Monday, March 23, 2009

Where Do We Go From Here?

Much has been written about our soon-to-be-thrust-upon-us “change” in health care delivery. I keep hearing about how our system is “broken,” untenable, limits access to the “47 million” uninsured, and needs immediate change. And yet somehow I do not see a broken system each day.

Currently, I see people coming to emergency rooms and being cared for faster than ever. I see people who actually are appreciative of the health care they receive more than those who are disgruntled. I see doctors working late hours to clean up their work as they struggle to get home in time to catch the end of their daughter’s play. I see surgeons reaching in bellies at all hours of the night with miraculous instruments as they pluck an inflamed appendix from the depths of the pelvis. I see state-of-the-art facilities, instruments, and automation. I see quality of life changed by neural stimulators that permit a patient with Parkinson’s to walk again. I see lives restored by biventricular defibrillators that can be checked from the patient’s bedroom or the countryside. I see teams of people devoting enormous amounts of energy to achieve health care “perfection” preventing infections, bed sores, medical errors while simultaneously trying to control costs. In short, I see a team effort of all involved, working together with the common goal of trying to take care of patients well in a remarkably competitive environment fraught with unbelievable regulatory requirements only rivaled by the nuclear power industry.

You know, do we see the glass half empty, or do we see it half full? I think, right now, right here in the good ol’ U.S. of A., we’ve got a pretty good health care thing going. Most kids get vaccinated, people are getting the anti-smoking message, people are living longer, and patients are empowered with information like never before. Oh sure, we've got a long way to go, but haven't we done some miraculous things with our current system? But we fail to see this for what it is. Instead, we hear that fetal mortality higher in the US than other “developed” countries, that we spend more per capita than any other country in the world with “poor quality.” And yet, I see more ninety-year olds on the wards now than I ever did as a medical student or resident. Is this just me? Is this because we’ve done a bad job at caring for these individuals? At least a few brave souls have disputed some of the assumptions. And there are certainly plenty of others who want to make sure we understand the problems. (Like there won't be any problems with the alternative). Oh sure, there are the scandals, the mistakes, and patients with just plain bad care, but taken as a whole, is America’s health care as bad as we’re being led to believe? Could at risk for throwing the baby out with the bath water?

I wonder.

I wonder because while some report there are 47 million uninsured, why do we never hear about the 253 million who are insured? Oh sure, many have to pay higher premiums and co-pays, and those payments are rising faster than water in the Titanic, but could there be another alternative policy for change that preserves the good in our system while meeting the needs of the disadvantaged? Is a health care system like the Department of Motor Vehicles drivers license facility or the VA Health System really what each of us wants?

As we ponder this vision, perhaps we should ask ourselves if these “lowest common denominator” policy initiatives in vogue right now might lead us to just that.



Anonymous said...

Welcome to the Ivory Tower. As one who travels to the west side of Chicago three times a week and sees alot of folks who can't get access to care, I couldn't disagree more. And this post hits on the main problem that I see as the argument for whether one looks at those individuals as low life, lazy, and unmotivated, and deserving of their health care predicament, or victims of many of societies ills that have placed a large part of our population in marginalized positions from which it is hard to escape. In other words, who has a better chance of success; the kid growing up on the west side of Chicago or the kid who is growing up on the North Shore outside Chicago? Sure there are some bad actors in these communities, but then there are the Bernie Madoffs of the world that populate rich communities and cause just as much crime and injustice as these common criminals in low income neighborhoods, but many are struggling to get by on their lousy public school educations and lack of role models to show them there are paths to success in our society.

If you live and practice on the North Shore, everything looks like honey and roses, but if you head out to rural communities and to impoverished neighborhoods, where some major medical centers (University of Chicago?) are designing schemes to keep the uninsured out of there hospitals, the picture is quite different. Public Aid, which should support this population, is a joke in the State of Illinois and begs the question why are poor people less deserving of reasonable health care than our elderly? At least that is the way I interpret the fact that it reimburses so poorly compared to Medicare and we on the North Shore send all our public aid patients to the residents clinic rather than caring for them ourselves (at least in primary care).

