Health Care: Good Reading

[drscott]

Hat tip Greg Minkow's blog: long but rewarding Atlantic article on health care reform. They killed his father, and the bill was $636,687.75.

Comments

[txkink.livejournal.com]

A very good and detailed read though I think there are some questions to a few of his assertions.I do agree that hospital acquired or nosocomial infections are a travesty in this era, but I know our infection control officers at my hospital are like storm troopers about hand-washing.

I agree that there are many financially motivated doctors who benefit from ordering procedures, but I cannot understand how anyone can line their pockets by ordering lab tests. Now I work at a government funded county hospital for a salary, meaning I get nothing extra no matter what I order or do, but I don't know how any doctor could get extra money from lab tests. Every lab we order goes through the submission process to insurance carriers or covered by the tax-supported fund for uninsured patients. Maybe it can be done in the private world somehow but I would be surprised to find out how they do it. The financial and legal repercussions for trying to cheat Medicare and insurance companies would dissuade most doctors from even trying.

The line about doctors in Dallas versus small-town Oregon might have some other explanations (as a doctor working in Dallas). The way I read him, he seems to imply that since Dallas is a larger city it would have more specialists (agreed), but he again makes it sound like these specialists are ordering unnecessary tests to pad their wallets. As I see it, the specialists are necessarily in larger cities because they can't support even a small practice in more rural areas but also many of these specialists work at major medical schools which are also located in major cities, not rural ones. Because of this we get referrals from all over the region meaning some of our sickest and most complicated cases may not be Dallas citizens at all. These patients are also those requiring the most complicated and expensive diagnostic tests and treatments. I'm a psychiatrist but our unit has the reputation for taking patients with both severe mental illness and severe medical issues including dialysis. We've had calls from as far away as Kansas City looking for admission for such patients. I would guess that in the Oregon town he mentions that these more complicated and difficult patients are transferred to larger cities because they can't handle such cases. Another issue on the same subject is that Dallas has at least one if not more Level I trauma centers, again meaning that smaller cities and towns with severe trauma cases send all their patients to Dallas. Our heliport at Parkland often looks like a scene from M.A.S.H. with helicopters coming and going. Maybe this is an oversimplification on my part, but that one issue struck me as more complicated than he might know.

[dr-scott.livejournal.com]

You're referring to this comment, I think: "Most physicians, meanwhile, benefit financially from ordering diagnostic tests, doing procedures, and scheduling follow-up appointments. Combine these two features of the system with a third—the informational advantage that extensive training has given physicians over their patients, and the authority that advantage confers—and you have a system where physicians can, to some extent, generate demand at will."

About diagnostic tests particularly, many people think they are ordered in excess as a CYA maneuver, which helps protect against malpractice suits. I think you're right that it's less commonly directly beneficial to the doctor, though there are apparently places (I'm thinking of Florida) where it's not uncommon for the doctors to own some part of the test facilities, for example for MRIs. This is a Sunbelt phenomenon, mostly, and I suspect it's much more prevalent in retirement areas or places where the population is unsophisticated and fails to question whatever the doctor says.

I think his point about specialists is more that they are highly compensated, while generalists are not well paid for talking to patients, taking histories, doing coordination work, and being patient advocates. The spending stats may not be based on pateint residence but on location of facility, which might wel lessen his point as you say - referrals and travel for complex cases would then tend to make areas where specialists practice more apparently costly. But I think that other studies have shown that it is true that specialists do generate their own demand to some extent, with otherwise similar urban areas showing widely varying costs.

[audrabaudra.livejournal.com]

I had an experience with being under/uninsured in the American health care system recently. We were treated worse than dogs, and what happened to my husband would not have happened in any civilized system that is truly there to heal people, not to make money.

And I say that as a person who's had extensive experience with health care under so-called "socialized" systems.

Years ago, I had a child in the United States, then a bit later, another baby on the NHS in Britain. The care on the NHS compared to the American care was amazing. Imagine having a health visitor come to the home of a young mum with a toddler and baby to check on everyone! I wanted for absolutely nothing. The hospital might not have been brand new, the beds might have been old, but the human factor was outstanding.

