It's Thanksgiving...
This Blog is primarily for pointing out the negative aspects of our broken American health care delivery system (and to explore how we should fix it).
But today is Thanksgiving, a time that we should be thankful, and remember that things are not all bad, and could certainly be a lot worse.
There are many things about health care in America that are amazing...the secret will be to retain the good, to throw out the bad, and to create anew to the limits of our imaginations.
BE HEALTHY
Thursday, November 27, 2008
Tuesday, November 25, 2008
Medicare Mess
Food for thought as the forces for and against health care reform, and the different models for reforming the health care system begin to align.
Most recent proposals, including President-elect Obama's plan, advocate augmenting the current system of private health insurers and the government-run Medicare and Medicaid.Myths abound, and part of the process of forging a workable solution to the American health care morass will be to move lawmakers and the public towards reality.
Medicare, which provides payment for the majority of the medical care for Americans over the age of 65, is often pointed to by policy-makers as a model of health care efficiency. Reportedly, only 3% of Medicare expenditures go towards administrative costs, compared to 20%-30% for private insurers.However, while direct expenditures on Medicare administrative costs may be low, layers of draconian regulations that Medicare has created, and indirectly passes on to the rest of the health care industry, create incredible amounts of waste.
Case in point...I love taking care of the elderly. In the past, my practice has gravitated towards geriatrics, and while I love taking care of patients of all ages, I think I enjoy my older patients the most. My practice moved about 40 miles this year, from Maryland to Virginia. I have been enrolled with Medicare for almost 10 years. When my practice switched states, I had to enroll with another Medicare provider. I filled out stacks of papers. The only change was the address. Five months later, I am still not enrolled. In the past, to make up for such delays, Medicare allowed retroactive billing, so that physicians could see Medicare patients, and when their enrollment became official, they could receive payment for the work they had done. Bad for cash flow, but if you could get by that, at least you could see patients. Now, Medicare has proposed limiting retroactive billing to only 30 days. Squeezed on all sides, it's damned hard to see Medicare patients.
Need more convincing? Medicare establishes the payment schedule for the care that doctors provide, and private insurances tend to use these rates to set their own (did someone say price controls?). Unfortunately, Medicare reimburses the work of primary care physicians at a far lower rate than other types of physicians. Many physicians have found that it costs them more to see a Medicare patient (business overhead) than they are paid. At least two things have happened as a result. First, many primary care physicians are unable to see Medicare patients (the people who often need the most help). Second, medical students, many of whom incur incredible amounts of debt during medical school (many of my Georgetown medical students report debt levels between $200,000 and $300,000!!), avoid going into primary care medical specialties. A recent JAMA report showed that only 2% of American medical students are going into primary care, though it is well known that primary care doctors are the backbone, and the most cost-efficient part of the health care system.
In other words, Medicare has systematically created a crippling shortage of primary care physicians.
What is the lesson here? Is a government entity by nature unable to administer health care in America? That conclusion ignores that Medicare has many positive aspects. As mentioned earlier, it is a far more efficient administrator than private insurance.Case in point...I love taking care of the elderly. In the past, my practice has gravitated towards geriatrics, and while I love taking care of patients of all ages, I think I enjoy my older patients the most. My practice moved about 40 miles this year, from Maryland to Virginia. I have been enrolled with Medicare for almost 10 years. When my practice switched states, I had to enroll with another Medicare provider. I filled out stacks of papers. The only change was the address. Five months later, I am still not enrolled. In the past, to make up for such delays, Medicare allowed retroactive billing, so that physicians could see Medicare patients, and when their enrollment became official, they could receive payment for the work they had done. Bad for cash flow, but if you could get by that, at least you could see patients. Now, Medicare has proposed limiting retroactive billing to only 30 days. Squeezed on all sides, it's damned hard to see Medicare patients.
Need more convincing? Medicare establishes the payment schedule for the care that doctors provide, and private insurances tend to use these rates to set their own (did someone say price controls?). Unfortunately, Medicare reimburses the work of primary care physicians at a far lower rate than other types of physicians. Many physicians have found that it costs them more to see a Medicare patient (business overhead) than they are paid. At least two things have happened as a result. First, many primary care physicians are unable to see Medicare patients (the people who often need the most help). Second, medical students, many of whom incur incredible amounts of debt during medical school (many of my Georgetown medical students report debt levels between $200,000 and $300,000!!), avoid going into primary care medical specialties. A recent JAMA report showed that only 2% of American medical students are going into primary care, though it is well known that primary care doctors are the backbone, and the most cost-efficient part of the health care system.
In other words, Medicare has systematically created a crippling shortage of primary care physicians.
The lesson is that we need to be able to identify those aspects of our system that work, and those that do not, to keep what does, and throw out that which does not. We need to retool without fear to find what will work and what will cost less...and our guiding principle should be...KEEP IT SIMPLE.
