Wednesday, February 06, 2008

F*ck 'Em


Or help 'em. Those, it seems, are the philosophical options in the funding of health care nowadays. In order to balance the budget, George Bush wants major cuts in Medicare and Medicaid. Primarily, his plan is to cut back on payments to hospitals and nursing homes. There is also on the table a pending cut of ten percent in reimbursements to physicians, but I'll not make this post about that except to say the obvious: there's only so much blood in that turnip. Somewhere there's a floor below which doctors can't and won't go. We're there, in my opinion. Care will become less available. But I'm out of the provider loop nowadays. So let's talk about recipients.

What do you do with people who can't, for whatever reason, afford medical care? You either bar the door, or you let them in. F*ck 'em, in other words, or help 'em. And if you help them, but don't pay hospitals enough to cover the costs, then in order to stay afloat, hospitals must shift the burden to those who do have coverage. Our politicians may be cool with deficit spending, but hospitals aren't, and can't be.

Controlling Medicare and Medicaid costs mainly by cutting reimbursement is, to use a sophisticated economic term, moronic. Unless the plan is to ration care by putting a bunch of hospitals out of business. I'm all for accountability and for the eliminating of waste in the system and for promoting best practices. But, as I've said previously, at some point this country will have to face the fundamental question: how much can we spend on health care, and how will we divvy it up? If we choose to ration care, or to have different levels of care for those that can pay and for those that can't, then let's just stand up and say it, rather than slither around it.

The problem with the (conservative) view that people ought to bear responsibility for their health care and retirement costs is that not everyone can. Many people count on Social Security -- anathema to so many on the right -- and retirees are expected by their former places of work to have Medicare to cover their medical needs at some point. It makes sense to me to index premiums and payouts based on a person's ability to pay. But the scattershot approach of continually lowering reimbursement to providers is chickenshit: it begs the question, and hides the real philosophical differences at work. Picking up corpses is cheaper than paying for care (if they smell bad, we could have illegal aliens do it). So would it be to send those who can't afford care to some place where they can do their damn duty and die. But if that's abhorrent, and if we choose to provide care, then cutting the payments for it simply shifts costs to businesses and rich people -- the very constituency Bush is trying to protect in choosing to pay less rather than to increase revenue. Isn't it cleaner and more transparent to adjust taxes to cover expenses (while doing everything possible to reduce costs)? Maybe the upcoming election will clarify where, as a country, we stand. F*ck 'em, or help 'em. Time to make the call.

Oh, and George's budget also has significant cuts in funding for medical research, as well as a 400 billion dollar deficit. So fuck us all.

57 comments:

jcm said...

here's one canadian that is thrilled by what seems to be happening in the us primaries. i love the way you have outlined your country's dilemma. here's hoping america is ready to move away from the focus on fear-mongering and towards caring for those who are less able to pay for their healthcare or retirement.

YES, WE CAN!

good luck, america.

CanadaGoose said...

Here's another Canadian* who also wishes you luck. I think perhaps some of the $490+ billion spent to date on the Iraq war could make a dent in the health care needs of Americans.
But that's naive, I suppose. The cost of war vs domestic needs has been discussed for as long as I can remember.
Two months before we left California in early 2004, our "health insurance" for two adults went to $900 per month. $10,800 per year. No Rx coverage and large co-pays for everything else. Who can afford that? Not many. And not us.

*A permanent resident since 2006, soon to be a citizen, I hope.

Patrick said...

I do not think very many middle and upper class Americans (e.g, “voters”) understand that they are already paying for all US healthcare. Taxpayers fund Medicare/Medicaid, and then they pay their insurance premiums, and then they pay deductibles. All that money drains along the same channels, into the same pools. Sure, health costs are rising across the board, but the sticker price for, say, an ER visit or a new hip is rising lock step, right along with it. Absent a major change in the way the system works the same people will continue to pay for healthcare for everyone.

Now. What happens when you start to cut funding in one place? If taxpayer dollars for Medicare/Medicaid are sent elsewhere, either one of two things (or a combination) happens: (1) services provided remain the same and the sticker price goes up to shift the losses back to those same taxpayers, or (2) less services are provided to those who cannot pay. Just like you said.

But there is a moral component to providing healthcare, too. No right thinking, progressive, wealthy nation ought to make basic services like general care unavailable to its citizens. (Or frankly, to anyone living within the borders, but that’s a different fight, I suppose). And no rational and fully informed taxpayer would want to fund the insurance cartel, I mean industry, when the net effect of that system is the same care but with greater costs and reduced access for the poor.

