Consequences

It was a pleasant, if cold, night. Pleasant, that is, right up to the very moment Frederick Fleet screamed “Iceberg, right ahead!” From that point on, things really went downhill for the passengers and crew of the RMS Titanic.

Yesterday, in what should have been a snoozer of a Patient Centered Medical Home steering committee meeting, I had an iceberg, right ahead moment.

We were weeding our way through the myriad requirements we must satisfy to apply to be recognized as a Patient Centered Medical Home. Among them are assorted issues dealing with communication among hospitals, specialists, and primary care settings. I won’t bore you with the details but let’s just say there’s a problem with hospitals that’s about to get a whole lot worse.

The root of the problem is that when congress plotted the metaphorical course of healthcare reform from Liverpool to New York, they didn’t take into account the possibility of icebergs. And in the case of healthcare reform, the icebergs are the absolutely chillingly named unintended consequences.

Among many other things, the reform moves health spending from fixing problems to preventing problems. That sounds great, both for money saved and for healthy populations. Well, it sounds great unless you’re in the business of fixing problems. In which case, you now have a problem. The solution for the hospitals (the ultimate fixers) is that—like cosmic black holes—they have begun sucking up and destroying all the medical practices around them. It’s really economics 101. To survive, they need to control a greater degree of the “production line.”

So increasingly, if someone is hospitalized, rather than refer them back to their primary care doc for follow-up, there’s a huge incentive to instead refer the patient to the hospital-owned doctors for follow-up. In fact, why even bother to let the patient’s main doc know they were in the hospital at all? It’s an opportunity to “steal” the patient.

A little while back, before we steamed into these iceberg-infested waters, I noticed the water was getting pretty cold. First, my own insurance was getting a tad… unreasonable. Then I started getting calls from my patients that all kinds of business-as-usual diabetes items were suddenly not being covered. My analysis? The health plans know that the golden goose is in the oven. The free ride is coming to an end. They get 30 million new customers next year, but those fuckers are really sick. Many of these folks are the ones the plans have been denying coverage to for years. These people, God forbid, might actually use their health insurance. The jig is up, and the plans know it.

The next 12 months will be hell for those of us that need anything from our health insurance. And what happens after that? Honestly, God only knows. I even chatted with a health plan actuary recently, and he told me his plan is scared shitless. There are so many variables that they really don’t know if they are gonna make a mint or lose their shirts. It could go either way. So during the one last dying ray of light before the sunset, they gotta make all they can. Right now.

My health insurance, designed for the working poor in my state, goes away in 12 months and 13 days. Poof! It will be gone for all time. My premiums will go up, up, up. My deductible will go up, up, up. My coverage? Well I don’t know yet, but I’m not feeling too optimistic at the moment. Of course, given my coverage woes over this last couple of months, things might actually get better.

Wait a minute. Did I really write that? Huh. I must have drunk more than I thought I did.

So I’m probably just getting paranoid at this point, but a recent article by my D’Mine colleague Mike Hoskins about the possibility of generic test strips bummed me out, rather than cheering me up. If, in the unlikely event this new company survives the barrage of law suits filed against it by behemoth J&J, and actually gets a cheap semi-universal test strip to market, it’s a game changer of epic proportions. And maybe not for the best.

There could be unintended consequences. Iceberg, right ahead.

What if Medicare decides to cover only such third-party generics? On one hand, it would serve the greedy bastards right. On the other hand, bye-bye new meters. Ever. There would be no financial motive for the big players to innovate. In no time we’ll all be back to using four-pound plug-into-the-wall Ames Eyetone meters. Will we also be forced off of pumps, pens, even disposable syringes? Will we be back to one glass syringe and two needles (that you have to sharpen when they get dull) per diabetic?

Iceberg, right ahead, indeed.