Healthcare reform

With the recent victory of this administration in passing health care reform I felt it was time to talk again about the importance of this issue and some of my own experiences in the last year of my surgical training.

I was, and still am of the belief that reform, whatever form it might take, will be successful as long as we manage to make health care universal. Partly because our system already is universal but defective. No matter if you have insurance or not, if you show up in a hospital with a problem that needs to be addressed, we’ll treat it. We ethically can not turn people away because they lack insurance. People therefore who lack insurance regularly show up in the ER for primary care, or worse, with a problem that could have been addressed by a primary care doc weeks before but now has become so severe they have no choice but to get treatment whether they are insured or not. For instance, I had a patient who arrived in the ER with a gaping, necrotic sore on his cheek. It had started as an abscess, gotten progressively worse, and he tried draining it himself, inadequately, because he was uninsured. Over the course of a week though the sore had eaten through his face until it actually communicated with the inside of his face. The result? Two teams of surgeons later, an ICU stay, and an extensive reconstruction, a 10 dollar problem became who knows? A 50 thousand dollar problem? More?

We have a choice here. We can have an ethical system that treats people who need care in a thoughtful, sensible fashion, addressing problems through prevention, and appropriate care at the right time. Or we can have a system where people get their primary care in ERs, often showing up long past time their problem becomes critical and inevitably, more expensive. Guess which is less expensive? It’s not necessary to have a single-payer system like Great Britain, Canada or New Zealand. It’s not even necessary to have a public option as countries like the Netherlands demonstrate. You can even have a very generous system that is based on highly-regulated private insurance with subsidization for the poor, as in France or Germany. All of these systems beat ours with regards to cost and performance. What do all these systems have in common but is lacking in ours? It’s simple, they’re universal.

At any given time I can scan the ER roster in whichever hospital I happen to be working at (my program requires me to train in both small private hospitals and large academic tertiary-care centers) and look at what kinds of primary complaints the patients have. It’s a trick we often employ at the end of shifts to make sure there isn’t some lingering surgical consult waiting for us right before the end of the day. It’s shocking because you routinely see a laundry-list of primary care problems showing up in the ER. Why? One, Baltimore has problems – poverty, high levels of uninsured, chronically ill patients, IV drug abusers, and violence. The result is a system where people are treated chronically in one of the most expensive ways possible, in the ER.

We have spoken extensively on where the excess costs come from. Most of the costs can be summarized from these factors:

1. An excess of cost in administration far out of line with most countries around the world.
2. Pharmaceutical costs – especially due to the effects of direct to consumer advertising (DTCA) encouraging use of more expensive, newer drugs (which is only allowed in the US), Medicare part D which forbids collective bargaining for lower drug prices, and a broken patent system that allows drug makers to patent and charge more for non-novel medications.
3. The absence of a universal system that prevents risk-sharing, and causes the uninsured to avoid treatment until problems are more critical, and more expensive.
4. Excessive reimbursement of physicians for procedural skills, rather than cost-saving physician roles such as primary care and family practice that emphasize early diagnosis and proper management of disease.
5. Excesses of cost caused by “defensive medicine”. While torts themselves don’t cause a great deal of monetary damage, the culture they create is one of paranoia in physicians who make decisions with lawsuits in mind, rather than the interests of patients and society
6. The excessive costs in ICU care, especially at the end of life, which may also be reduced by better EMRs with recording of living wills, and public information campaigns designed to inform people about the pain, invasiveness and futility of “doing everything” in the elderly.
7. The absence of an electronic medical record that is universal which causes redundancy in testing as patients see new doctors who then order redundant tests because sharing of information is so inefficient.

The health care bill is limited in scope, despite what the cranks say. It should be clear by now that commentators such as Glenn Beck, Rush Limbaugh and Sarah Palin have absolutely no legitimacy in this debate. Between their birther hysteria, nonsense rumors such as “death panels”, and their general demeanor it should be clear there is no point even discussing their criticisms. Similarly right-wing funded think tanks such as Citizens for Patients’ Rights are not honest brokers, using cherry-picked details of other health systems to suggest they perform worse than ours, and the data does not support this.

So what does this bill do correctly?

1. It provides for universal coverage, most importantly. This should actually save us money because the current system distributes the cost of the uninsured to the insured through higher premiums at the same time the improper access to care is more costly. Distributing the costs to the free-riders should lower our premiums at the same time the uninsured will now receive better, cheaper care.
2. It does not go single-payer, which I think based on analysis of single payer systems worldwide provides less-satisfactory care.
3. It eliminates loss of care for pre-existing conditions, a limitation that forced many people out of being insured altogether.
4. It creates uniform regulations on insurers designed to distribute risk and prevent premiums from increasing – hopefully this will be similar to the Netherlands system (which happens to have the highest satisfaction with their care in the world).
5. It improves funding for community mental health care – a huge cost saver in the long run because mental health hospitalizations are way more expensive than just providing the mentally ill with the care they need outside the inpatient setting.
6. It provides funding to increase incentives for going into primary care.
7. It encourages use and funding of generic alternatives to brand name drugs.
8. It does have some provisions for evidence-based practices that may ultimately save money, and prevent errors, but this is a double-edged sword. When implemented poorly sometimes these provisions just create more paperwork and “check-box medicine”.

Where does this bill fail?