Maybe we should all spend some time down at Strogers or Provident Hospital to see what alot of this country is struggling with in terms of access to care. Ditto for our exposure to other countries and their plights.

Laura said...

About that 47 million... lies, damn lies, and statistics:

Anonymous said...

Well, I'm posting here as the "kid" (ok, 42 now, but still) of a blue-collar steel worker. And I'm convinced that my dad, that blue-collar steel worker, wouldn't be with us today if the health system we have today had been "fixed" by the government. Why? Because instead of getting in, getting diagnosed, and getting the surgery he needed as quickly as he needed it, he'd have been waiting, or possibly not even have been diagnosed correctly in time.

See, Dad has emphzyma. He smoked most of his life. He had already had two heart attacks at a fairly young age, and had 5-way bypass surgery several years before this happened. He had been coughing, not unusual for someone with emphzyma, but his doctor didn't like it and wanted an x-ray. He made him get one - immediately, no waiting. The doctor saw a spot on the x-ray. Again, it could have been the emphzyma, and the doctor said so, but he said he just didn't like it, and want it checked, so sent him to a specialist - again, no waiting. The specialist didn't like it either, and decided on a biopsy, which needed to be done.. you guessed it, right away, I think within a week or so.

Well, the biopsy showed lung cancer. It was in an extremely early stage - the doctors said they never catch it this early. So, they operated to remove the lobe of the lung where the cancer was. Again, they operated within a couple of weeks after the biopsy. Really, no waiting... they operated as soon as they could after having done the biopsy. They told us later that it turned out the kind of cancer he had is an extremely aggressive kind. Most people do not survive, because it is seldom caught early enough, and it grows too fast to remove all of it. They were able to remove all of the tumor before it had spread anywhere, and he didn't even need chemo. He has had no signs of the cancer for over 2 years now.

I doubt under any kind of socialized medicine this would have even been caught this early. And even if it had been, I doubt the doctors would have been allowed to move forward with testing, as they were mostly going on the fact that it just didn't "look right" or "sound right". And since it hadn't spread, it wouldn't have been an "urgent" case yet, and he would have likely been on a waiting list until it did become urgent, and therefore too late.

Balancing what the insurance paid with medicare (or medicaid, I get the two mixed up) and what my parents had to pay on their own wasn't easy, because my parents aren't rich. But better that than a "free" system that wouldn't help at all.

And I agree that we need to reach out to those who don't have health care, and find ways of helping them too. But not at the expense of throwing out a system that, overall, does work reasonably well, and replacing it with one that will work equally poorly for everyone. I would rather find ways of raising up the few than bringing down all to a worse level.

Laura said...

osxgirl2004, agreed. My husband was diagnosed with testicular cancer twenty years ago when the mortality rate was much higher. It had already spread to his lymph nodes and lungs, and MD Anderson moved heaven and earth on his behalf. If we were Canadians or Brits, I doubt the outcome would have been the same. I realize that we have the occasional horror story... but then so does the NHS, and theirs tend to be *because* of the system, not in spite of it.

Al said...

As a RN and a patient I have discovered one thing that is at the heart of the problem. Patients are not the customer of doctors and hospitals, insurance companies are. Few people have any idea how much health care costs and how to shop around for a good deal. They aren't required to become knowledgeable consumers. They pay their deductible and overlook what is being charged because the medical practitioners deal with companies, not individuals. Would Walmart, Target, et al. be as cheap and efficient if prices were decided by a third party? Oh, wait we know what happens. The failed USSR's long lines and poor selection showed the outcome. If health care becomes more controlled by the government the true consumer is still another third party. One that has no inherent desire to be efficient due to a profit motive. The answer is to give more power to the consumer. Allow more tax free accounts or any way to give back money to individuals and their families to use as they see fit.

Chris said...

I think Keith has it all wrong. No one is suggesting that the poor do not have access to health care because they are "bad" and "don't deserve it." We provide health care even to those who are in prison, although they, indisputably, are the low lifes of society.