BE HEALTHY
Saturday, November 22, 2008
Visionary Change or Incremental Reform?
Health care, global warming and energy, the economy, the war on terror, which is the top priority? Can we handle them all at once, some of them, one of them only, or even just part of one?
I say think big, but keep it simple.
The answer, I think, can be found in chaos theory. Chaos theory describes the workings of complex, seemingly indecipherable (chaotic) systems, and simply stated, finds that if we step back far enough and look with the right perspective, we can find predictable patterns.
Looking at all that's going on right now, even with a focus on health care or global warming, it can seem dauntingly confusing. But if we step back, and maybe change our perspective a little, borrowing from chaos theory, we can find simple patterns.
What are we trying to accomplish in all these endeavors? Really, the same thing.
We're trying to improve the human condition.
Is there a common thread in our approaches to these problems?
One common thread is that we try and make fixes that are affordable.
Are there dominant forces that affects all the systems at once?
Yes. One is that, more than ever before, all systems are connected.
That was obvious this week, as Congress considers a bailout for the auto industry. American car makers' bottom lines suffer against their international competitors because of rising health insurance costs. And the American auto industry's most serious problem is that it has not innovated in response to rising energy fuel costs and the need for lower CO2 emissions. And, the decades long battles over the middle east, and more recent terror threats are based on our need for scarce oil.
So, if we hope to act effectively, we really have to address everything at once.
Think BIG, but keep it simple, and communicate clearly.
1. Declare our commitment to clean energy and energy independence within 10 years.
2. Assist the auto industry only to the extent that U.S. carmakers commit to pollution-free cars within 5 years.
3. Single-payer health care reform now.
BE HEALTHY
I say think big, but keep it simple.
The answer, I think, can be found in chaos theory. Chaos theory describes the workings of complex, seemingly indecipherable (chaotic) systems, and simply stated, finds that if we step back far enough and look with the right perspective, we can find predictable patterns.
Looking at all that's going on right now, even with a focus on health care or global warming, it can seem dauntingly confusing. But if we step back, and maybe change our perspective a little, borrowing from chaos theory, we can find simple patterns.
What are we trying to accomplish in all these endeavors? Really, the same thing.
We're trying to improve the human condition.
Is there a common thread in our approaches to these problems?
One common thread is that we try and make fixes that are affordable.
Are there dominant forces that affects all the systems at once?
Yes. One is that, more than ever before, all systems are connected.
That was obvious this week, as Congress considers a bailout for the auto industry. American car makers' bottom lines suffer against their international competitors because of rising health insurance costs. And the American auto industry's most serious problem is that it has not innovated in response to rising energy fuel costs and the need for lower CO2 emissions. And, the decades long battles over the middle east, and more recent terror threats are based on our need for scarce oil.
So, if we hope to act effectively, we really have to address everything at once.
Think BIG, but keep it simple, and communicate clearly.
1. Declare our commitment to clean energy and energy independence within 10 years.
2. Assist the auto industry only to the extent that U.S. carmakers commit to pollution-free cars within 5 years.
3. Single-payer health care reform now.
BE HEALTHY
Thursday, November 20, 2008
Assuring the Insurers
It was reported today in the New York Times that a number of large health insurance groups have signalled possible cooperation with President-elect Obama's call for universal insurance, as long as obtaining health insurance becomes mandatory for everyone...
Of course we'd love to help the health insurance industry...the industry that has made their product so expensive and/or denied care to so many that almost 50,000,000 Americans go without health care...like the spouse of a patient that we heard about today. Nice couple with a small child. Unfortunately, the spouse had the misfortune of being diagnosed with multiple sclerosis, and has been going to expensive neurology appointments, and receiving expensive treatments, paying out of pocket, until recently when they found that they couldn't afford the cost of having both a small child and an expensive medical problem. So, they made the logical choice. Who could argue? Children, of course, come first. I guess they can put off the medical care until their child grows up, as long as they don't want to go to college, that is.
BE HEALTHY
Of course we'd love to help the health insurance industry...the industry that has made their product so expensive and/or denied care to so many that almost 50,000,000 Americans go without health care...like the spouse of a patient that we heard about today. Nice couple with a small child. Unfortunately, the spouse had the misfortune of being diagnosed with multiple sclerosis, and has been going to expensive neurology appointments, and receiving expensive treatments, paying out of pocket, until recently when they found that they couldn't afford the cost of having both a small child and an expensive medical problem. So, they made the logical choice. Who could argue? Children, of course, come first. I guess they can put off the medical care until their child grows up, as long as they don't want to go to college, that is.
So, it only makes sense that with the great job that health insurance has done so far, of course we should place all of our health care eggs in their basket, even make purchasing health insurance mandatory. That way, every American would have the opportunity to pay insurance premiums that increase at three to four times the annual rate of inflation, or the opportunity to pay thousands of dollars in deductibles before they actually get any care paid for by their insurer, or the ultimate opportunity...to have their claim arbitrarily denied when they need help the most.
