient preference, and malpractice fears. At a minimum, the Baldacci health plan should offer malpractice protection for decisions doctors make based on well-established medical guidelines, such as the Ottawa Ankle Rules, and set limits on malpractice damage awards for pain and suffering. It should require some co-payment and some deductible for all health insurance plans, with sliding scales for each based on income. Everyone should have to pay some part of the cost of their health care, so when they make decisions about spending health care dollars they are committing part of their own cash.

It may be that such proposals are in the legislative details of the plan, which have yet to be released. Or, they could be developed in response to suggestions from the plan’s proposed Council for Health System Development. However, the lack in the plan at this point of virtually any reference to such ideas suggests they are nowhere on the horizon.

Failure of the Baldacci plan to address these factors driving utilization of health care services threatens the plan’s credibility with doctors, hospitals, and insurers, and ultimately threatens the plan’s ability to control costs. Health care costs cannot be controlled if we as patients do not control our appetite for health care, and if we can sue without significant restraint. I am not going to order fewer expensive MRI scans if patients push me for them, and I can get sued for not ordering a scan even when the evidence suggests it is unnecessary.

The health care cost containment lid can be put on doctors, hospitals and health insurance companies, but as long as patient demand continues to cook, at some point the lid is going to blow off. We, as individual patients and as a collective society, are part of the problem; we must, therefore, be part of the solution, and the governor’s plan should include specific provisions to drag us kicking and screaming to the plate.

P.S.: Next column – belated Mother’s Day. Mom always said to do the work first, then play.

Erik Steele, D.O. is a physician in Bangor, an administrator at Eastern Maine Medical Center, and is on the staff of several hospital emergency rooms in the region.