How would you fix the access problem?

Squashed asked me:

I appreciate your thoughts on healthcare. And I agree that the bill that just passed congress (probably) won’t do enough to slow cost increases. I also appreciate that you’re at the forefront of working out innovative solutions that, hopefully, will lead to less expensive or better quality coverage for many people. And I also understand the worry that some of the insurance reforms will create additional hurdles for innovators. But I’m not satisfied with, “Maybe some innovator will come up with something clever” as a way to ensure that everybody gets coverage. We’ve got thirty or forty million uninsured people in the country. Most cannot afford health coverage now. Nor could they afford coverage if it became marginally less expensive. What is your proposal for these thirty million people?

Here’s my response:

The first thing we have to clarify is that health insurance doesn’t equal access to healthcare. Health insurance theoretically implies that people will be financially protected if something catastrophic happens (even though 60% of bankruptcies in America had medical bills as a component…and 82% of those people had health insurance). Health access means being able to receive healthcare services when you need them.

Insuring everyone in America surely doesn’t mean everyone will have access. That was the assumption when Massachusetts passed their mandated insurance law in 2007. The wait time to see a generalist is now around 50 days in Massachusetts. The same thing will happen all across America when the mandates go into effect. Only about 2 to 5% of graduating residents went into primary care this year. In any highly functioning system, supply must equal demand. In other developed countries, about 75% of demand is primary care. Unfortunately, our industry is composed of 75% specialists and rising every year. Primary care is already overworked and underpaid. Therefore, accessing a primary care doctor who accepts health insurance in 2014 will be very, very difficult. Unfortunately, we’re about two generations behind the ball on this one and a policy enacted today to encourage more doctors to enter primary care won’t take effect in a meaningful way for at least another 20 years. The cheapest plans people can purchase are always those that require a primary care gatekeeper. These plans are going to be rendered almost useless in about 5 years as more and more boomer primary care physicians retire because they’re simply burned out or reach retirement age.

We have to remember that supply isn’t organized in America in an equitable manner based on need. Access also means having an equitable healthcare System that’s meant to function like a unified whole. Many rural and inner city, poor areas in the nation have little to no access to primary care. How are mandates going to affect areas of the country with an inequitable amount of gatekeepers? Are people going to be mandated to purchase insurance they can’t use?

Realizing there’s surely not a quick way to fix this, we have to imagine a future where there are no primary care doctors and the point of entry for an individual into the industry will shift to something else. And that’s exactly what we’re working on at The Future Well. Scott Switzer, the co-founder of the Tim O’Reilly-investment, Open X, recently left his position and joined us about two months ago as the third partner in The Future Well. Open X is essentially an open source Double Click that powers about 25% of all ads on the internet. Our first product we’re making answers the following questions when you’re in a medical bind and may need professional attention:

  • When should I take care of this?
  • Who should I see? (specialist, generalist, retail clinic, etc.)
  • How much should I expect to spend?

Since overworked primary care physicians refer about 70% of their visits to specialists, if we point you to a specialist instead of a primary care doctor, we’ll automatically be “correct” (in terms of the consumers experience) 70% of the time. Why should people, when spending their own hard earned money, waste money on a primary care doctor visit just to get a referral that will happen anyway 70% of the time? So that’s about all I can say right now about this app. Give us a couple of months. It will be very, very minimal. We’re starting in NYC.

Beyond that, solving the access problem in America assumes that we have a needs-based System rather than a profit-driven industry. If we fix the profit-driven industry problem and move toward a needs-based System by paying doctors for wellness instead of sickness, maybe we can fix the access problem for our children and grandchildren? But I’d say a quick fix to this problem of being uninsured is to add up all of their medical bills in a given year and if that financially ruins them, simply pay their bills. We bailed out the auto and banking industry. Why not bail out a hundred thousand or so individual with exorbitant medical bills (that’s a horrible solution by the way…about as horrible as bailing out the auto industry).