When We Talk About Health Care, We're Forgetting One Important Group: The Already Insured

By Michael Bader, AlterNet. Posted June 19, 2009.

The New York Times recently ran an article about the movement within primary-care medicine to develop systems that allow doctors to spend more time with their patients.

New technologies enabling doctors to electronically record, store and manage records, handle appointments, bill insurance companies, refill prescriptions and communicate directly with patients are allowing physicians to spend more time seeing fewer patients while maintaining their incomes.

One physician moved from a large clinic where she was required to see 25 patients per day to a smaller, more efficiently run practice where she saw only 12. Instead of only treating presenting symptoms, she was able to better understand her patients' entire history. Another doctor made house calls, managing most of his practice through special software on his laptop. Both providers maintained regular contact with their patients via e-mail.

There is overwhelming evidence that patients who get more time with and attention from their providers do better. Compliance and follow-up improves. Fewer medication errors are made. Hospitalization and re-admissions decrease. Benefits accrue not only to patients but to doctors, who feel more engaged, successful and fulfilled in their work. And, of course, society benefits in the form of lower medical costs. It's a win-win proposition all around.

Yet the progressive side in the political debate about health care tends to neglect this aspect of quality health care in favor of issues of access and cost. Who will be covered and who will pay for it dominates the discussion. Care for those with none, cheaper care for those with some, guarantees of care of everyone -- these are our goals.

But what about people who already have insurance, whether from their employers or because they can afford it? What's their stake in reform? What needs of theirs are addressed by the campaign for universal coverage? Are we writing them off as potential allies or relying on their altruism and basic liberal sensibilities for their support? In either case it's a mistake.

The pain and suffering fostered by the American health care system isn't limited to those who can't afford access to it. It occurs every day in the many ways people feel treated like a thing, and not a person, in their interactions with their providers. If we can find creative ways to put relationships on a par with cost and access at the heart of our campaign, we might energize people who today are on the sidelines of this struggle.

Behind debates about efficiency, technology, compliance and treatment outcomes lay the transformative power of relationships. The relationship between patient and doctor, it's quantity and quality, is powerfully implicated in medical outcomes.

For many people who do have medical coverage, getting in contact with a doctor is difficult, mediated as it is by labyrinthine office procedures, phone queues or office policies that simply prohibit it. Once an appointment is made, not always a simple matter, patients often wait for a long time.

When they eventually see their doctors, they are made to feel that their problems, questions and concerns are taking up too much of their providers' time, which is apportioned in 5- to 15-minute increments. Referrals to specialists often take weeks or months. Follow-up is usually left to the patient, who may or may not be proactive enough to do so.

The result is what psychologists call an "anxious attachment" to the doctor and to the medical system in general. Lacking a secure sense that one is correctly understood and reliably cared for, patients give up, become cynical or nervously dependent and needy and fail to internalize the treatment and care that is being offered. Treatment outcomes suffer, prevention strategies founder, hospitalizations and emergency-room visits increase, and everyone involved -- including taxpayers -- pays the price.

When a doctor has time to spend with a patient, a more trusting and caretaking relationship can develop. Patients feel understood. Doctors learn about patients' real lives and social context, which enable them to tailor their treatment to the idiosyncratic needs of the three-dimensional people under their care. It is axiomatic that when someone who is sick feels understood, he or she feels better, more engaged and more likely to take care of him or herself.

These issues are exaggerated among people who have no or limited access to care. But there isn't a person I know who has medical insurance who doesn't have a story about neglect or mistreatment at the hands of the medical system, who doesn't share the frustration of not being able to get through to the doctor or of the latter being unresponsive to his or her needs.

Recently, a family member asked me for help with her 17-year-old daughter, who had been suffering from intense back pain for two months. This girl eventually saw her primary physician at a local HMO, who told her that only the physiatrist in charge of physical medicine (including physical therapy) could order an MRI.

When she went to the PT department, she was told that she first had to have physical therapy for four to six sessions before the physiatrist would see her and, if necessary, order an MRI. My friend raised hell and got the physiatrist to order an MRI before physical therapy began, although it took 10 days to schedule. She was then told that it would be another 10 days before she could meet with the physiatrist, who would read the MRI, evaluate her daughter, and recommend treatment.

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Michael Bader is a psychologist and psychoanalyst in San Francisco. He is the author of Arousal: The Secret Logic of Sexual Fantasies, and Male Sexuality: Why Women Don't Understand It -- and Men Don't Either. He has written extensively about psychology and politics.

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