No, the issue is simply one of economics, but as Dr. Wes says, it is not at all clear that the rush to a government-run system we are now in is the best course of action. There has really been no serious public discourse on this matter and not many alternative ideas floated.

Keep in mind that your arguments are the same ones that lead to the welfare system that was eventually acknowledged as a bad response to the poor's plight and bi-partisanly dismantled in the '90s. We don't want a repeat of that scenario.

Mike said...

"I see people coming to emergency rooms and being cared for faster than ever."

I, as a patient, do not see this. As a patient I see lower level employees running me through a gauntlet of tests, forms and other pre-MD-face-time work which means I'm still in the ER for 4 or 5 hours for something that should be quick and easy. Maybe from the physician's side you see a patient and 10 minutes later they are gone, but that's not the whole story.

Anonymous said...

This is the first time I have posted having read this blog for a long time.

I am the parent of a profoundly brain damaged child from meningitis at birth at a very famous hospital (she's 10 now though cognitively less than 1 year) and we have now had 17 neurosurgeries, chronic seizures, implants, etc. We know the system and we know how to avoid the ER waits and the like. But we have seen countless tragedies by this point. The healthcare system here works when things are aligned -- we know how to align them. But we have seen lots of failures, often because folks are just not paying attention, both medical personnel and patients.

Between my work and ourselves we pay $2000/month in primary and secondary insurance. It works and we will continue to pay, but how many can afford that ?

I can tell all manner of stories about insurance companies from amazing service when you are (our daughter that is) a multi-specialty customer where $300,000 was spent to save your life to the catch-22 of an HMO that lost pre-authorization letters and wanted to revoke paying for surgery that was already done. (HMO, never, ever, again -- employment decisions made on that). It is what we have here in the US and it will not change. But, there will be new options added on, I suspect.

My neighbor is French Canadian by birth. Her sister in Canada was diagnosed with melanoma last month. She was in treatment in two days- radiation/chemo, the whole gamut. They prioritize there. It may not be pleasant at times but it is based on what the best knowledge is at the time as to who needs treatment when.

My wife is from Denmark. Wonderful, quiet country (usually at least). I always describe it as having a somewhat lower average income and an incredibly compressed standard deviation on income compared to the US. By choice, they live that way. They have universal healthcare. They also have a private system to let you jump the queue if you want. You just have to be willing/able to pay. My mother-in-law is getting crummy heart care there, but she lives in the middle of nowhere. It would be the same here, I suspect (private or otherwise is not the point).

There are lots of variations, but no system can work omnipotently. We all have to be part of it. The world is not going to turn upside down as America tries to come to terms with the present by moving away from the past.

We should talk and experiment. It will not be the end of the world to change. Eyes/ears open, data being collected and honestly, objectively assessed, changes made as results are apparent. It will be a ride.

Stuart said...

Well, Keith,
Whose Ivory Tower?
If you want the health care system managed with all of the compassion, efficiency, and effectiveness of the public school system, then government health care is for you.
Just one more government bureaucracy that doesn't care about outcomes, just intentions.

Can anyone explain to me how health care will be less costly when we add an army of government bureaucrats to burden the system?

Anonymous said...

You know what you don't see Doctor? Me... You know why? Because I am uninsured, and don't make much above the minimum wage. I can barely cover rent and food, much less pay for doctor visits. That's why it's been nearly 10 years since I've gone to a doctor, except for a couple trips to the emergency room. Oh yeah, those trips... My credit record is still suffering because of those emergency room visits that I could NOT afford to pay for. So, I don't visit a family doctor, I stay sick, I am a less productive individual because of that, which of course limits the potential for me to rise economically in order to gain meaningful health coverage - and repeat.

Of course, I would not expect someone with a salary like yours to understand the plight of the under-employed and uninsured. What have you got to worry about, eh?

DrWes said...


Have you applied for Public Aid? Illinois (and most states) have such programs in place.