1. While the electronic medical record (EMR) is being implemented, there is still no provision for making the EMR universal – every hospital will always have a different incompatible system making transfer of records tedious and increasing the expense of redundant testing. It doesn’t need to be the same program as long as the record is stored in a universal format – kind of like having many brands of DVD player, but agreeing they all have to have the same format, rather than relying on VHS or BetaMax to out-compete one another again.
2. Nothing is being done to address defensive medicine. A huge amount of excess costs are generated by fear of torts, and the legal system is the worst way to protect against malpractice – the usual justification for allowing our current tort system to persist. Torts don’t prevent malpractice because there isn’t a real logical relationship between quality of care provided and the decision to sue. It’s a well-known fact that the most important aspect of lawsuits have to do with personal disputes rather than complications or outcomes. Lawsuits really only increase costs, physician insurance premiums, and at its worst can create an adversarial relationship between physicians and patients – especially when complications occur. An injury fund, similar to what is used for vaccine torts, could go a long way to provide expert analysis of malpractice claims, fair provision for real injuries from complications (which do not always equate to malpractice), while allowing physicians to practice in a responsible way without fear of being sued whenever a patient has a bad outcome. I do not want to see this issue used to damage our ability to access the courts, I want to see a fairer system, that provides compensation to the sufferers of complications without wrecking good doctors careers, and without pitting patients against doctors over bad outcomes when all involved are doing their best.
3. It is unclear what effect, if any, this bill will have on decreasing administrative overhead from insurance claims. Physicians will still have to have extra staff to deal with dozens of different claims processes and rules. There will still be incentives for insurers to deny claims. Insurers will still use punitive paperwork to burden physicians and hospitals whenever expensive tests or procedures are ordered. Under George Bush, the cost of medicare administration increased 30% in 3 years despite flat growth in enrollees, largely due to subcontracting administration to private companies (sound familiar?). Public health care administration is famously inexpensive, and prior to privatization costs pennies on the dollar. Private health care administration is more expensive and is more inclined to be adversarial – designed to prevent reimbursement to increase profit. A public option may have helped prevent these excess costs by forcing private insurers to compete with non-profit administration. At the very least, subcontracting of medicare administration should be stopped.
4. The hysteria generated by denialists and their “death panels” prevented a very healthy and good discussion on what end-of-life care should look like. There is near-universal ignorance of what ICU care is like, and what “doing everything” means for a patient. We have the capacity to replace nearly every organ system with a machine, at great expense. We can replace the heart and lungs with VADs and ECMO, we can replace kidneys with dialysis and fluids, we can replace the guts with central lines and TPN (nutrition given intravenously), and you don’t really need a brain for us to keep you alive forever. The immune system can fail and we can fill you to the gills with broad-spectrum antibiotics (and generate resistant organisms). Short of liver failure, an ICU can extend life to an extraordinary degree through these invasive technologies. But we have failed to have a discussion about if and when these technologies should be implemented, whether or not futility should play more of a role in our discussions of their use, and what effect on public health and societal welfare this level of care generates. We do not have a crystal ball that tells us when our technology will bring someone back from the brink, or merely prolong the inevitable – sometimes creating a heartbreaking amount of suffering for a patient . But what we do need is a serious national discussion about when it is appropriate to use these resources, when doctors can safely say care is futile, and the economic and public health impact of using these resources so extensively. The denialists short-circuited this discussion by saying we just want an excuse to unplug Grandma. The reality is we should be talking to Grandma and our families extensively before she gets plugged into the machines. The point is to have consent and choice from individuals before they lose capacity to make end-of-life decisions that is informed by the reality of how invasive and painful ICU care can be.
5. Worst, and possibly most offensive, is the exclusion of non-citizens from being covered. I am sorry but I have to use all caps. THEY WILL STILL SHOW UP IN THE ER. The problem is not solved, we will still have to treat them because we are ethically bound to. The question is will we do it in an intelligent and planned fashion, with primary care visits and proper provision of care, or will we continue to address their problems only when they are the most critical and expensive? This sad nod to the xenophobic undercurrent in politics is illogical and destructive. It will cost us more to keep the status quo on illegals. We should just suck it up, and acknowledge it’s cheaper to just treat illegals as citizens than to force them into using ERs as primary care. That may upset our sense of justice, but other countries do it for our citizens, and in the long run, it will cost less.

So not surprisingly healthcare reform doesn’t look like what I would make if I were benevolent dictator of the US. But hey, that’s our country, that’s what compromise looks like. The problem, and this is where the denialism comes in, is that in this debate one side isn’t interested in any solution. Being as apolitical as I can be one can reach no conclusion but that the Republican party has simply become unglued by this issue, and it’s a damn shame. The arguments against universal health care are divorced from fact. From the conservative economic standpoint of controlling cost, one can not defend our current system. The evidence clearly points to an escalation of costs far out of proportion to other universal systems. Universal systems around the world provide better care for half as much per capita, or less, with universal access. From the point of view of a health-care worker concerned about fair distribution of care the current system is indefensible. It simply does not make sense, economically or from a public health point of view to continue having the insured unjustly subsidize the the uninsured, and to treat our critical care access as a primary care office. The way the opposition uses denialist tactics, like cherry-picking stories from the three single-payer systems to make it look like universal health care can only look like the socialized systems is dishonest. And finally, the hysterical arguments about death panels, communism, and loss of choice are just absurd conspiracy theories. They act as if any system created will be written in stone but the reality is it will be fluid and we can adjust it as needed to suit the demands of voters. The advantage of public involvement in health care is that public institutions are actually accountable to voters, rather than stockholders. The incentive of a more public system will be for greater responsiveness to the citizenry, rather than serving a select group of individuals with a financial stake in people not receiving medical care.

I’d like to see a debate between the two parties that honestly addresses the flaws of the system, rather than the one we currently have which benefits no one. Republicans could rise to the occasion and help shape the current system into one that might be a tighter, sleeker system devoted to efficiency and sensible spending. However, the Republican party that once existed (if only in my mind) of hard-minded, rigorous thinkers that represented the legitimate concerns of business and small government has been replaced by ludicrous shriekers like Beck and Limbaugh, who have nothing to offer but paranoid fantasy and racist fear-mongering.