I apologize if my sarcasm regarding the health insurance industry isn't clearly evident in my writing, but I'm new to blogging and I'm working on my writing chops. But to use a simile to make myself more clear, giving the health insurance industry more control over health care seems a little like the Roadrunner allowing Wile E. Coyote to make his dinner plans for him.
BE HEALTHY
Wednesday, November 19, 2008
Do you care? Do we care?
Do you care?
We met a new patient, a patient with AIDS which had been controlled on medications, but they could no longer afford the medications, so they were stopped. Unchecked, AIDS did what AIDS does, and the patient developed pneumocystis pneumonia, and was hospitalized, subsequently going into kidney failure, all of which required an expensive stay in the ICU. Thankfully, the patient's acute problems improved. Now, in addition to having to find an AIDS specialist that the patient can afford, and a source of affordable medications, not to mention the general stress of having to live every day with a life-threatening condition, there are also massive hospital bills to contend with.
Do you care?
I'd mentioned a patient last week who, unable to get health insurance or afford their cardiac medications, had a heart attack. They required 3 stents to re-open the blocked arteries in their heart. Very expensive. Now on another medication, Plavix, necessary to keep those newly opened arteries open. Also expensive. Has a follow-up with the cardiologist next month, a planned nuclear stress test, and a renal artery ultrasound (to see if there is a special reason that the patient's blood pressure is so high). All very expensive. And oh, by the way, still doesn't have health insurance...pre-existing conditions.
Do you care?
Member of my health care team told me about a loved one who had the pleasure of having a kidney stone recently. Despite working in the health care field...no health insurance. They knew they couldn't afford a visit to the ER, so sat at home, in tears, and waited the agonizing hours, through excrutiating pain, until the stone passed.
This is all occurring in a prosperous small city, nearly in the shadow of a gleaming new hospital, filled with the best that modern medicine has to offer.
Do we care? Do we really care? Because if we really care, then relax, because all this is fixable. We have treatments for all of the problems mentioned above...we have great clinicians, amazing medications, mind-blowing surgeries. All we need is a system that delivers them in an affordable manner. And if we really care, then that's the easy part. A challenge, yes, but still the easy part.
We're faced with an intimidating array of challenges today. But in those challenges are the opportunity to re-capture the best that we are capable of. Other generations have faced worse circumstances, most notably our parents and grandparents, who responded to the Great Depression and World War II with wisdom, sacrifice, and might.
We can't sit back and watch from the sidelines. Our system needs participation to function. President Obama won't be able to do this on his own. Wake up America and do what Americans do best...do we care?
We met a new patient, a patient with AIDS which had been controlled on medications, but they could no longer afford the medications, so they were stopped. Unchecked, AIDS did what AIDS does, and the patient developed pneumocystis pneumonia, and was hospitalized, subsequently going into kidney failure, all of which required an expensive stay in the ICU. Thankfully, the patient's acute problems improved. Now, in addition to having to find an AIDS specialist that the patient can afford, and a source of affordable medications, not to mention the general stress of having to live every day with a life-threatening condition, there are also massive hospital bills to contend with.
Do you care?
I'd mentioned a patient last week who, unable to get health insurance or afford their cardiac medications, had a heart attack. They required 3 stents to re-open the blocked arteries in their heart. Very expensive. Now on another medication, Plavix, necessary to keep those newly opened arteries open. Also expensive. Has a follow-up with the cardiologist next month, a planned nuclear stress test, and a renal artery ultrasound (to see if there is a special reason that the patient's blood pressure is so high). All very expensive. And oh, by the way, still doesn't have health insurance...pre-existing conditions.
Do you care?
Member of my health care team told me about a loved one who had the pleasure of having a kidney stone recently. Despite working in the health care field...no health insurance. They knew they couldn't afford a visit to the ER, so sat at home, in tears, and waited the agonizing hours, through excrutiating pain, until the stone passed.
This is all occurring in a prosperous small city, nearly in the shadow of a gleaming new hospital, filled with the best that modern medicine has to offer.
Do we care? Do we really care? Because if we really care, then relax, because all this is fixable. We have treatments for all of the problems mentioned above...we have great clinicians, amazing medications, mind-blowing surgeries. All we need is a system that delivers them in an affordable manner. And if we really care, then that's the easy part. A challenge, yes, but still the easy part.
We're faced with an intimidating array of challenges today. But in those challenges are the opportunity to re-capture the best that we are capable of. Other generations have faced worse circumstances, most notably our parents and grandparents, who responded to the Great Depression and World War II with wisdom, sacrifice, and might.
We can't sit back and watch from the sidelines. Our system needs participation to function. President Obama won't be able to do this on his own. Wake up America and do what Americans do best...do we care?
