Medical technology was pretty simple in those days too. People who had heart attacks or suffered major trauma died quickly. There were not many cures for cancer and premature babies just died - Some of us may remember when Jackie Kennedy's baby did not make it. People could evaluate their situation with the advice of the family doctor and get it right.

Those days are gone. Only the most daring of us would try to service our own car let alone build a car out of parts. The array of potential medical treatments, tests and drugs that we face today is both miraculous and overwhelming. 

Our medical payment system, however, is stuck in the good old days. We don't buy health care, we buy hospital days, MRI's, open heart surgeries, medications and so on. Each of these billable services is very precisely defined and exhaustively described in one of several coding manuals. It's sort of like a medical care parts book.

To get some idea of the mind numbing detail of fee for service billing you can go to your local library reference desk and ask about CPT codes or order a manual online from the American Association of Professional Coders. Wonks Anonymous finds no free online source for this information If someone knows of one please send it to chris@WonksAnonymous.com and he will be happy to revise this entry.

If you get your hands on one of these coding manuals you will notice one thing. There are very few billable codes for counseling, health education and care and case management.

I suppose that someone, somewhere, really believes that consumers actually assemble their own medical care out of components part and I expect that there are some consumers who actually do. Most of us don't really care about any of this. We want to be healthy or, if this is not possible, to cope with our chronic health problems with dignity and a moderate amount of comfort. We want a doctor or a group of doctors who can evaluate our health, coach us on the best course and provide us with the needed treatments. However we pay for it, this is the simple goal.

As it currently stands, medicare and other single payer systems, and many insurance plans are based on fee for service medicine with all its complexity and problems. Here a good doctor patient relationships will help to overcome the problems of our overly complex payment system, although I have heard some physicians in private practice complain about the low compensation for actual patient contact.

At the same time, many insurance companies have adopted a new variant of this system. Formerly, people with insurance paid for a policy and then let the insurance company pay for care. Now we see Consumer Driven Health Plans that require significant out of pocket payments for medical services up to a rather high deductible - say $5,000 - and may even require cost sharing, coinsurance after this. For a short guide to these plans see this blog. 

In these plans the consumer is supposed to respond to market incentives and choose care based on price as well as on a doctor's advice. Say I have unexplained bouts of dizziness and my doctor recommends an MRI to rule out problems with my brain. In the new consumer driven plans, I get to make the final choice. Do I want to spend $1,500 to get the MRI or would I rather just pay my rent and hope that the dizzy spells don't come back?

Isn't choice wonderful!