Improving American Health Care Through Better Public Understanding

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Opinion Piece By George A. Huber, JD, MSIE, MSSM, Professor of Public Health Practice, University of Pittsburgh

A Chinese proverb instructs that: “If you are planning for a year, sow rice; if you are planning for a decade, plant trees; if you are planning for lifetime, educate people”.  In health care it would follow that the better educated Americans are about their own personal health, and about the services available to them and how to pay for them when they have a problem, the better the health system will become over time from provider, financing and outcome perspectives.  Understanding and communication among the public, the patient, the health care professional, the payer, and the politician (the five P’s) should also improve.

There are at least three levels of individual health care learning opportunities starting with personal health, fitness and prevention.  This level is at least initially addressed by schools.  The second level involves where to go for diagnosis, treatment and after care, and how to pay for them.  This level is expected by government, as proposed through health care reform, to be fulfilled by health care providers and insurers.  The third level is in many respects the most complex since it places all adults in the position of concerned citizens in trying to understand the major elements and their relationships to one another within the health care delivery and financing system itself.  This kind of understanding is crucial to effective policy development.

This third level is in many respects the foundation for the other two levels.  Unfortunately, the general electorate, most policy makers, media, and even some health care providers and insurers don’t know enough about the overall health care system and its key components to help in making effective changes a reality.

In Western Pennsylvania a case which demonstrates this point involves the refusal of the dominant health care system, UPMC, to renew it long-term provider contract with the dominant health care insurer, Highmark.  UPMC’s reason for non-renewal is that Highmark is buying a provider health care system of its own, West Penn Allegheny, and will, therefore, compete with UPMC as an “integrated delivery and finance system”, or IDFS, that is, an arrangement where providers and insurers are corporately linked.  UPMC also has its own insurance company, however, UPMC does not want to contract with Highmark thus giving Highmark the opportunity to channel patients from UPMC to West Penn Allegheny.

Up until this point in time most people were happy with their insurance coverage and their doctors although there were complaints about the cost of insurance and the need for more competition among providers and insurance companies alike.  These complaints were supported by the media and by politicians.  This is also a classic example of being careful about what you ask for because it might just come true.

Under the current commercial contract between UPMC and Highmark, people with Highmark insurance are covered when they use UPMC physicians and hospitals.  With some exceptions, such coverage will not exist when there is no contract between UPMC and Highmark, and people are concerned that they will be subjected to non-covered pre-existing conditions if they switch from Highmark to other insurance companies in order to have coverage to maintain their UPMC physicians and hospitals.  One distasteful alternative is to just pay charges in order to use UPMC providers.

UPMC has responded by saying that it has contracted with four additional insurance companies which are not competing IDFSs, and which are available to provide consumer coverage for both UPMC and West Penn Allegheny health care providers.  In fact, UPMC contends that what it intends to do is support the addition of much needed competition to the Western Pennsylvania health care market in the form of two major IDFSs (UPMC and Highmark) rather than one, and the addition of four major insurance companies who can contract with both IDFSs.  UPMC has also stated its willingness to address concerns about pre-existing conditions, at least until health care reform eliminates such provisions.

Understanding by the general public of this difficult situation is confounded by those people expected to be in the “know” and whose propaganda is intended to advance a political agenda rather than an educational one.  One public health official commented that he seriously didn’t realize that charitable non-profit hospitals could compete.  Another state legislator intends to offer a bill to force binding arbitration between UPMC and Highmark even though the insurance commissioner believes that there is no statutory authority to intervene other than as a non-binding mediator.  The newspaper advocates that since UPMC is tax exempt it “belongs to the community”.  Even if UPMC meets the letter of the charities law, the argument is made that it does not meet the spirit of the law by “pushing millions of patients off a cliff”.  Finally, UPMC’s tax exempt status is being challenged in the media as is the use of subscriber generated surplus by Highmark to buy the West Penn Allegheny provider system.

Lack of understanding causes public reaction to be more susceptible to mis-information and fear rather than to more rational thinking.  This is true whether the topic is national health reform or health care competition in Western Pennsylvania.  Improving health care literacy is a continuous, long-term, uphill objective to accomplish.  Perhaps some of the best educated people in America about health care are Medicare beneficiaries for reasons of maturity and experience.

The United States has more published research articles about health literacy than any other developed country.  Yet, many of its outcome measures fall below those of a significant number of these countries.  Perhaps there needs to be a greater push for transition from the bench to practice.  Starting the various levels of learning process at earlier stages of life might make sense as well.  In any case, it should be a top health care policy, and it should begin immediately.