We need a public option with a French accent

I’ve been thinking a lot lately about the inefficiencies in the US health insurance system, as compared with what seems to be the amazingly efficient French system. Most talk is centered on inequity here, which is the bottom line, of course. Still, we like to believe that the economy (and all progress in this country) is driven by efficiency, innovation, and productivity, so the contrast in this case seems rather alarming.

Listen here to author T.R. Reid on his experiences in doctor’s offices around the globe, seeking help for a “bum shoulder”. Listen, particularly, to his account of the French system of files and payment processing.

[In France and other ‘Bismarck model” European countries] These are private docs, private hospitals, and mainly private insurance plans…

This business in America where we have the in-network deal or we have to get pre-authorization; any doctor, any clinic, anybody in the entire country, you chose ‘em, you go, and insurance has to pay the bill within two weeks or so…

[French doctor’s offices] are Spartan... What’s missing [...] is the files and files of patient records, and there’s no billing office… the patient comes in, out of her pocket she pulls […] the Card Vitale, he puts it in a reader on his desk and her entire medical record shows up on the screen. He chats with her about her problem, he’s typing down what she’s got wrong, and he says “I’m going to prescribe a course of antibiotic” […] and he’s typing all that up. He’s finished with her, […] he hits one key on his computer and the entire bill has gone to her insurance company, he’s going to be paid in three days, and she’s gonna get her copay back from the insurance company within two weeks. Done. No paperwork.

Compare that to the situation now facing my sister, trying to get her daughter needed treatment for a deforming case of scoliosis. The condition is not, of itself, life threatening, but further deformation could begin to impact internal organs, including her lungs. The girl has, since birth, been very susceptible to lung ailments.

The treatment is thoracic spinal fusion, a 7-8 hour surgery that, while not uncommon, is far from routine. My sister’s search up and down California for a doctor competent to perform the surgery who would also accept Medicaid led to UCLA, where the surgery is performed, apparently, hundreds of times per year.

My sister lives in Northern California, so the team at UCLA worked with her doctor up north to coordinate some of the pre-op work and insurance submittals. There were two necessary pre-op trips to LA. The surgery was scheduled for today, September 15. The family flew down this weekend, mom, dad, the patient, and her twin sister. Dad and sis planned to go home Friday, while the patient would not be clear to travel for three weeks, so she and mom would stay down here.

What do you say to a kid about to go under the knife? I told her it would all be over in two days, and she wouldn’t have to think about it anymore.

So I was sickened yesterday when I heard that the surgery had been postponed for at least three weeks, because her Medicaid paperwork had been lost in some shuffle or another and UCLA won’t do the surgery until it is pre-authorized. In the meanwhile, her parents must find money to change tickets and buy new ones, putting more financial stress on an already stressed family.

“Medicaid is a government program!” I can already hear the screeches. But this situation isn’t unique to public insurance. It’s due to an approval system in use by public and private insurers, and it’s stupid, and it’s wrong, and it wastes time and money.

There is (or there was a couple of weeks ago) language in the current house bill that would enable electronic funds transfers between doctors and Medicare/Medicaid, and presumably other public insurers. That’s a good step.

Now how about language that removes pre-approval from the transaction? The doctor treats, the doctor gets paid. If there is reasonable suspicion of fraud after the fact, it becomes a criminal investigation. If the fraud were committed against a public plan, the charges would be federal, and the penalties would be stiff, and would include prison time.

I’d like it if we followed the Swiss model, and made for-profit basic health insurance illegal. If we can’t do that yet, we should build a strong new public option, while strengthening Medicare and Medicaid. These programs should have zero pre-authorization requirements, and be dedicated to innovating payment and record keeping systems.

If the private sector won’t do it, the government must. And if the private sector wants to remain competitive, it’ll have to go along.

(Here's the NYT story on Reid's book.)