Denialism

How will the candidates fix American health care?

—

by

MarkH
in

I don’t know. There was a pretty good piece in the New England Journal of Medicine, but it’s really not clear enough for most readers (including myself).

The McCain and Obama websites give fairly comprehensive looks at their health plans, but nothing useful for a lay reader.

The good news is that both campaigns have a plan. The bad news is that it is virtually impossible for anyone who cares to make heads or tails of the two and compare them effectively.

Well, gentle reader, I’m going to do you a favor. As an educated and knowledgeable professional, I am not going to try to parse through the various written statements, all of which leave me with more questions, in order to help you understand the issue.

I’ve left requests with both campaigns to ask to speak directly to other human beings, and if all goes well, to present to you an unbiased look at both plans and their implications.

Don’t hold your breath. Obama’s website has a pretty easy way to leave press inquiries. McCain’s not so much.

I just realized, I should probably outline a few problems.

First, in the U.S., we cost more and yet deliver worst outcomes than most industrialized nations. Second, we leave large numbers of the population uninsured.
Third, we compensate doctors based on physical procedures done to patients and don’t compensate for using thinking a research to answer a question to improve a patient’s health.
Fourth, our medical education is expensive.

So, graduating physicians have little incentive to take their debt-ridden bodies into a relatively lower paying primary care specialty and effectively force them into higher-paid, but less needed sub-specialties. We also create incentive for doctors to spend money by ordering tests and doing procedures, rather than by developing and following evidence-based guidelines.

The technology for electronic health records has been available for years, but for small practices such as my own, the cost is tremendous. EHRs improve patient care in innumerable ways, including tracking tests and other data, and improving communication with other providers and with patients.

That’s just a few things from a doctor’s perspective.

Comments

  1. The Chemist

    I never understood the low standard of care relative to money spent here in the US.

    In other countries I’ve been to it’s one of two things: I’ve seen lesser care for lesser money. Or the care is better for about the same, or equivalent for a little less.

    More importantly, in the last category you don’t have to wait a month to get an appointment with a specialist. My experiences with the system in the US(regardless of the competence of the doctors) has made me write it off as one of the worst I’ve seen without having seen that many.

    I spent a decent bit of time navigating the system, paying out of pocket, only to eventually ignore the problem in hopes it would go away. It has mostly, fortunately.

    Reply
  2. D. C. Sessions

    Alas, I have little hope for improvement. Two of the fundamental problems with the US “system” is that it:

    1) Has huge overhead built into it, with major amounts going to administration at all levels.
    2) Has built-in cost externalizations that horribly distort resource allocation.

    Neither candidate even proposes to tackle either one.

    Obama, to be fair, at least acknowledges the first problem and admits that there’s no practical politcal way to remove fingers from the pie. I’m not persuaded that that really justifies a plan that, in effect, just adds another bit of administrative overhead to the system.

    I would have thought that the Democrats might have had a prayer of going after the second, but I’ve seen no sign of it, and have my doubts that they will since any real attempt to clean up that mess will require budgetary line items that are poison in an election year.

    Reply
  3. jim

    Years ago I worked for a a company which created electronic medical record software. (Medicalogic, software engineer) You are correct the software is expensive.

    Some of the other barriers to entry were:
    1. Resistance by some physicians to give up paper scratches or dictaphone. (although we did have an interface to import transcription into the record)
    2. EMR forces you to think about your work flow and possibly standardize in a group. In a small practice this is not too much of a problem, only a couple of physicians. In larger practices etc. this became more unwiedly.
    3. Some types of practices see huge numbers of patients and recording (dermotologists) their mixtures slowed them down. (even with some planning) They would just write 20/80 blah de blah.
    4. Training. The whole thing can be quite overwhelming. Also you have to take time out of the day to do the training.
    5. Typing. While a lot of the system had point and click and could generate a note (and store discreete values eg height, weight, body temp.) Chief complaint, History of Present illness etc. had to be typed in. Some older physicians were not good typists and had an aversion to look at if they were fumbling. (this was almost 10 years ago, probably less now)
    6. We did not host the system, the practice did so they had to buy hardware, install and maintain it. (we could do the install for them, no extra charge) Then they had to configure their preferences etc. It took a lot of thought and time on their part.(of course, we had people to help them with that, but that was consulting – $’s)
    7. Dr.s had to sign their notes. So if a lab came in (imported) or a transcription etc. They had to “sign” their notes. For some reason a few Dr.s resisted this practice. (still don’t know why, most did “sign” their records)
    8. Many more reasons. I am sure the barrier to entry is lower now, but the cost is still high in terms of $ and time to set up.

    I looked at Google’s electronic health record and was not impressed. It is an electronic piece of paper.

    Yes, EMR’s properly used can have a dramatic effect on health care. I think the system would be better served to host it for a physician. Charge them a monthly fee and make sure it is HIPAA compliant.(and data is exportable in a known format if they ever want to end the service)

    As for the whole health care problem the incentives have to change. I am not sure government owned and controlled health care is the answer. (it is a resource allocation problem, government isn’t effecient at that.) But yes the current system has some major pain points.