Monday, November 17, 2008
West Virginia - Let's Go from Worst to First
As a doctor to many West Virginians, and a West Virginian myself for the last nine years, it was disappointing, to say the least, to see the results of the CDC report, released today through the AP (http://www.washingtonpost.com/wp-dyn/content/article/2008/11/16/AR2008111600850.html?hpid=sec-health), showing that Huntington, WV is the unhealthiest city in the nation.
This report adds insult to injury, in a state known to have many of the worst health statistics in the nation, to have the unhealthiest city in the nation as well, and for it to be broadcast in such an unflattering way.
Maybe statistics are a dry way to look at things, but the fact is, underlying these statistics is a great deal of real suffering and unsupportable expense.
West Virginians, aren't we fed up with the worst?
Governor Manchin, Senators Byrd and Rockefeller, doesn't it sting to continually see statistics like this, and know that it means that so many West Virginians are suffering?
Why don't we turn this around?
Let's be the first state in America to enact meaningful health care reform, in the form of a state-based single payer system that brings affordable health care to all West Virginians. Let's show the nation the way to improved health statistics and improved health care.
Worst to First...
BE HEALTHY
This report adds insult to injury, in a state known to have many of the worst health statistics in the nation, to have the unhealthiest city in the nation as well, and for it to be broadcast in such an unflattering way.
Maybe statistics are a dry way to look at things, but the fact is, underlying these statistics is a great deal of real suffering and unsupportable expense.
West Virginians, aren't we fed up with the worst?
Governor Manchin, Senators Byrd and Rockefeller, doesn't it sting to continually see statistics like this, and know that it means that so many West Virginians are suffering?
Why don't we turn this around?
Let's be the first state in America to enact meaningful health care reform, in the form of a state-based single payer system that brings affordable health care to all West Virginians. Let's show the nation the way to improved health statistics and improved health care.
Worst to First...
BE HEALTHY
Sunday, November 16, 2008
What Would America Do?
Who doesn't love stories of the American dream?
Someone who pulls themselves up by their bootstraps, and makes something greater than that which they were initially given?
Only, I don't hear that so much today.
Here's one I did hear...
A new patient came to see me, someone who has significant health problems. Had worked hard for years, but last year got laid off, and then lost their health insurance.
Was able to find other work, but was denied health insurance due to pre-existing conditions. Finally got some coverage, and medicines had been re-started, only wasn't able to afford some of them.
Most of our visit was spent trying to figure out which medicines we could switch to that the patient might be able to afford. We also got some baseline labs.
I called the patient a few days later to discuss the lab results, only they were in the hospital, having had a relapse that could have been prevented had they been able to take their medications...
It's the weekend, a time when many Americans go to their places of worship, so I'll pose some theological questions:
1. Did God give us love and the task to use that love to help take care of one another? I believe the answer is YES.
2. Did God give us knowledge and the intelligence to create the miracles of modern science and medicine? Again, I believe the answer to be YES.
3. Did God give us the wisdom to fix our health care system, and the guts necessary to make the decisions necessary to do so?
BE HEALTHY
Someone who pulls themselves up by their bootstraps, and makes something greater than that which they were initially given?
Only, I don't hear that so much today.
Here's one I did hear...
A new patient came to see me, someone who has significant health problems. Had worked hard for years, but last year got laid off, and then lost their health insurance.
Was able to find other work, but was denied health insurance due to pre-existing conditions. Finally got some coverage, and medicines had been re-started, only wasn't able to afford some of them.
Most of our visit was spent trying to figure out which medicines we could switch to that the patient might be able to afford. We also got some baseline labs.
I called the patient a few days later to discuss the lab results, only they were in the hospital, having had a relapse that could have been prevented had they been able to take their medications...
It's the weekend, a time when many Americans go to their places of worship, so I'll pose some theological questions:
1. Did God give us love and the task to use that love to help take care of one another? I believe the answer is YES.
2. Did God give us knowledge and the intelligence to create the miracles of modern science and medicine? Again, I believe the answer to be YES.
3. Did God give us the wisdom to fix our health care system, and the guts necessary to make the decisions necessary to do so?
BE HEALTHY
Thursday, November 13, 2008
To Make Health Care Reform Work: Lower Health Care Costs
Every serious attempt to reform the U.S. health care system dies with the same question, the only question that seems to matter any more..."How are you gonna pay for it?"
Therefore, any attempt to reform the health care system that hopes to have any chance at success, or to make it past any state legislature, must anticipate, and clearly address the question.
There are two exceedingly simple ways to lower the cost of health care in the United States:
1. SIMPLIFY
2. PREVENT THE PREVENTABLE
First and foremost, the United States health care system is trapped within and weighed down to the point of breaking by a horrible, complex mess of Byzantine rules and regulations that complicate care and GREATLY INCREASE COSTS.
The key to successfully reforming the U.S. health care system is to greatly SIMPLIFY these rules and regulations.