It’s time for the US to join the rest of the free world in a single payer system.

Matt M said...

Like most people, I expect to have Social Security and Medicare to take care of me after I retire.

The future of Social Security has been problematic for years, and we are advised to fund our own retirement plans. However, it is rare to hear warnings that, at some point, health providers will refuse to accept my Medicare. Do I need to fund my own retirement medical plan? Or just never retire?

GDad said...

About that deficit - isn't it also a surplus, depending on how you count the money?

Man, that would be great. "No, MasterCard, you actually owe ME money. And you have to give me cookies."

Sid Schwab said...

Patrick: I agree about single-payer, and said so here in a post. I can tell you (no surprise) I'm in a small minority of physicians; the concerns, from a doc's point of view, are legit: total loss of input into many aspects of care including reimbursement. But like you, I hate to see so many healthcare dollars going to the myriad moneychangers.

Matt: only time will tell.

Patrick said...

Do you feel, as a physician, that a single payer system (whatever the version) would be more restrictive on your treatment options than the constraints you currently feel from medicare/medicaid reimbursement, and the restrictive scope of coverage from private insurance plans?

It seems the 30 years since 1977 have left your hands pretty tied in a lot of ways, including control of care and reimbursement . . . . is that argument against single payer really all that legitimate in 2008, or has it become something of a red herring?

Sid Schwab said...

Patrick: No, I don't think it would, personally. Which is a point I've tried to make to my fellow docs. Plus, as I said (fancifully perhaps) in my posts on the subject (here and here, enabling legislation could well have certain safeguards, empowering panels of providers, etc.

Patrick said...

Oh, man. Your older posts just bumped my afternoon Contracts reading right off the table. That means I'll be called on in class today for sure! Your posts made my point, except, uh, better. And pithier.

I'm no genius, nor am I at the cutting edge of the issue, so maybe that's why is it mind-boggling to me that informed people actually think that the fundamental structure of our health care system (supposedly an insurance-tempered free market) is a good one. Maybe it used to be, sometime before I was born. But today is NOW, not then, and something is awry in a picture where the number one precipitator of bankruptcy is . . . . medical debt. Heath care is supposed to promote heath, not ruin your life.

On an even more pessimistic note, there are lots and lots of reasons to think that change is nowhere near the horizon. It would take a LOT to overcome the inertia of an industry hat is 16+ percent of the GDP. But I am hopeful that a new (blue) administration this fall will take a few simple steps to keep the really unfortunate from being systematically screwed out of basic care.

AlisonH said...

My daughter the microbiology PhD candidate chose the grad school she did because it seemed to have the best chance of not having its medical-research funds cut, it had just too good a program, surely it wouldn't be cut. Then they did anyway, just like all the rest. They want to cut again? Those funds are already bone dry.

(This Californian did her part and voted for Obama!)

JP said...

Uncanny that I am "working from home" in a local coffee shop today, reading your blog, when a professorial type walks in (polka-dot tie, dead give away). He introduces himself, and turns out he works for a health care strategic advisory firm. A political science expert, he was a former advisor to president Reagan's medical health cabinet, and not at all bashful about announcing to the room his pull for McCain this year.

He was lovely, but the encounter gave me chills. We don't just elect a president, we elect an entire body of extended advisors. It's not just a democrat or republican in office; it's a whole army of them. The tendrils of a candidates platform extend far indeed. I hope we keep this in mind this election year, when deciding what army our country is prepared to fight against next.

Sid Schwab said...

JP: wish you'd showed him this post. Interesting to know what he'd have said.

Alison: dry, indeed. And I'm caucusing Saturday.

Sarah said...

My DH lost his job and me (since i'm preggo) and the kids are on Medicaid. We have to out of the county to actually see a Dr. or go to the hopsital because NO ONE in this county takes Medicaid patients. My son has Interstial lung disease and is on oxygen, seriously this is a major pain in the butt.

Oh and why did my DH lose his job??? Well all I know is that my son had racked up over $100,000 in medical bills in 6 months and the company he was working for had there own insurance. They said it was for budget reasons, uh huh.

#1 Dinosaur said...

Hey Sid: you really shouldn't keep your feelings bottled up inside like that. Go ahead and say what you really mean.

