Forty years as a surgeon in university and community hospitals gives some authenticity for the following reflections regarding the failings of our health care delivery. Partisan rhetoric has led to shouting matches rather than reasoned choices, while the most fundamental issue in health care reform has yet to be stated: should health care be continued as a profit-driven enterprise? If a problem well-stated is a problem half solved, a clear answer will allow for progress. Here are the some of the problems I have observed:Retired surgeon John Gary Maxwell is former director of the surgical residency program at New Hanover Regional Medical Center and a professor emeritus at the University of North Carolina and the University of Utah medical schools.
Health care is already rationed and socialized. We have an unacknowledged disparity between insatiable demand for health care and a capability that cannot meet it. We now find health care rationed on the basis of who will receive care, not on what care will be provided.
Rationing does not apply to emergency care. The unemployed laborer severely injured in a car crash or the farmer who collapses will be given the best care possible. No expense will be spared, all needed consultants will be called, all necessary surgery and definitive care completed.
The patient who presents for planned, scheduled health care gets a different reception. Those needing elective heart surgery, or joint repair, for example, are filtered carefully. Care is rationed by ability to pay.
Insurance coverage, pre-approval, deductible, non-covered services, co-pays, will all be scrutinized. If the patient cannot pay, he or she will either not receive the needed care or will be directed to public facilities or programs that depend heavily on outside or tax-supported funding.
What is certain is that the hospital bill for the well-insured will be sufficiently high to cover expenses generated by poorly insured or uinsured patients.
If "spreading the wealth" is socialization, our system is already socialized, with the "haves" paying for the "have-nots" by a tax on the wealthier group. This explains a $15 aspirin, $10,000 to $15,000 antibiotic bills, and bills for heart surgery of $250,000 or more.
We resist "socialized medicine" from the federal government while oblivious that we have embraced socialized medicine delivered -after profits - by the insurance industry.
A crisis is dangerously imminent in which the "haves" will not be able to pay for the increasingly larger segment of "have-nots."
Rationing of medical care in a non-profit system should be based on society defining what services should be provided, not on restricting care on the basis of income, as in a profit based system.
We currently give priority to crisis care rather than preventive or other types of care. For the best care to the greatest number with the least expense, we should to place preventive care first.
There are inequitable and unreasonable variations in the system. The rates of people having surgical removal of atherosclerotic plaques in the carotid artery, coronary artery bypass or joint replacement operations varies so widely across the nation that it appears that factors other than well-defined indications for the operation are responsible. Could the income generated for hospital, clinics, and ancillary services be a major factor in these widely different rates?
Doctors' pay is equally disparate. Despite similar length of training, extreme variations in amounts paid different doctors exist nation-wide. Six- and seven-figure incomes are common among several specialties, while general surgeons, pediatricians, internists, family practitioners and geriatricians whose education was as arduous - and who may put in more hours - earn far less.
Should limitless profit be the motivation to choose medicine as a career? Inequities in earnings have their origin, in large part, because doctors' pay is based on fee for service.
The more tests performed, the more X-rays ordered, every consultant called, every operation done influences income - directly or indirectly.
The solution to these disparities is one that will not sit well with some of my colleagues: Doctors should be paid a base salary commensurate with their time in education and the responsibilities they carry. Increases in pay should be based on such factors as measurements of quality of care, research and teaching. Highly specialized fields requiring extra education and experience, remaining current in new techniques and extra call on nights, weekends and holidays should be compensated.
Fear of litigation, defensive medicine and end-of-life care contribute to costs. Excessive X-rays, unnecessary consultations and inappropriate antibiotic treatments - all contributors to the cost of medical care - are used to ward off malpractice litigation that can be catastrophic for the doctor. The results of these seldom change treatment or give a better outcome.
End-of-life costs constitute the majority of the total health care dollars spent on each individual. The final 90 days often account for 30 percent to 40 percent of lifetime medical costs. CAT scans, repeated blood tests, ventilator support, dialysis, are often done for fear of litigation or demanded by family members who want "everything" done.
Expense of final days can decimate the family finances without bringing benefit or qualify of life. Decisions made before the stress of imminent death, would allow patient dignity without sacrificing financial solvency.
Tort reform, unequivocally needed, is a small wave in the financial tsunami of our dysfunctional health care delivery.
Continuity of care is disappearing. After work hours, emergency rooms often are the only available caregivers. Care within the hospital is increasingly provided by hospitalists whose entire professional work is inside the hospital. Patient and assigned hospitalist may never have seen one another.
Dr. A will send the patient to the emergency room, where Dr. B will decide on admission. Hospitalist Dr. C provides the care, with the patient discharged to Dr. A's partner, Dr. D, in a system fraught with chances for errors and poor outcomes. All four doctors will send separate bills for their disjointed services.
Other issues: profit, payers and an attitude adjustment for Americans. Rejection of payment claims for any reason, is in the best interest of the insurance company, and claims are often returned for minor or nonexistent deficiencies, denied for pre-existing conditions, alleged improper coding and for failure to receive pre-approval. "Beneficiaries" have their policies cancelled for technicalities when the condition is expensive to treat.
In Great Britain several years ago, a perceptive woman afflicted with a bowel disease requiring a great deal of medical attention, offered me her view: "Americans have no sense of community welfare, no willingness to be discomforted in the least for the greater good of the entire population."
She might have been blunt that well-insured Americans say, "I got mine. To hell with you!"
Unless personal selfishness can be refocused to the common good, health care in the United States will remain with irrational rationing and inappropriate and financially unsustainable socialization by insurance, drug and medical supply industries.
Despite professing Christian love for our neighbor, it has fallen to President Obama to call us to the painful truth: "We are ... the only advanced democracy on Earth -- the only wealthy nation -- that allows (health care) hardship for millions of its people."
The fundamental question in the discussion of improved health care deserves repeating: With its widespread and profound problems, do Americans truly want health care to continue as a profit-driven enterprise?
Monday, December 07, 2009
From a retired surgeon's perspective
My friend emailed me the link to this story but I thought I'd share the whole darn piece here because real health care reform, the kind that changes our current mess of a system so that it works for everyone not just those fortunate enough to still have a job that carries health benefits with it, is needed now. It's our shame as a nation that we have yet to find a way to take care of all its citizens.