Quality Medical Care and Affordability – Wish List or Reality?

One cannot turn on the news without hearing about the need to have Quality Medical Care at an Affordable price.

Quality and Cost-effectiveness – can they co-exist? What are the issues that truly drive the costs of medical care?

To answer these questions, one must first define “Quality” and “Affordable.” The American Medical Association and the American Academy of Family Physicians defines Medical Quality as the degree to which healthcare systems, services and supplies for individuals and populations increase the likelihood for positive health outcomes.

But defining “affordable” is much more difficult.

Are we looking at the actual cost of each individual item in the healthcare delivery system? Or are we looking at the total cost to get the expected positive outcomes?

What is considered a positive outcome? To the patient, it can mean a cure, control of a condition with prevention of complications, or palliation. To the physician, it’s the ability to improve their patient’s quality of life, hopefully extend longevity and prevent disease, while making certain they follow their most basic of tenets: Do No Harm.

To the entity paying for the healthcare service (whether insurance company or the firm’s self-insured fund), a positive outcome means that cost is managed effectively. And if this patient is injured in the course of their employment, the employer considers a positive outcome to include returning their injured worker to his/her baseline pre-injury state of function, while limiting lost work time and permanent disability.

The cost of providing even the most basic of medical care continues to increase.  For physicians, expenses are increasing. Yet, it is a known fact that their reimbursements have either been stagnant or even decreasing.

Large governmental payors, like CMS (Medicare) and State Medicaid services, are decreasing their reimbursement to physicians. Most private insurance companies base their reimbursements on a percentage of Medicare.

While the money paid to physicians for care is frequently looked at as a large cost driver in medical care, there are many other cost drivers, including:

  • Employer commitment to Return to Work issues and transitional duty programs for injured worker
  • Relationships between employers, payors, and medical care providers, who specialize in workers’ compensation (occupational medicine)
  • Administration of medical care, including bill review and utilization review
  • Aging population
  • Increasing number of workers with chronic illnesses
  • Cost of prescription drugs
  • Medical errors
  • Diminishing number of physicians who are interested and/or trained in occupational medicine
  • Unrealistic expectations for outcomes
  • Issues of fraud and abuse
  • Issues of Lost time on the job, including temporary and permanent disability.

The aging population, along with the increased number of chronic illnesses in our population definitely drive the costs of medical care upward and can negatively affect the outcomes. Improving education for physicians regarding these issues is paramount.

Equally important is educating the general public on wellness and prevention. Of course, education is only part of the issue. Implementation is key. And, there is a cost for that. According to the Centers for Disease Control & Prevention (CDC) in 2005, more than one half of the American population lived with at least one chronic disease.

One would assume that improved education and information between physicians and patients, would allow us to reduce the cost of administering the healthcare. If physicians are compensated based on outcomes, the need to spend large amounts of monies on utilization review would diminish. This would account for significant savings.  If there were these savings, then there would not be the needs for bill review and the added expenses they incur.

This author believes we can have quality medical care that is affordable. But it requires focus in the following areas:

  • Produce and use better information for healthcare decision-making
  • Evidence-based medicine and outcome studies, including case durations and cost, disability management both in occupational and non-occupational environments
  • Appropriate use of technology
  • Reduce medical errors
  • Advance primary care
  • Electronic Health Records implementation
  • Promote wellness and enhance prevention efforts
  • Reduce the number of chronic diseases
  • Help population to address needs/issues in their control
  • With increasing use of electronics in home and work environments, include ergonomic education for prevention of injury
  • Align financial incentives with health quality and efficiencies
  • With the above in place, decrease the costs of administration of healthcare dollars

Quality medical care at an affordable price can be a reality as long as the medical providers and payor community work together with the patients to provide the best care without unnecessary intervention in the form of paperwork or frivolous case reviews.

Together the three parts of the equation can work together for the best outcomes for all.

– Alesia J. Wagner, Regional Medical Director, Southern California

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