Buckeye Surgeon said...

Doc- You ever check out the PNHP website? (Physicians for National Health Ptrogram). http://www.pnhp.org/publications/proposal_of_the_physicians_working_group_for_singlepayer_national_health_insurance.php?page=all

Sid Schwab said...

Buck: I hadn't. Thanks. It's got lots of content!

rlbates said...

Dr Sid, one of my biggest concerns (not just the reimbursement) regarding single payer is how "basic services like general care" will be defined. I know that as a plastic surgeon, I have an odd view point (maybe) but it's often difficult to get people to understand that the scar revision is cosmetic not function, that the nevus is benign (they know if they say it "has changed" then it "needs" to be removed), that yes they might benefit from that breast reduction but don't quite meet their insurances standards (and I won't lie for them, sometimes they hint at that). So where will the line be drawn. We all know there will have to be some rationing of care for it to be affordable. Many aren't ready for that.

Sid Schwab said...

ramona: we're already at the mercy of those decisions being made by others. In my fantasyland, maybe panels of providers would be able to establish rules that make sense. But it's a reason for concern, all right.

In any case, my point (in this post, anyway) was mainly about the folly of approaching health care cost escalation only by cutting reimbursements.

Anonymous said...

Dr. Schwab, lol, I think I may love you. You are so straight forward. You just hold nothing back. It is always refreshing to read your posts, becuase you pull no punches.

My daughter told me something last week, I did not know. She is the manager of a high rise apartment complex, in a very fluent area. This place does extensive background and credit checks on all applicants. She told me the one and only thing that is NEVER used to determine someone's eligibility for an apartment, is any and all medical bills being against their credit. Even one's that have a court judgement against them. If they have a $40.00 past phone bill that was turned into collection, they will not be allowed to move there, but they can have many thousands of dollars of outstanding medical bills and it is completely overlooked.

She tells me this is standard procedure at many places who base eligibiility on credit reports. This should certainly tell us something about our current medical system. Jesus, go to the ER for 6 hours and get a $14,000.00 bill for it. Its out of hand. Bring on the NHS.

Xerxes1729 said...

The amount that could be spent providing all the health care that could conceivably be beneficial to any group, from the entire US to a single insurance company's pool, is basically limitless, and so care must be rationed. There's no choice in the matter, and no miraculous machinations of the invisible hand or our political leaders can overcome that fact.

Anonymous said...

Why is so healthcare so absurdly expensive?

Just imagine if we weren't struggling with a dire physician shortage- we would be bankrupted!

American Abroad

Richard said...

Perhaps medical care is expensive in America because Americans demand the best, and nothing short of it.

If one was willing to settle for a level of care equivalent to say, Mexico, costs would be reduced. Not that Mexican health care is really that bad in the grand scheme of things (the Mexican medical graduates I've met are excellent clinicians).

When you demand rapid access to a dizzying array of services, many not absolutely necessary or intended to extend duration of life in the already seriously ill, all delivered with top-of-the-line technology and pharmaceuticals, it gets pricey, and fast.

Top it off with defensive medicine because many physicians are deathly afraid of a malpractise suit, and you create a fiscal explosion, which is inevitably followed by an implosion of providers (which we are now witnessing).

It isn't doctors who are expensive (they're a relatively small piece of the financial pie), it's the high expectations and demands placed upon the system. Until Americans recognize that rationing is necessary, that going from pretty good medical care to superb-whatever-you-demand medicine is a extremely expensive step, then the American health care system will continue to collapse until expectations and the ability to pay for them come into line.

Anonymous said...

Give me cheap Mexican style care with the option to top off out of my own pocket.

Also, Richard, malpractice is not a driving force on the number of medical tests ordered. States with malpractice caps order just as many tests as anywhere else.

There is an interesting website called the Dartmouth Atlas that you should look into.

American Abroad

Buckeye Surgeon said...

Anon-
Medical malpractice is certainly a factor in the ordering of unnecessary tests. The point you make about states with malpractice caps is weak. It doesn't matter if you're sued for $250,000 or $4,000,000; the personal stress of litigation, of seeing the word "negligent" when applied to the care you provided overwhelms any mere monetary punishment. One's professional reputation and a sense of personal self-worth will trump any arbitrary "punitive damage".

Anonymous said...

Sid, may I ask what your answer would be to this problem? You want a NHS - fair enough. But how does one go about funding this program considering that our taxes are already through the roof.

