Editor’s note: This commentary is by Steve May, who is a licensed independent clinical social worker (LICSW) providing psychotherapy from his Burlington office. He has previously worked for the Hemophilia Federation of America and the New England Hemophilia Association supporting the needs of chronically ill patients in a variety of settings.
[T]his year, I am going to try something different. I want my financial planner to make all the decisions for me about whether or not to get a prostate exam. When I’m done there, maybe my doctor can decide about the match for my 401(k). After all, this makes about as much sense as Shumlin’s all-payer plan for medical decision-making. Clinical decisions really are bulky and cumbersome; they don’t fit neatly into the four corners of a spreadsheet. Good care can’t simply be decided through a rock-scissors-paper tournament. Maybe we could all use a Magic 8 Ball or try flipping a coin. You see, Gov. Shumlin has decided that accountants are more important to the administration of health care services than medical professionals.
As a licensed independent clinical social worker, I have a master’s degree in social work. Beyond just my classwork, I needed 3,500 hours of clinical work hours under supervision, plus I needed to pass the clinical exam where I demonstrated mastery of the information my peers say I am supposed to know. Beyond that I have worked in mental health for more than a decade. But my clinical judgment obviously is not enough. It seems that the business cycle matters most, and should my clients have actual needs worth fighting for, we both would be adversely treated under the governor’s scheme.
All payer or global payments as it is better known elsewhere says that every patient is worth a set dollar value to medical providers. As such, you (as the provider) are incentivized to provide the least care possible. In reality, that means creating a very real barrier to providing basic adequate health care. Whatever monies aren’t spent in a given year on adequate care can be clawed back by the provider. This perverse math creates disincentives to providing routine care.
Chronically ill patients represent a drag on the health care system under Shumlin’s proposals. They have often done nothing to create their own personal health crisis. Rather they are simply more unlucky than most in some grand genetic lottery. Those who most need to have access to reliable health care will suddenly have the greatest challenges in accessing it, because their care is more costly. Not only will chronic health needs require health professionals to spend more time and resources on these patients, the pay stream to be associated with these folks are now going to be diverted from the care professionals profit back into the care of these most needy individuals.
I do not want to look at the people and families in my care and suddenly find that I need to treat them more or less like a bushel of soybeans.
What will happen when a patient has gone through their allowance for the year? Do we just let the sick be sick. Rue the day that arbitrary barriers to care determine who is worthy of treating and who is damned to an administrative black hole? Patients are people not commodities. If my client who happens to be schizophrenic needs more intensive care I will want to treat them and their very real mental health needs. I do not want to look at the people and families in my care and suddenly find that I need to treat them more or less like a bushel of soybeans. Pay as you go has afforded patients and their families across Vermont to enjoy basic mental health services for generations.
More to the point, are we destined to make decisions about care based upon where we are in the calendar year? Are we really going to pit one health provider against another because not every patient needs will be treated equally. Do we really want a health care race to the bottom as a society? What about those amongst us who have the misfortune to be pricey to care for? Under this two-tiered system, barriers to caring for these chronically ill clients will represent at minimum an occupational risk to care providers. At worst, they become a professional liability for doctors and other providers.
When the state supported resources are finally gone, patients will be saddled with expensive supplemental plans. The fortunate will pay out of pocket, poorer folks likely won’t be so lucky. Do we simply exhaust the patients’ care allowances until it’s gone and just accept that basic adequate care will become the province of those who can afford it? Do we really want to be a place where you get the best care your money can buy, and if you’re poor you’re stuck and if you’re of means you’re not.
Simply started, shifting means rationing care. Incentives to provide less care may please the bean counters but is contrary to the administration of sound health care for patients. This system turns both care and patients into commodities. It doesn’t lead to improved care for patients or providers. It does however represent bad medicine for the people of Vermont. Our people here deserve far better.
