Thursday, February 7, 2008

One man's take

Everyone else is doing it; I figured it was time to articulate some sort of stance on the "health care crisis". It's an issue I've been vaguely aware of for a long time, but hadn't put any real thought into it because, truthfully, I was pretty ignorant of the issues and options. I've never been one to get involved in political issues. I wasn't the class president sort of guy. I'm a grinder. I like to show up evey day, take care of patients, operate, and let the "smart people" figure out what to do about compensation and coverage. But with the upcoming election, it has become apparent that universal health care has become a lightning rod issue. Change is on the horizon. The present system isn't working. We live in the wealthiest country in the history of the world and millions of people either have no coverage at all, or inadequate coverage. ER's have turned into overcrowded dumping grounds where people go when they're too sick to go anywhere else. This patchwork quilt of multiple private insurance plans casts too narrow of a net. Employment based insurance works well when everyone in town works at the steel mill or the auto plant, but that paradigm of employment is disintegrating in America.

No one spends more per capita on health care than the United States. So where is all that money going? Why are there have-nots amongst us?

You have to start with a Defining Principle. Ask yourself, is it a fundamental human right to have access to health care? Your answer to that will guide all subsequent decision making. By a "right" this means not only that one has access, but that the provision of such access does not cause one to tumble into financial ruin. Showing up in the ER with a severe headache and being sent home with tylenol after a negative CT scan will get you a bill for several thousand dollars. Does every American citizen have a "right" to adequate preventive and emergency healthcare, or is health care merely another "commodity" to be purchased or earned? That's the issue. It's as simple as that. Where do you stand? For comparison, consider housing or sustenance. Are these human rights? Do you have a right to eat? Is health care the same type of issue?

Universal health care can come in two conceivable flavors. One would be a single payor system, presumably government run, that would be available to every American citizen. We're talking cradle to grave, socialistic health care. Your kid comes down with strep throat? Take him to the pediatrician and don't worry about co-pays. You're having severe abdominal pain? Go to the ER and get your CT scan, US, whatever it takes. The other form of universal health care would involve some combination of government programs(Medicaid) and an expansion of private health insurance. This is where the concept of "mandates" come into play. Just like it's illegal to drive a car without insurance, you would be required, with government subsidization in the form of either tax rebates or lump sum payments, to purchase a basic minimum of health insurance from the private insurer of your choice. In this system, free enterprise and the open market system is preserved.

Several questions:

1. I spent a substantial part of my training years working at Cook County Hospital. This was a government subsidized charity hospital. And it was a shit hole. Patients waited 6 months to have giant, painful inguinal hernias hoisted out of their scrotums. Women waited weeks for their breast surgery. The place smelled and too many of the employess didn't give a damn. Physicians who have trained at VA's and county hospitals across the nation will concur; the government doesn't exactly have a good historical track record running the show in the health care business. How will they do when the entire country falls under their domain?

2. What will happen to Kaiser and all the HMO's if a single payor system were implemented? Do they go out of business? Is this illegal? Is it fair? We're talking about shutting down multi-billion dollar enterprises.

3. The mandate system is absurd. The sort of people without insurance are exactly the kind of people HMO's don't want in their plan. You don't think premiums are going to drift higher and higher? Are we looking at a future of $4000 deductibles?

4. Theoretically, medical expenditures have no definable cap. In fact, it's infinite. If enough money is available, it will get spent. Take for example the 89 year old demented guy who comes in with an UTI, develops a DVT, gets septic, half the hospital staff is consulted, he starts vomiting, CT scans are ordered, he crashes, is intubated, etc etc. You could describe his hospital course as a series of problems, each with a diagnostic confirmation and an appropriate treatment plan. Or you could say: an old guy came into the hospital and embarked on the dying process. Thereby skipping alot of the nonsense and expense. The deal is, at some point, if you want to make health care available for everyone, rationing is going to be an inevitable component of making it financially viable.

5. How do doctors get paid? Do we become employees of Uncle Sam? What happens to quality of care if physician salaries drop so far as to make medicine an unappealing career choice. (Glorified civil servants).

6. Will a two-tiered system develop? The top tier consisting of upper middle class and wealthy Americans who can afford so-called concierge care and get their procedures done quickly and conveniently at stand alone boutique surgicenters. I have a friend who maintains this isnt a horrible thing. If you're receiving foodstamps, you oughn't be able to buy filet mignon and a bottle of beaujolais. Hamburger and milk and eggs, no problem.

7. When are we going to explicitly define "futile care"? When are we going to make it mandatory for patients in hospitals to have DNR/End of Life forms completed upn admission?

Sometimes, it's just too mind boggling to think we will be able to efficiently reform our broken system in the foreseeable future. The uninsured are a drain on society, no doubt. But it goes deeper than that. The well-insured demented gork who sucks thousands of dollars every day out of the ICU is just as much a drain. We have CEO's of for-profit HMO's raking home 7 figure salaries; but what did you expect? That's what CEO's of private companies are supposed to make. So why are private companies in control of doling out our health care dollars? It makes my head spin. I have a case now.... let me know when somebody comes up with the panacea....


rlbates said...

I don't know what to add. I too am a "grinder". Wish I had the solution.

Anonymous said...

After reading your post, I'm more confused than ever. So much to consider. So much at stake.
(puts head back in sand)

Sid Schwab said...

Those are excellent questions. I know I don't have the answers. A comment: I don't think single-payor implies government-run hospitals any more than medicare does. But I agree: all the government hospitals at which I've worked -- SFGH, the VA -- had more than their share of employees that didn't give a shit. I assume at some point the system will look like medicare, with a single payor but a mostly private system. There will be overt or de-facto rationing at some level. Hopefully, there will also be panels of providers and patient who will have real input into how it works, including reimbursement levels. Who knows. My plan is still to stay healthy until I die.

Sid Schwab said...

PS: stop calling me Dr Schwab.

Jeffrey Parks MD FACS said...

Sorry doc... old habit.

Anonymous said...

What we have in the Netherlands is mandatory insurance, but with a few additional provisions: insurance companies have to accept anyone, no matter what their state of health is and have to charge everyone the same. This holds for basic insurance which covers all normal needs. It is not perfect, but it works pretty good.