And did I hear the news correctly; that Hillary wants to garnish the wages of people who don't sign up for her health program? Please tell me I misunderstood.

Anonymous said...

At least with a NHS or single payor type system, the entire issue of rationing will be on the table open for everyone to see and debate. You get what you pay for. If you don't pay for it, you don't get it. The current system of under the rug, covert rationing is bringing the whole system down.
Everything related to health care financing is a secret, and both patients and physicians no longer have any trust in the system.

Sid Schwab said...

anonymous (7:24 am): I'm no economic expert. But if there were some sort of single-payer, government-funded system, there would no longer be health insurance premiums (for my wife and me, it's currently 12K/year.) Business would pay whatever it is they now pay (or less, presumably) to that source rather than to insurance companies. There'd also be savings from the elimination of all the profits and other overhead expenses of the innumerable insurance companies. Combined with vigorous pursuit of "best-practices," some actual medical expenses could be lowered. And yes, it might well be that the "universal" plan would be more basic and prioritized (ie, rationed); and that, if the country agreed to it, there'd be an option for more comprehensive coverage for a price.

And much as I hate paying them, I think taxes in the US, compared to most other countries, are hardly "through the roof." Plus, liberal that I am, I'm not opposed to looking at ways to lower costs of social security by indexing payouts. One might also hope that the day will come when we'll be able to cut military costs, too. And if we were ever able to get back to the days of balanced budget (remember Clinton?) we might even get to the point where a third of our national budget isn't spend on debt service.

Like I've said before, at some point, as a nation, we have to decide how much we want to and can spend on health care and what our priorities will be. I assume I'd not be on anyone's list as a candidate for a heart transplant.

Dan said...

Dr. Schwab and readers,
Sara Robinson of Orcinus fame recently posted part 1 of Mythbusting Canadian Healthcare.

In it, she discusses widely disseminated tales of problems with Canada's single-payer system with an eye towards the operation of such a system in the US. While I find some of her claims to be a bit over-optimistic, she sets down the foundations of a very good case for implementing single-payer insurance in the US. It is also a great foundation for starting an actual dialog on the subject rather than flinging about lies and epithets (e.g. "Commie!")

When discussion turns to the high cost of American healthcare, I am reminded of a talk I saw by DeBakey a couple of years ago. He put up a slide showing the increasing costs of healthcare divided into actual medical costs and administrative costs. The medical costs at the bottom of the graph increased linearly as one might expect. The administrative costs at the top exploded along an exponential growth curve--our healthcare dollars are largely going to pencil-pushers.

His overall conclusion was that the current system is untenable. Sooner or later, something has to give. I would hope that enough physicians realize this and become part of the solution (whatever that may be) rather than having something forced upon them.

SeaSpray said...

Interesting post and comments. Last night I was reading a blog authored by someone in Canada. the author is concerned because her friend has been diagnosed with cancer for which she need surgery but is on the "waiting list" for her turn to have the surgery and then she will be on ANOTHER "waiting list" to be scheduled for the follow-up radiation.

I know health care in the states has serious problems and who knows what is going to happen, but I am so very grateful I CAN get in and get things done when they need to be.

Dr S...I know we don't agree with all things political...but I have to say...for the first time since I registered to vote (18)that there isn't one candidate that I feel passionate about and it is disturbing to me. I have been watching the talking heads and I just don't feel the passion yet. I am a conservative - usually but I am NOT partisan and have been watching all of them. Pros and cons in both camps for me right now. I would trust McCain militarily but he says nothing on the economy. Obama, in my opinion is a most powerful and inspiring orator but I am hung up on substance and experience. When I hear him speak...I can envision him being quoted for inspiration and also having visuals replayed. I absolutely believe he has a promising future but just not sure about the White House...yet. Of course it is who they surround themselves with too. There are pros and cons for the others too and I will keep following and hopefully someone will start soaring above the others.

Sid Schwab said...

seaspray: a program of universal coverage doesn't HAVE to involve long waits, any more than it does now; it all depends on the level of funding people are willing to support. If there enough beds and enough docs and nurses, it won't be a problem.