At the risk of boring my dear readers, but to give just a taste of the administrative nightmare that medical organizations must traverse, the following is a simplified version of what needs to be considered today, in America, when billing for a patient visit...in order to submit a bill for service, every time I see a patient I have to calculate a level of visit code, which is based upon:
The lesson, of course, is that we need to SIMPLIFY THE SYSTEM! It is impossibly complex, does not improve patient care (probably diminishes and limits it), does not provide accurate data (it's too complex to use accurately), and adds a huge amount to the cost of medical care. There need to be greatly simplified and nationally uniform billing and coding schemes and one simple uniform national billing form. The current system, as determined and applied by Medicare/Medicaid and the hundreds to thousands of health insurance companies needs to be thrown out and completely redone and greatly SIMPLIFIED and uniformly applied across the country. Without this change, health care and health care reform will be too expensive. This needs to be STEP ONE of fixing and reforming the health care system.
STEP TWO is to PREVENT THE PREVENTABLE. In other words, and I'll try to be brief, a large proportion of medical care today involves preventable problems, such as obesity, diabetes, heart disease, smoking related lung problems, and many preventable cancers. It is well known that as our population ages that the costs of caring for these often PREVENTABLE conditions are going to expand, and likely become unsupportably expensive. We must embark on a national campaign to BE HEALTHY, to exercise and eat better, and to limit smoking. This must be officially, governmentally, coordinated and supported in homes, schools, and places of work. Such a campaign is necessary and will have a HUGE impact on our national well-being and health care expenditures, without which health care, and health care reform, will be too expensive.
To summarize, the number one requirement of successful health care reform is to successfully answer the question, "how are you going to pay for it?" The way to pay for it is to SIMPLIFY the system, and to PREVENT PREVENTABLE medical conditions.
BE HEALTHY
Therefore, any attempt to reform the health care system that hopes to have any chance at success, or to make it past any state legislature, must anticipate, and clearly address the question.
There are two exceedingly simple ways to lower the cost of health care in the United States:
1. SIMPLIFY
2. PREVENT THE PREVENTABLE
First and foremost, the United States health care system is trapped within and weighed down to the point of breaking by a horrible, complex mess of Byzantine rules and regulations that complicate care and GREATLY INCREASE COSTS.
The key to successfully reforming the U.S. health care system is to greatly SIMPLIFY these rules and regulations.
At the risk of boring my dear readers, but to give just a taste of the administrative nightmare that medical organizations must traverse, the following is a simplified version of what needs to be considered today, in America, when billing for a patient visit...in order to submit a bill for service, every time I see a patient I have to calculate a level of visit code, which is based upon:
- Whether the person is new to the practice or a previously established patient
- Is being seen for evaluation and management of a medical problem or for preventive care (or some combination of the two, in which case you need to calculate and submit two codes)
- Then one of 5 billing codes is selected based upon:
- The number of items discussed in the patient's "history of present illness"
- The number of systems discussed in a patient's "review of systems"
- Whether or not or how many items have been reviewed from a patient's past medical history, family history, or social history
- The number of body systems examined, and the number of items within each system in the physical examination
- Then the level of medical decision making must be estimated, which is based on the general risk of the case, which can be minimal, low, moderate, or high
- The complexity of the diagnosis or treatment options
- The complexity of the patient data (testing) that has been performed (which, I suppose are all quite subjective)
- But, you could bypass all of the above and bill based on time, if at least one half of total face-to-face time involved counseling or coordination of care
- Then we have to assign diagnostic (ICD-9) codes to each diagnosis, which can be extremely difficult, because the coding system is incredibly complex and sometimes uses names for diagnoses completely different from the terminology doctors are taught
- Then CPT codes for any testing or other services that we may have provided
- Then, all this information has to be arranged on a billing form, which is different for each insurance company, and is so complex that it is usually done by billing staff.
- To make matters much worse, the insurance companies have large staffs, and often deny claims or large portions of them, based on idiosyncratic, arbitrary decision-making schemes.
The lesson, of course, is that we need to SIMPLIFY THE SYSTEM! It is impossibly complex, does not improve patient care (probably diminishes and limits it), does not provide accurate data (it's too complex to use accurately), and adds a huge amount to the cost of medical care. There need to be greatly simplified and nationally uniform billing and coding schemes and one simple uniform national billing form. The current system, as determined and applied by Medicare/Medicaid and the hundreds to thousands of health insurance companies needs to be thrown out and completely redone and greatly SIMPLIFIED and uniformly applied across the country. Without this change, health care and health care reform will be too expensive. This needs to be STEP ONE of fixing and reforming the health care system.
