When anyone in the United States talks of health care, they are usually talking about sick care, or as I call it, after sickness care. In contrast to before sickness health care, after sickness care is much more straightforward—something is broken and it needs to be fixed. The goal of after sickness health care is to relieve suffering and extend meaningful life through treatments and/or medications. The word patient, the term usually associated with all healthcare consumers, actually means “one who suffers” and is therefore most appropriate for use with after sickness care than with before sickness health care. In 2004, it was estimated that more than 90% of all national health expenditures was used for after sickness care.
After sickness care is what the medical professionals are educated and trained to do and is what they do best. With the exception of some government-run healthcare facilities (e.g., Veterans Health facilities across the country), after sickness care is delivered by private, independently-owned healthcare businesses. The after sickness healthcare personnel include medical doctors of various kinds, assistants to doctors of various kinds, dentists, optometrists, pharmacists, chiropractors, therapists of various kinds, audiologists, speech pathologists, dietitians, social workers, and a wide variety of other support professionals. Healthcare professionals provide a wide range of services and can prescribe drugs that are more potent than available over-the-counter.
Sometimes people are able to “fix” a medical problem without consulting paid healthcare professionals. When we get the common cold, we often need to simply get plenty of bed rest, take over-the-counter cold medications to lessen symptoms, and drink plenty of liquids. The human body can even fight off a sickness on its own without the need for professional care (in the case of ear infections, for example).
What is After Sickness Care?
In after sickness health care, our minds and/or our bodies are not functioning properly and we seek remedies when symptoms tell us something is wrong. Unfortunately, our aging minds and bodies are programmed to deteriorate with time and therefore the need for after sickness health care is inevitable for most people and usually increases with age. In fact, health spending per person is highest for people over the age of 65.
In after sickness care (see the figure below), the patient presents himself/herself to a healthcare professional (usually a doctor or nurse practitioner) with a medical problem characterized by symptoms. In cases of emergencies when time is of the essence, the patient is directly transported to a hospital for care. The healthcare professional’s job is to run tests and diagnosis the problem associated with the symptoms. Fixing or managing the medical problem usually requires various treatments (like physical therapy, diet changes, surgery, or psychological interventions) and/or medications. The treatment plan recommended for a given diagnosis depends on the illness and ranges from the simple (e.g., advice to go home and rest for a few days) to the extensive (e.g., lengthy cancer treatments).
Patients may have to consult more than one healthcare professional before a satisfactory diagnosis is obtained and treated. In addition, several different treatment options may be available for a given condition or disease situation. After testing and diagnosis, the patient may have more than one treatment option and must assess the benefits and risks (and cost) of each. Multi-step treatment plans must be evaluated for efficacy (i.e., did it produce the results expected) after each step is completed. Medical treatments and medications are not guaranteed to work for all people all of the time.
The three possible outcomes of after sickness care include:
- Elimination of the health problem through treatments, surgery, and/or medications. Examples include setting a broken bone, bringing out-of-control cancer to remission, or prescribing an antibiotic to get rid of an infection.
- Management of a chronic disease or condition through long term (more than three months) monitoring and prescription drug therapy to minimize symptoms, disability, or death. Examples of chronic diseases that need management include diabetes, hypertension, arthritis, emphysema. People with chronic conditions typically manage their illnesses with periodic medical attention and occasional need for care due to complications from their conditions.
- Unsuccessful treatment. When after sickness care is inadequate to either eliminate or manage the health problem, the patient suffers, becomes disabled, or dies. In many situations, the care emphasis changes to one aimed at minimizing suffering rather than prolonging life. Patients with a terminal condition or the infirmity of old age fall into this category and often require long-term care services associated with normal functioning (e.g. dressing, eating, going to the bathroom) in addition to medical care.
Financial Considerations in After Sickness Care
In the United States, the “ability to pay” still defines who receives the highest quality of after sickness care and who does not. The uninsured American who cannot pay out-of-pocket will likely be denied many healthcare services (only emergency room treatment is guaranteed by law to all). Private healthcare businesses deny services by simply not allowing the uninsured to make appointments or by requiring payment upfront. In addition, variations in after sickness care also exists because some insurance plans are more “generous” (i.e., higher actuarial value) than others. Americans with less “generous” health insurance (and low ability to pay out-of-pocket) are often not presented with the most expensive (and effective?) treatments available, even if these treatments would make the difference between life and death. Doctors are aware of which patients have the most “generous” health insurance coverage and which do not.
Because health care is delivered by private for-profit businesses in the United States, payers (usually through distant third-party insurance companies) have been forced to manage reimbursement so that they only pay for “medically necessary” services associated with specific diagnoses. As a result, not all after sickness care sold by healthcare businesses is covered by health insurance plans. Healthcare businesses are not required to deliver healthcare value and quantity (especially care that is expensive) pays more than quality of care. This conflict of interest between financial gain and delivery of quality patient care demands cost management by both payers and patients.
Under this for-profit healthcare system, individual health insurance companies are free to set medical practice guidelines to make sure that healthcare businesses do not “milk” the payers (and, of course, so that they receive maximum profits for themselves). Healthcare businesses are required to match diagnoses with tests and treatments that fit the insurance companies’ guidelines or the healthcare business will not be reimbursed for its services. This reimbursement/practice guideline arrangement has created a system where the delivery of the “best” quality health care is reserved for those with the “ability to pay” rather than what is best for the health of all Americans.
Because insurance companies used to take advantage of Americans in the individual and small group health insurance markets, Obamacare (PPACA) defined a minimum set of Essential Health Benefits (EHB) that must be covered. Other group health insurance plans have historically covered the Essential Health Benefits and more. Because the EHBs are not specifically defined (10 broad categories are listed), insurance companies are still free to tweak what specific treatments they will reimburse and what treatments they will not for a given diagnosis.
One area of after sickness health care that is not covered by health insurance coverage is long term care in assisted living and nursing home facilities. Americans must buy separate (and costly) long term care insurance or pay out-of-pocket. This type of after sickness health care is funded by patients directly, or when they run out of funds, by Medicaid, the health insurance program for America’s poor. Medicare pays for limited (less than 100 days) rehabilitative care (skilled services) in a nursing home.
Summary of After Sickness Care
After sickness care consumes over 90% of all our national health spending and involves the treatment of symptoms that cause suffering, disability, and/or eventually lead to death. The goal of after sickness care is to eradicate disease, relieve suffering, improve quality of life, and prolong life. After sickness care includes services that help eliminate (e.g., setting a broken bone, prescribing an antibiotic for an infection) or manage (e.g., prescribing drugs for type 2 diabetes or hypertension) symptoms associated with diseases, injury, or incurable conditions. Given that human bodies are programmed to decay and die, after sickness care is something that we all will require at some point in our lives. Not all after sickness care is 100% effective for all patients all of the time.
In the United States, the quality of after sickness health care varies because the “ability to pay” governs who gets what care. Patients with “generous” health insurance coverage (or the ability to pay out-of-pocket) receive the “best” quality of care and the uninsured are often denied all except emergency care.