by Janet A. Ginsburg

“Pricing health care? It’s not that easy” – that’s the headline in today's Chicago Tribune. The story outlines one of the more glaring Catch-22s of modern American health care, while deftly puncturing the myth of consumer choice.

It begins with the sad tale of Margaret Zilm, a Kansas City woman with a $5,000 deductible policy and a cataract in need of removal. Poor Margaret was spun in circles as she tried

know how much her insurance company would pay. Her insurer refused to tell her. And the Missouri Department of Insurance hid behind a curtain of confidentiality, citing policy against revealing the details of doctor / insurer contracts.

As reporter Judith Graham notes:

“This wasn’t a problem until recently. Insurance used to cover most expenses, shielding people from the true cost of medical care. But new products – “consumer-driven health plans” – shift more financial responsibility to individuals and families, giving them a reason to pay more attention to what they’re spending.”

“Consumer-driven health plans”? If anybody's being driven, it's consumers -- six million, so far -- who are forced by spiraling insurance premiums to accept these less-for-more, high-deductible plans. Rather than create a health care system designed to promote health – both individual and public – we now have a tangle of secret deals wrapped in a free-market bow of consumer choice.

A handful of states and insurers actually are trying to bring some transparency to the process, but it’s not easy. There is often a gap between the list price of a medical procedure and the negotiated price insurers’ pay. Further complicating matters, health-care costs are notoriously fragmented, with everything from lab tests to hospital rooms billed as separate charges. It's like buying a car but being billed separately for the doors, trunk and headlights.

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Still, the six million who can afford this bureaucratic nightmare are better off than the 45 million-plus who don’t have any insurance at all.

In an ironic twist, the biggest health threat to those who are insured -- and to public health in general in the U.S -- isn’t any single disease, but this vast pool of un- and under-insured Americans.

By the time the first human case of a contagious disease is identified, chances are quite good it has already spread, possibly far and wide. "Flu-like”symptoms? We have learned stock up on drug store remedies, stall calling a doctor, and hope we don't end up wheezing into an Emergency Room. (“Flu-like” symptoms can be triggered by any number of bugs, from West Nile to SARS and, of course, the flu -- even cases of non-paralytic Polio have been described as “flu-like.”)

Infectious diseases that aren’t particularly contagious (at least for people) such as the H5N1 strain of bird flu, can still spread person-to-person if there’s enough close contact. Imagine how fast pathogens actually built to travel get around. One good sneeze in a crowd and it’s a box of Kleenex for everyone.

Since many diseases are zoonotic – meaning they infect multiple species, including ours -- there is a lot of interest in using animal health surveillance as an early warning system. But such an early warning system, whether sampling migrating birds and testing poultry for signs of avian influenza, or keeping tabs on sniffly pets ,1 only works if it can be quickly acted on.

Likewise, breakthroughs in rapid diagnostics, such as mass tag PCR 2  -- which gives physicians the ability to test for multiple pathogens simultaneously with results in a matter of hours -- can only make a difference if they’re widely available.

That means revamping the health care system so that it’s health-driven, not “consumer-driven.” And that means lowering barriers to basic care 3, investing in rapid diagnostics, and expanding surveillance efforts.

People who are sick shouldn’t have to think twice about whether they can afford to see a doctor. They shouldn’t have to wait until they are so ill, they end up in the ER (often at taxpayer expense), possibly having exposed countless others along the way.

The high cost of health insurance, fluffed into the stratosphere by prices inflated to ensure profits at discount, puts everyone at greater risk. High deductibles are a false savings. Health care isn’t a privilege. It’s not about choice. It is common sense for the common good.

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1) Animal Surveillance

That set off alarm bells for Larry Glickman, an epidemiologist at Purdue University's Veterinary School who developed the National Companion Animal Surveillance Program. A sneezy cat is more likely to be whisked off to the vet’s than its sneezy owner, who will try to tough it out with a stack of over-the-counter cure-alls. Sick kitties may turn out to be an important early sign of a bird flu outbreak. Glickman has also used pet data to chart diseases such as leptospirosis and Lyme.

2) Rapid Diagnostics

Mass tag PCR uses special molecular tags that are coupled with genetic probes to identify specific pathogens, both bacterial and viral. Dozens of pathogens can be tested simultaneously.

Microarray tests are the new darlings of diagnostics. Researchers at Columbia University have been working on a test capable of identifying a virus in 14 hours, from a library of nearly 9,000 genetic probes representing 1,710 vertebrate viruses. Though a quick process of elimination, the test can also be used to spot new, never before seen, viruses. Work is also underway on a bacterial array.

3) Drugstore Clinics

The next big thing in health care is the In-Store Clinic. Pharmacy chains CVS, Rite-Aid and Walgreens plan to open hundreds of clinics over the next couple of years, partnering with companies such as Minute Clinic (“Your sick. We’re quick.”) and Take Care (“Professional Care. Always There.”) Venture capitalists are bullish and it looks like boom times for nurse practitioners.

By some estimates there could be as many 3,000 such clinics within a few years, with thousands more to come. They are well located for public health initiatives such as vaccine programs, and for quick preliminary diagnoses using tabletop micro-array tests. Their large computerized databases could also be used for tracking outbreaks.