STEP TWO is to PREVENT THE PREVENTABLE. In other words, and I'll try to be brief, a large proportion of medical care today involves preventable problems, such as obesity, diabetes, heart disease, smoking related lung problems, and many preventable cancers. It is well known that as our population ages that the costs of caring for these often PREVENTABLE conditions are going to expand, and likely become unsupportably expensive. We must embark on a national campaign to BE HEALTHY, to exercise and eat better, and to limit smoking. This must be officially, governmentally, coordinated and supported in homes, schools, and places of work. Such a campaign is necessary and will have a HUGE impact on our national well-being and health care expenditures, without which health care, and health care reform, will be too expensive.
To summarize, the number one requirement of successful health care reform is to successfully answer the question, "how are you going to pay for it?" The way to pay for it is to SIMPLIFY the system, and to PREVENT PREVENTABLE medical conditions.
BE HEALTHY
Line in the Sand, Part Two: the line is being crossed
Follow-up today from the patient with an abdominal mass, unable to afford care, despite the possibility of an untreated cancer (mentioned previously in Line in the Sand).
First of all, I find it interesting that, when I bring up the fact that I am writing a blog about our broken American health care system and the need for health care reform, patients like this express their willingness to allow me to write about them on the internet. I worry about confidentiality issues, but every patient I have mentioned it to has expressed gratitude that a doctor would take an interest in this way. It should be noted that I will continue to omit, and even modify, some information, to protect identities, and I won't mention the age or gender of any patient.
Anyway, this patient came back for a follow-up appointment. My nurse had inquired with a specialist in our organization about the possibility of offering a low-cost option for surgery. We were told that the patient would have to put down $10,000 before the procedure would be considered.
The patient, luckily bright and resourceful, made other plans. They called a previous physician, in another country (South America), and have arranged a medical vacation. Cost of the surgery plus a two-week hospital stay: $2,000. Cost of the rest of the trip (two months), all costs included: $1,200. So, a patient is forced to leave the country to get reasonably priced medical care! We hope for a positive outcome.
We can no longer tolerate this situation. People are suffering, not due to disease, but because of a health care structure that systematically denies care, rather than giving care. This is a humanitarian crisis playing out insidiously in front of our faces. How we address this is a test of our humanity, a test of our nation just as dire as any terror threat. We die inside, as a nation, when we allow people to suffer in this way, unnecessarily.
Tuesday, November 11, 2008
People are Dying and it Has to Stop
It's a remarkable challenge trying to help patients, difficult even under the best circumstances.
This is not the best of circumstances, however. The growing number of patients unable to afford medical care is changing typical patterns of diagnosing and treating common medical conditions, increasing complexity and costs in our medical system, and of course, impairing our ability to provide care.
A recent patient presented with four weeks of sinus symptoms. In fact, the very day the patient came in they had finally begun to feel much better (I take credit for that). They'd had the typical array of annoying cough, nasal congestion, facial pressure and pain, and ear pain. The symptoms had continued for an entire month, but remarkably, on the day of this appointment, had suddenly improved. As the symptoms had improved on their own, albeit slowly, there was no need for any particular treatment.
At the end of the appointment, however, the patient asked when the diarrhea would improve. Diarrhea? What diarrhea? It had started a few days earlier. My intuition told me that something was awry. Diarrhea isn't typical for a sinus infection. I questioned the patient, had they taken anything to treat the symptoms? In fact, unable to afford a doctor's visit at the time, and worried about the possible costs of treatment, they had located some old unused antibiotics, and had taken them. It just so happens that this particular antibiotic, not typically used for sinus infections, is associated with a potentially dangerous type of bowel infection, Clostridium Difficile colitis, which presents with diarrhea.
Now, rather than a simple sinus infection, we have a bowel infection as well, one that is sometimes difficult to treat, and has become increasingly prevalent, and aggressively infectious. Would have been much easier had she just been able to come in earlier, and not taken to self-doctoring that so many feel forced to try.
I discussed the case with a colleague who told me about another patient who, sadly, unable to afford care, had fared much worse. The patient had complained of pain, but when a diagnostic test was recommended, deferred due to excessive cost. They returned once more months later with the same pain, but once again, could not afford any testing. Finally, they came back, again months later, and the test was done, revealing what was then a late-stage cancer to which they would succumb a short time later.
Effective health care reform is a necessity NOW. The human toll of a broken health care system is real and expanding; the economic toll is immense, both in terms of the costs of later-stage and more serious health conditions, and also lost wages and productivity.
Health care reform is the civil rights of this era. We must attack this issue with the same passion and energy NOW, and not let the moment slip away again, as it has so many times in the past.
Monday, November 10, 2008
Don't Get Sick
Not a bad day in the office...the usual array of deferred basic lab tests and immunizations. One individual performed minor self surgery, fearful of the costs that an ER or actual surgeon would have entailed. The minor self surgery resulted in a minor complication, but luckily, we were able to intervene. Nothing life-threatening, thankfully.
I can take some solace in the fact that, apparently, my patients and I are not alone. The current edition of the American Medical News reports on the October Kaiser Health Tracking Poll, in which "36% of those surveyed said they delayed medical care they needed, up from 29% in the April poll. Similarly, 31% skipped a medical test or treatment, compared with 24% in April, and 27% didn't fill a prescription, up from 23%."