As to the political scene, yes we differ; to me, McCain (who is clearly the nominee now) will basically be another four years of Bush policy. If you like the war, the deficits, and the idea that anyone who thinks our money could be better spent in the "war on terror" if we had less of presence in Iraq is "waving the white flag," then he's your man. I agree Obama is inexperienced; but he's brilliant, and if you look at his website for policy, it's very well fleshed-out and thought out. I figure after eight years of despair and being unable to be inspired or feel proud of what this country stands for, it's worth going for a little inspiration. Can he actually bring about the politics of cooperation and problem solving? If he can't, it'll be because there are still too many in Congress who want to score political points more than they want solve hard problems. In my opinion.

SeaSpray said...

Isn't that always the way with Congress...unfortunately? They go in with ideals but then are faced with the lobbyists and have to make trade offs?

McCain can't be totally like Bush because there are a lot of conservatives that DON'T like him. I heard Chris Matthews say the other nite that Anne Coulter said if McCain becomes the nominee then she will campaign for Hillary!

Shoot...I would PAY to see that! ;)

I also have heard that Rush Limbaugh has been really speaking out against him too.

What confuses me is that Juliani was way more liberal than McCain and yet conservatives were backing him -obviously not enough though.

McCain stands a good chance of drawing in the dems who don't want Clinton or Obama.

I will check out obama's site.

Anonymous said...

I find all the debate about single payer and multi payer and all of it incredibly tiresome. Coverage is irrelevant, because whether you have all coverage or no coverage, without cost control everything else is unsustainable.

Every few days we get a demented patient from a nearby nursing home who has essentially no quality of life and has not been mentally alive for years. They have some complaint that generally boils down to a mass of comorbidities. They are admitted and receive the full miracles of modern medicine, keeping them alive for another month or two at the cost of 10, 20, or 50,000 dollars. The family is informed that at this point we are basically doing every function of living FOR the person, from breathing to going to the bathroom, and this will never change for the 2 or 4 months they have to live. The family screams "everything must be done".

This does not happen in other countries. And until this scene stops playing itself out in every hospital in America, everything else is irrelevant.

Sid Schwab said...

anonymous: bingo!!

GingerB said...

This guy has an interesting blog:

http://healthpolicyandmarket.blogspot.com/2008/02/bush-budget-dead-on-arrival-but-it.html

He says the Bush "cuts" are a reduction in future Medicare spending increases from 7 to 5%.

I don't know about you, but I haven't seen a 7 OR a 5% salary increase that didn't involve MAJOR butt busting from me in several years.

We got serious cost problems here in River City.

Anonymous said...

I have to agree with "anonymous" above. As both a trauma surgeon and an intensivist, I have near daily discussions with patient's families about end of life issues. I am always surprised by either how little people understand about illness or how willing they are to deny that it's not likely that their 90 year old granny who got hit by a bus is going to walk out of the hospital anytime soon, if at all. Very clearly "rationing" health care isn't something any politician who enjoys his career would ever touch, and yet, just as clearly, it's something that will eventually happen. I would think that limitations to care at the extremes of old age or illness would be the first place to start. I think that the public's perception of the abilities of modern medicine are often grossly overstated. This may be from TV or it may be from the "failure is not an option" mentality that we healthcare providers are trained with. We have all participated in "futile" care, and how many times have you heard your colleagues say, "If I'm in that situation, just let me go." However, somehow, we are unable to discuss those ideas with patient's families well. Personally, I have felt at times that I would be accused of trying to "kill" somebody and I think that fear limits how far people are willing to go in withdrawl of care discussions.
Why is it that even when the family agrees that death is inevitable, they want to continue aggressive treatment? I use my, "You are simply prolonging your mom's death and suffering" line but it usually doesn't faze them.

I wish I could use my "If your dog was incontinent, in a coma, had renal failure, on a ventilator with no chance of coming off, and continuously bleeding, you would let him go because it would be cruel to continue. However, if it's your mom, you press on!"

Sid Schwab said...

anonymous (trauma surgeon): I couldn't agree with you more. I often wondered what those families would choose if they were told, okay her medicare benefits are gone; we'll do whatever you wish, but the bill will now be your responsibility...

I often felt that some families wish to go on because no one wants to bear the responsibility of saying no more. I (as do you, it seems) tried to relieve them of the responsibility when I felt it proper, and told them that I thought it best to provide comfort... Sometimes they seemed relieved to be able to take the advice. Clearly, futile care is a huge part of the escalating costs, and it'll take a big change in attitudes of lots of parties to get it to change.

Anonymous said...

Trauma surgeon here, Sid, I have exactly the same thought.