A few years ago now, I was in a vehicle accident in New Zealand and paralysed my arm. As I am a legal resident of that country, the ACC takes care of me, and the care has been jaw-droppingly good. ACC care is rationed; if I'd smoked, no operation. But I have had literally $100,000 worth of care on the ACC, and my surgeon is world class. He has given me the use of my arm back from absolutely nothing, and I pay absolutely nothing by way of premiums, co-pays, deductibles or any other system designed to enrich shareholders.

Flash forward: this summer, while visiting the US, my New Zealand husband suffered a separated shoulder. We went to the ER at the nearest hospital with our travel insurance. My husband was given an x-ray and told to go see a specialist...whenever. Indeed, "whatever" was the attitude that greeted us, from the receptionist when I said we didn't have "an insurance card" to the MD on duty.

We were not told to put ice on the shoulder, and Ross wasn't even given any pain medication to get through the weekend. The so-called "doctor" couldn't be bothered to tell us the name of a specialist to see. He turned his back on us as we left. We came to learn that my husband had cracked ribs, too, which the hospital hadn't cared enough to look for. What would have happened if a jagged edge of bone had scratched the sac around Ross's lung? That hospital and that doctor could have cared less. We didn't have insurance, you see, not the kind that a hospital can ride into the ground, so we were shown the door.

It was disgusting. I have lived in three countries, yet I have never been subject to such callused indifference in a supposedly medical setting--but then I've been spoilt by the "evil" and "Orwellian" NHS and ACC.

I was ashamed for the US's treatment of my man compared to how well New Zealand treated me after a catastrophic injury. This place is disgusting, and quite honestly, Curtis, it's getting the care that it deserves. I'll be happy to go back to NZ and be looked after soon--and Ross will not go near another US medical facility for fear of the outrageous bill and the lack of basic competence.

[dr-scott.livejournal.com]

Well, it's a little unfair to take one example and apply it to the entire US -- how one is treated depends wildly on where one is, at the attitude of the facility, and the doctor who happens to be on duty that day. Even fully insured people can be treated very badly, and vice-versa.

You remind me of my separated shoulder anecdote. I had one beer at a wedding party in Arlington, Mass., and was running home to Cambridge on Mass Ave when I tripped over a 1/4" edge of a sidewalk block. Tumbling, I landed on my shoulder. I walked the rest of the way home and put a bag of froxen peas on my shoulder.

I was a member of a well-regarded nonprofit HMO (Health Maintenance Organization), Harvard Community Health Plan. With no profit motive and few of the incentives to overuse of the fee-for-service systems, care was still somewhat haphazard, and patients who didn't know anything tended to get assembly-line treatment.

I went to their ER. The doctor on call was a snotty young fellow just out of medical school; he was certain I had dislocated my shoulder, and at 2 AM the x-ray tech was not in, so he wanted to go ahead and try to re-locate my shoulder, so he directed the nurse to give me a shot of Demerol (pain killer.) I objected, since I knew Demerol might interact poorly with the MAO inhibitor I was taking (phenelzine.) This adverse interaction had recently killed a young woman in NYC under similar circumstances, a notorious case. The nurse obviously agreed with me, but the doctor told her to go ahead anyway, so she did. Luckily I didn't react in any way, and the x-ray tech showed up soon after, so the doctor's valiant effort to re-locate ("closed reduction") the shoulder joint never happened, since the x-ray showed it was just separated (ligaments stretched and damaged.)

I could have died from his arrogance. And "treatment" consisted of doing nothing, so while surgical intervention right after separation can reduce long-term consequences, they did nothing. I never saw an expert, so I don't know if "nothing" was actually the best treatment.