This is the irony of American health care in the year 2008. The U.S. is the most powerful nation in the world paired with the most dysfunctional health care delivery system.
My advice? Take care of yourself. I'm only half kidding. The best way to protect yourself from the financial stress is to avoid getting sick, not making necessary that nasty battery of tests and prescriptions that we physicians tend to insist on (and tend to force patients into foreclosure).
Most (though not all) of the serious medical issues that we deal with have a large preventable component. The top causes of death, consistently, in the U.S. are cardiovascular disease, cancer, diabetes, and smoking-related lung disease. By my reading of the medical literature, healthier eating, regular exercise, and tobacco avoidance could prevent more than 50% of these problems. We don't have many (any?) medications or surgical treatments that effective.
So, your best defense is to take care of yourself, or risk becoming a victim of the system.
Be a rebel. Save your house by eating a salad and going for a jog.
BE HEALTHY
I can take some solace in the fact that, apparently, my patients and I are not alone. The current edition of the American Medical News reports on the October Kaiser Health Tracking Poll, in which "36% of those surveyed said they delayed medical care they needed, up from 29% in the April poll. Similarly, 31% skipped a medical test or treatment, compared with 24% in April, and 27% didn't fill a prescription, up from 23%."
This is the irony of American health care in the year 2008. The U.S. is the most powerful nation in the world paired with the most dysfunctional health care delivery system.
My advice? Take care of yourself. I'm only half kidding. The best way to protect yourself from the financial stress is to avoid getting sick, not making necessary that nasty battery of tests and prescriptions that we physicians tend to insist on (and tend to force patients into foreclosure).
Most (though not all) of the serious medical issues that we deal with have a large preventable component. The top causes of death, consistently, in the U.S. are cardiovascular disease, cancer, diabetes, and smoking-related lung disease. By my reading of the medical literature, healthier eating, regular exercise, and tobacco avoidance could prevent more than 50% of these problems. We don't have many (any?) medications or surgical treatments that effective.
So, your best defense is to take care of yourself, or risk becoming a victim of the system.
Be a rebel. Save your house by eating a salad and going for a jog.
BE HEALTHY
Sunday, November 9, 2008
Line in the sand
I've lately been forced to learn to practice a new style of medicine. I like to call it "no cost medical care." It may be the ultimate way to lower health care spending...make medical care (or the insurance that usually pays for medical care...or the new wrinkle, rising health insurance deductibles) so expensive that no one can afford it, so no one gets any.
It began before the economic downturn, but now, with real hard times, it's becoming increasingly common...patients can no longer afford any significant aspect of their medical care.
It began insidiously. The first few times it was only that a patient couldn't afford some screening labs, important to their care but nothing life or death.
But then, I started to notice that patients were refusing to have crucial labs or tests, ones necessary to make an important diagnosis or treatment decision. At first, I was so taken aback, even indignant, that I nearly refused to treat the patient's problem.
But after the third or fourth time, I began to incorporate this new limitation into my practice style. It was kind of a throwback to the old days. If I have only a patient's history and physical exam findings, along with a very limited set of available treatments, can I fix what ails them? Often, I could, though it wasn't easy.
On the right day, seen in the right light, if I'm in a particularly good mood, it can be kind of fun...a challenge. How to take care of patients who can barely afford coming to see me, and can't in any way afford typical testing, hospital or ER care, specialist referrals, and certainly not most common medications.
It's certainly not an optimal way to practice, though. Patients are avoiding almost all preventive care, such as mammograms, colon cancer screening, and immunizations. It's a bet that we will begin to lose in the near future as people are diagnosed with late-stage cancers and preventable diseases become more common again.
And I will miss important diagnoses or mistreat simple problems because I didn't have available the basic testing and typical treatments for many problems.
It's already happening, as patients of mine are putting off surgeries for gallstones, infections, and obvious skin cancers.
But it really hit home recently. A very dignified, polite patient came to me for treatment of abdominal pain. I reviewed their chart and found that the problem had been worked up about six months ago, when they were found to have a growth in their abdomen. While the growth may have been a sign of a number of different diagnoses, cancer was certainly a consideration. The patient had decided, due to limited funds (and no health insurance) to defer immediate surgery in the hope that they could find less expensive care in another country. Unfortunately, that option proved also to be too expensive. The pain continued, and maybe a cancer has continued to grow.
This is the line in the sand. I told this patient as much.
Treatment for this patient's problem exists. In a five mile radius from my office, there may easily be 30 doctors who could treat this patient. Definitive diagnosis with follow-up studies and surgery is a simple matter.
It is deplorable that we have a system that denies easily available care to those who need it. It says something horrible about us. It is increasingly difficult to take part in such a system.