I have endless patients who for whatever reason, would like to stay in the hospital for "just one more day."

I, who spend the majority of my life it seems, trying to get OUT of the hospital, can't quite get it.

At times, I have said to the really egregious ones, "You're welcome to stay, but your insurance will deny payment because you do not have medical necessity to be here. Thus, you'll be stuck with the bill." That's all true, and it often works.

In the cases of futile care, I also agree that if it came down to it and people were presented with personal financial responsibility, things would change quick.

Anonymous said...

You guys are spot on. The problem is that other countries don't do it by explicit rationing - it's culturally accepted that you let people go when it's their time. I can't think of a good way to get people to do that here. Age limits are unfair because everyone knows a 90 year old in better shape than most 60 year olds. Yet anything physician or hospital initiated (i.e. not objective) will guarantee massive ill will on the family's part.

It's like medical malpractice - people think we can just export other country's systems to fix things, but many of the problems we have with ours aren't systemic, they're cultural and no legislation will change them.

enrico said...

I'll post my thoughts later, but for now, I am most shocked that the unhinged right of the medical blogosphere haven't come by with their canned talking points. (note: I mean unhinged, crayzee, asshat, etc. not simply right-of-center)

See what happens without them? Sensible people can actually respectfully debate issues--even with differing political viewpoints!

Enjoy it while it lasts...

Sid Schwab said...

anonynous (11:41) That it's cultural is an excellent point. If we really want cost-effectiveness, we'd eliminate private rooms with color cable TV, expect families to participate more in after-care or even, as in some cultures, in-hospital care; and certainly end-of-life attitudes would have to change. I assume it's not impossible. The question is which promotes the other: the systemic or the cultural shifts.

enrico: call them asshats and they will come. Tut, tut.

Anonymous said...

Seaspray, there is also waiting lists in the US for many specialists. When my mother had colon cancer and her family Doc was sending her to a GI Doc. (before her diagnosis)His office made the referral and she received a card in the mail with her appointment on it. It was for 7 months later!

When I called the office because I thought it was a typo, I was informed that all appointments for new patients are scheduled for 7 months out. Two weeks later she had another appontment with her fmaily Dr. and I went with her. The first question he asked was if she had seen the GI Doc yet. I showed him the card they had sent.

He finally personally called and talked direcrtly to the GI Doc. who then saw my mom at the hospital the following week to do a colonoscopy.

Once she was an established patinet, it has never been an issue getting in to see this doc and he is very good to her. She could call his office this morning and see him this afternoon if the need to do so was there. But, yes, there are waiting lists in the good ole US of A.

Anonymous said...

I do wonder if we aren't already rationing? Just last week I lost a friend who was only 54 years old. She had alot of medical issues and the biggest one being her heart. She was in the hospital at New years, and when they were doing a heart cath they were unable to even get the wire through some of her arteries. They told her that they couldn't operate on her to open them because she would most likely die during the surgery.

To me, the key words here are "most likely". Becuase the alternative without surgery was "absolutely die". She came home, and was found dead by her fiance last Sunday.

When you are 54 and may "most likely" die while having a surgery, seems to me you ought to be in charge of making that decision for yourself. Most likely could also mean "maybe not"..

Sid Schwab said...

anonymous 8:17: indeed. And I suppose it will always be so, to some extent, no matter what. In the current climate, where hospitals and programs and individual doctors are judged, in part, by mortality rates (which are then published in newspapers and subject to all manner of misinterpretation) it can happen that a surgeon will behave as you describe, in part at least, to avoid taking on cases which might affect his numbers. I hope I never did; but there were times it was in the back of my mind...

enrico said...

OK Sid, sorry...I won't do the "Candyman, Candyman..." thing in the mirror for those types. ;)

Quick thoughts here because this has inspired a blog post of my own vis-a-vis healthcare costs from a Mexican POV, so I'll save the "meat" for that.

Waiting lists: already have them. As some of you know, I've gone through the crapper combine lately. I asked for a psychiatrist consult while I was home on vacation: 6 months was the LOWEST wait. If I was suicidal however, go to ER. What about becoming suicidal at the prospects for mental help?!