Your husband was treated very badly, and it's hard to believe they didn't even tell him to use ice. But I don't think it's fair to conclude that this was because he wasn't insured, or tar the whole US because of this incident, as you can be treated cavalierly and poorly in Canada or Britain just as easily despite the different systems there (I lived in Canada for five years.) While some of the national systems like Canada's and NZ's are spending much less per patient than the US does, all face issues of unaffordability from increasing costs and demographic issues -- the search worldwide is for smarter and cheaper systems. The debate now in the US is kind of covering that up, but Obama's effort implicitly attempts to begin reform of Medicare to get it away from unlimited fee-for-service -- which old people are very happy with, but which the country cannot afford in a few decades when a much higher percentage of the population is in that system. Young people cannot forever write blank checks for the old.

[txkink.livejournal.com]

A great reply both here and to my comment above. What happened to both you and this woman's husband is inexcusable. The doctor who ignored your warning about the MAOI should have been fired.

I cannot agree with you more on the subject of insured vs uninsured getting different care. I'm not told what a patient's funding status is until we're discussing disposition. It has absolutely no bearing on what I order in their care. In the ER especially, there's absolutely no distinction made between the two. The law states we have to treat all comers regardless of their funding. In fact in Dallas (as elsewhere) it was the doctors who refused to go along with asking patients if they were here legally or not. The hospital administrators floated that idea with us but ethically we were all opposed.

Many of the accounts I hear of horrible care seem to come from hospitals with trainees. This is not an excuse but is perhaps an explanation. Despite many rules about supervision, numbers of hours worked, etc. there are still problems with poor care - some of it due to poor supervision while others are from trainees who do not follow standard of care.

I am one of many doctors who desperately wants this system reformed. Our fear is that it will sink deeper into the mire of bureaucracy which will not improve care. Money is not and never was my motive for medicine. Even 14 years after residency my salary is $20K per year less than new graduates starting in private practice groups. My hope is that all those who have no coverage can have some consistent and reliable resource instead of the designation "self pay" which means they will ultimately get a huge bill.

[audrabaudra.livejournal.com]

Curtis, I know. I know it's desperately unfair to tar the whole country with one brush based on the anecdotal evidence about my husband's injury. Now that the emotion has worn off from my recounting, I will agree that American medical research drives the world, and our practitioners are fantastic here, too. I agree that a person might get treated poorly in Canada or the UK. I had an IUD inserted as birth control in the UK, and my US doc was appalled when I came over here, which goes to show.

Yet I think that if you go to an ER in the US and 1) you have a funny accent, and 2) you say you have "travel insurance" when the doctor (Yes, the doctor) asks if you have any coverage, then 3) the likelihood of being treated like cattle at the abattoir is significantly higher than it might be in a country where healthcare is more freely doled out.

I know it's hard to believe that the doc never told us to put ice on the injury, but he didn't. I'm extraordinarily detail-oriented in these situations, plus I still have a copy of his written orders, kept for our NZ insurance. He wrote instructions about 800mg of ibuprofen, but nothing else. When we got home and got Ross to bed, I Googled and saw that the primary treatment is ice. Couldn't believe that the doctor hadn't said a word about something so basic. Perhaps he thought the hospital would have to supply a cold pack if he did.

More, anecdotally speaking. NZ: I was in orthopaedic trauma in a bed across from a Swiss woman who'd fallen whilst penguin-watching in Antarctica and come to Christchurch as first port of call for treatment off the Russian boat (international!). She spoke French, and we chatted, but her English was quite poor. She was going home to Switzerland to recuperate, so her insurance sent a nurse to travel with her. The nurse was fluent, and she set about making the discharge arrangements. I was a witness to what happened next: a man from Christchurch Hospital came to Giselle's bed and explained to both women that Giselle would have to pay NZ$30,000 in cash before she could go.

It's only half the amount in Euros--15,000 or thereabouts--so it wasn't a huge burden. Still, the NZ hospital wasn't accepting the travel insurance's promises.

Limitations, then, on travel insurance wherever one goes...but Giselle wasn't sent back to her hotel room with advice to see a specialist "whenever," either.