It began before the economic downturn, but now, with real hard times, it's becoming increasingly common...patients can no longer afford any significant aspect of their medical care.
It began insidiously. The first few times it was only that a patient couldn't afford some screening labs, important to their care but nothing life or death.
But then, I started to notice that patients were refusing to have crucial labs or tests, ones necessary to make an important diagnosis or treatment decision. At first, I was so taken aback, even indignant, that I nearly refused to treat the patient's problem.
But after the third or fourth time, I began to incorporate this new limitation into my practice style. It was kind of a throwback to the old days. If I have only a patient's history and physical exam findings, along with a very limited set of available treatments, can I fix what ails them? Often, I could, though it wasn't easy.
On the right day, seen in the right light, if I'm in a particularly good mood, it can be kind of fun...a challenge. How to take care of patients who can barely afford coming to see me, and can't in any way afford typical testing, hospital or ER care, specialist referrals, and certainly not most common medications.
It's certainly not an optimal way to practice, though. Patients are avoiding almost all preventive care, such as mammograms, colon cancer screening, and immunizations. It's a bet that we will begin to lose in the near future as people are diagnosed with late-stage cancers and preventable diseases become more common again.
And I will miss important diagnoses or mistreat simple problems because I didn't have available the basic testing and typical treatments for many problems.
It's already happening, as patients of mine are putting off surgeries for gallstones, infections, and obvious skin cancers.
But it really hit home recently. A very dignified, polite patient came to me for treatment of abdominal pain. I reviewed their chart and found that the problem had been worked up about six months ago, when they were found to have a growth in their abdomen. While the growth may have been a sign of a number of different diagnoses, cancer was certainly a consideration. The patient had decided, due to limited funds (and no health insurance) to defer immediate surgery in the hope that they could find less expensive care in another country. Unfortunately, that option proved also to be too expensive. The pain continued, and maybe a cancer has continued to grow.
This is the line in the sand. I told this patient as much.
Treatment for this patient's problem exists. In a five mile radius from my office, there may easily be 30 doctors who could treat this patient. Definitive diagnosis with follow-up studies and surgery is a simple matter.
It is deplorable that we have a system that denies easily available care to those who need it. It says something horrible about us. It is increasingly difficult to take part in such a system.
Saturday, November 8, 2008
It's time for a revolution
I am a family doctor, working now for about a decade.
I went into medicine for mostly the right reasons...I wanted life to be more meaningful, directed towards helping others. And sure, I wanted to make a decent living, as well.
I was full of energy, naive enthusiasm, and hopefulness about the possibilities, and despite all I've witnessed, I still am.
But that hope is tempered, for better and for worse, with the first-hand knowledge and daily experience of a broken-down health care system.
We have so many miracles available today, in the form of new/better/refined knowledge, many wonderful treatments of all sorts, and so many people that care and want to help.
But our health care system, more pointedly, the system that finances health care, does not function, and is keeping millions of people from getting care.
I see the results of this broken system every day, in the form of more and more suffering and desperate people. The huge majority of the problems that these people have are preventable and treatable, but the system rarely rewards prevention, and now actively denies treatment.
This is a deplorable, and because the system keeps people from accessing readily available care, an immoral, situation.
I am writing this blog as a way to educate people to the realities of our situation, and to explore, develop, and educate people about the readily available solutions that could exist.
There will be stories based on what I see every day. They will be based in fact, but I will need to omit and change information to protect confidentiality.
The only limits to the care that we are capable of giving to all people today are in our imagination.
We must, and we can, create a health care system that functions for all people. A functioning health care system is one of the cornerstones of a healthy society.
BE HEALTHY
I went into medicine for mostly the right reasons...I wanted life to be more meaningful, directed towards helping others. And sure, I wanted to make a decent living, as well.
I was full of energy, naive enthusiasm, and hopefulness about the possibilities, and despite all I've witnessed, I still am.
But that hope is tempered, for better and for worse, with the first-hand knowledge and daily experience of a broken-down health care system.
We have so many miracles available today, in the form of new/better/refined knowledge, many wonderful treatments of all sorts, and so many people that care and want to help.
But our health care system, more pointedly, the system that finances health care, does not function, and is keeping millions of people from getting care.
I see the results of this broken system every day, in the form of more and more suffering and desperate people. The huge majority of the problems that these people have are preventable and treatable, but the system rarely rewards prevention, and now actively denies treatment.
This is a deplorable, and because the system keeps people from accessing readily available care, an immoral, situation.
I am writing this blog as a way to educate people to the realities of our situation, and to explore, develop, and educate people about the readily available solutions that could exist.
There will be stories based on what I see every day. They will be based in fact, but I will need to omit and change information to protect confidentiality.
The only limits to the care that we are capable of giving to all people today are in our imagination.
We must, and we can, create a health care system that functions for all people. A functioning health care system is one of the cornerstones of a healthy society.
BE HEALTHY
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