Obama: Anybody that says he's "inexperienced" WRT Hilary is ignoring obvious facts. Clinton doesn't even have one full term of experience more than Obama yet people act as though she's a "senior senator" by comparison. Being First Lady surely gives a lot of exposure but not decision making authority, much like being 1st assist in surgery vs. being the one doing the cutting--it's a different world when its your ass on the line. And let's not forget--Dubya's CV was being the Governor of Texas for one term, welching on the 2nd term to campaign, and nothing but failed business requiring bailout. Hardly the stuff of Commander-in-Chief experience.

Cultural norms: Whoever brought this up--awesome. Unlike the approach of one of the aforementioned nutjobs with posts like "Put down Granny," futile care needs to be tackled slowly, through education via different avenues. It does no good to present a spreadsheet about Grandma's impact on resources right before having to sign a DNR form. If these facts and ideas become part of the fabric of healthcare education, people hopefully will make more rational, less selfish decisions as a whole.

Sid Schwab said...

Rico: well said. See, now don't you feel better?

Anonymous said...

I think your comments on how we have major cultural impediments to a more sensible approach to end of life care are dead on. Until we have realistic expectations of what is and is not possible in modern medicine, that won't change. Watch "House" for a good portrayal of what the public thinks medicine is all about. I also agree with the fact that care is already rationed. In the community I work in, it's pretty hard to get evaluated by a subspecalist. Either they're not available because of a lack of interest in doing ER call, a general shortage of physicians period, or that they are available, but they won't take your insurance (or lack thereof). All of these probably come down to the simple fact that it's not worth the money for them to take care of you. Either because they won't get paid, or because the medical or legal risks are too high. In today's atmosphere of checking preop antibiotic infusion time, physician grading, soon-to-be mandatory public reporting of complication rates and cessation of medicare payment for common post-op complications like UTI's, DVT's and wound infections, it only makes business sense to cherry-pick the healthiest, most-insured patients to treat. And, ultimately, the practice of medicine is a business. Perhaps at some "downtown" academic centers with big endowments, the business aspect is less apparent, but for the solo practitioner hanging a shingle, it's a small business. However disillusioning that may be, I believe it's ultimately true.

As an aside, when physicians say "most likely" they (or at least I) typically mean "near guaranteed." Again, our culture teaches us never to say "always" or "never" because you'll inevitably have that one survivor who proves you wrong (and then sues.) However, when we say "most likely" we mean that person isn't going to be you.

adventures in disaster said...

Sometimes I honestly think I must be living in a different Canada than the one Americans are always complaining about.
First about wait times. If you require an emergent surgery because you have a tumour that is encroaching or has caused perforation than that is what it is..an emergency and you go straight to the OR. My father got diagnosed with colon cancer because he came to the ER with an acute abdomen. Straight to the OR for a resection and colostomy. He started chemo well within accepted guidelines and is doing just fine.
I am an ICU/trauma nurse in a large teaching hospital in Toronto. We also do a lot of incredible world renowned research..yes..we Canadians are responsible for some of the most cutting edge research being done today .
If you are sick and come to a big hospital and need surgery or the cath lab you get it. If you can safely wait? You may have to wait.
I hear tons about someone having to wait for a cath..of course just like Medicare in the US..as long as it isn't emergent you get an appointment. What people don't like is having their sense of entitlement shoved back into their faces.
It's the Er all over again.
No one wants to believe that they are less deserving of care right NOW. We as health care providers constantly have to tell these self absorbed selfish asses that really sick DYING people are in the machine right now..your fourth lumbar spine MRI is going to have to wait.
Here in Canada we do ration health care. We had the absolute gall to remove cosmetic surgery! The horror.
We told people they had to pay a whole 15 dollars for insurance forms and sick notes and camp fitness forms.
Our system isn't some alien thing to frighten Americans...it's Medicare. We don't cover dental or prescriptions for people under sixty five. But guess what? For a measly fifty bucks a month you can get extra insurance!! Just like the US. So we have a thriving insurance market and a good health care safety net. We also told the drug companies that we aren't going to pay so their CEO's can buy a private island. We demanded reasonable prices and we got them.
The US lets everyone bully them in the name of "free market".
I think what doctors don't understand is their reimbursement rates will go UP when the middle man gets pushed out of the process. Don't think that the government is going to run health care at a loss either. If the insurance companies can make billions on health care so can the government with much less waste/duplication they can make more..and more means docs get paid more.
You guys need to stop being so damn pessimistic.
Set up a basic single payer system for every one. Remember Canadians still pay a tiny payroll tax for their health care..wouldn't any US business love to stop paying the ridiculous rates they pay now?
Think about how much money can be saved in the system, the relief for businesses.
Anyone who wants extra can purchase a little extra policy just like me! I pay a hundred bucks a month for a family of three. I pay one fifteen dollar deductible once a year. All my prescriptions? covered..Dental? including braces..covered. Plus disability and a private room and lots more.
I get all the scary expensive stuff for next to nothing in taxes..hell I could add up my lifetime of taxes and it wouldn't cover the health care I have already received and all the luxury extras I pay a small premium for.