    Reply
  4. MKandefer

    Not that I don’t believe you, but whenever I broach the subject with individuals who see universal health care as “unamerican” at best, or “communism” at worst, I get responses like the following:

    1) We have little to no wait times in America.
    2) American health care is the best, look at the medical tourism.

    Some of your claims seem to suggest otherwise. In particular, “in the U.S., we cost more and yet deliver worst outcomes than most industrialized nations”. What do you mean we deliver the worst outcomes? Do you have any links I can peruse for some evidence?

    Reply
  5. Annie

    There are a couple of resources which may have all of the info you’re looking for, and I just blogged about them over the weekend. (Link at my name). The Kaiser Network’s Health08.org is as comprehensive a site as I’ve run across, and the Your Candidates Your Health site seems to be up to date with the platforms and policy stances.

    Reply
  6. Annie

    PS: The Kaiser Daily Health Policy Report just issued a post with links to the Obama and McCain health proposals and to their most recent responses to questions. Link at my name.

    One aspect I forgot to address in my previous comment is the total failure to include nurses and nursing in any of the health policy and proposals. There are three million registered nurses in the US who provide about 95% of ALL reimbursed health services (mostly attributable to the 24/7 nature of nursing in hospitals, nursing homes and other inpatient care institutions). Yet professional nursing receives no inclusion in key planning and decision-making, nurse experts are not included in reportage on in high level discussions, and the public has no idea about the role of nursing and its legitimate interests (which not for nothing make significant differences in whether patients will die from preventable causes, suffer preventable harm or have preventable morbidity).

    Reply
  7. PalMD

    http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=482678

    http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=482648

    http://www.npr.org/news/specials/healthcare/healthcare_profiles.html

    Reply
  8. D. C. Sessions

    Sorry, PalMD, but on seeing the title again I can’t help but think of the veterinary euphemism.

    Reply
  9. LanceR

    Yes, let’s discuss medical tourism. I don’t think the US will come out quite as well as people think. Wait times are short enough for people who can afford to pay their own healthcare. The rest of us end up sitting in the emergency room or the local free clinic for hours. And just TRY to get into a specialist in less than a week in anything less than a drop dead emergency.

    Reply
  10. D. C. Sessions

    And just TRY to get into a specialist in less than a week in anything less than a drop dead emergency.

    Maybe it depends on the specialty?

    I’ve had two orthopedic injuries this year, and both times had an appointment the next day with my practice-of-choice. Given that the first time I hadn’t seen the doc in question in ten years and still got in the day after I called, not bad.

    From totally unscientific observation, wait times vary all over the map. One co-worker is looking at several weeks to see a dermatologist (any dermatologist) for an irregularly recurring transient condition — which means, for all practical purposes, she’s not being treated. At the other end is my own experience with orthopedics. To be fair, ortho is one of those specialties where the clock is always ticking so practices pretty much have to hold some slots open for “emergencies” that aren’t in the 911 range but are still time critical.

    Reply
  11. MKandefer

    Thanks!

    Reply
  12. Jim

    Let’s be careful not to fall into the “grass is always greener” trap. In lots of places outside the US there are long waits for some types of care. That doesn’t automatically make US medical care the best or the worst.

    People follow the incentives they are presented with. If we want them to do something else then there has to be incentive to do that. Difficult problem, but extremely important. I don’t think either candidate addresses the fundamental problem.

    Reply
  13. D. C. Sessions

    I don’t think either candidate addresses the fundamental problem.

    (Emphasis added.) Profoundly wrong article.

    Reply
  14. Bryan

    Just a quick comment from someone who’s lived with both the US and Canadian systems; in regards to quality, access, and medical tourism.

    In some ways US medicine is the best – new methods and drugs tend to be available there before its available in other countries for example. But the flip side is access – in many cases those leading-edge treatments are only available to the wealthy. So while the best-of-the-best is available in the US, access to it can be poor and expensive. In contrast, in Canada it tends to take a few extra years before new procedures/drugs are adopted, but once they are access is universal – everyone from a homeless person on the street to an oil baron has access to the treatment/drug.

    As for medical tourism, its a two-way street. Many wealthy Canadians will travel to the US for treatments which are either unavailable here, or which have long wait-times here. In contrast, many low and medium income Americans travel to Canada (and Mexico) to access our lower cost drugs.

    Reply
  15. Ren

    I had an experience when I worked in the lab where a doc kept having a patient’s potassium level drawn and re-drawn because “this [very high level] can’t be!” Finally, I got fed up with being told (not asked) to calibrate and recalibrate the analyzers to run the patient samples. I called the doctor and asked if the patient was showing any signs of hyperkalemia. “No,” she said.
    “Then, do you mind treating the patient and not the lab results?” It wasn’t that I was overwhelmed with other, more pressing issues (I had to type and cross several units of blood while taking care of the chemistry analyzers). The biggest problem I had was that the potassium levels, and all that went to getting that test done, were very expensive to keep doing them over and over simply because the doctor was incredulous of the result.
    Later, she came down to the lab and apologized, explaining that she was “just a resident” and didn’t “quite know how to handle the situation.” Apparently, the patient had been running normal levels until that morning… He went into cardiac arrest shortly after the whole potassium debacle.
    You’re right… Something IS broken. I just can’t quite point to what that is.

    Reply

Leave a Reply

Your email address will not be published. Required fields are marked *