It's not brain surgery folks. If the insurance companies can make billions while shoving reimbursement rates lower and lower doesn't it make sense that the government can easily break even? They already have the bureaucracy (Medicaid/Medicare) in place. All they need to do is hire a few more people to add the rest of the names in the computer.
Businesses get their copay cut to half of what they pay to the insurance company now. Docs get higher reimbursement because the money is now in the federal system instead of in the insurance companies pocket.
There is also nothing wrong with making the people pay a copay too. We Canadians paid every month a nominal fee..it makes people have a sense of responsibility and reminds them that this stuff costs real money.
We also have played with a copay when you show up to the ER for a non emergent problem. It helped get a lot of people into the walk in clinic , now we have tried to add a clinic to every ER. Saves a ton of cash.
Innovation will save money too.

Trying being excited and creative and hopeful!!!! It is a wonderful system when you know that everyone who needs help gets it. Even if they have to wait a little while. something no one wants to do cause it makes them think we don't think they are so very, very special.

Sid Schwab said...

ad/dis: well said. One correction: medicare and medicaid are, in fact, administered by insurance companies; so there isn't exactly an infrastructure in place, in one sense. Also, I practiced not far from the Canadian border; over the years I saw several Canadians who, for one reason or another, couldn't tolerate the waits and came to me willing to pay on their own. Not many, but some. Young women frightened about waiting three months to see a surgeon for their breast lump, as an example. But I doubt those cases, multiplied by how many there were for other doctors, come anywhere near the numbers of people in this country who have no coverage at all, nor the impediments to care for those that have medicaid in many localities.

SeaSpray said...
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SeaSpray said...
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SeaSpray said...

Anonymous 8:08 - Yes I agree with you that there are wait times for 1st time/routine visits with many offices. Or sometimes a practice can't take anymore patients for awhile. I have to wait 3 months for a routine gynecology visit. The few times I had something i was concerned about...they saw me immediately. And many times I have gotten right in to a new doctor. The facility that I use for routine mammos often has a 2 month wait (Unless stat order) although once I left my gyno doc's office with order in hand and went right downstairs to see if they could possibly take me and they did. That was good timing thanks to a cancellation!

However, I personally have never known anyone to have to wait a long time once diagnosed with cancer and it has been established that surgery is required. Nor have I known anyone delayed in waiting for their follow up cancer treatment s/p surgery. You mentioned that at the time your mother your mother went for the GI appointment that she hadn't yet been diagnosed.

I honestly have never heard of anyone complaining they couldn't get their cancer treatment and I worked in a hospital for 20 years. But my knowledge is limited to my little corner of the world and so maybe there are exceptions across this vast country of ours. There probably is pt discrimination based on pt's ability to pay etc...or docs refusing MDCD pts because it doesn't pay enough.

AID-I don't pretend for a second to know anything about the Canadian health care system other than what I have read other Canadians say. Nor do I pretend to know everything about ours. It was a Canadian woman's blog that I was reading who was concerned about her Canadian friend who was diagnosed with cancer and put on a waiting list for surgery and then another waiting list for the radiation. Another Canadian a while back had said something to me about there being possible differences in care/modern equipment in Canada based on what province they live in as well as east coast verses the rest of the country. Again...I do not know the latter to be fact but what was presented to me by another blogger. It is all mind boggling. I wish we could combine the best of both systems and find our medical bliss.

I don't believe that our government can run a health care system with "much less waste/duplication" and therefore make more money than the providers now. Government and fiscal waste is synonymous in my mind. And just because the government has more money doesn't mean they aren't going to have the docs by the short hairs anyway, except now there is no competition for them to go to or option not to treat.

And maybe I am totally misunderstanding all of this and if I am...be patient with me and enlighten me further. :)

I would also be curious to know if all Canadian docs are happy with their system.

Complex topic...at least to me.

I have also read other Canadians that said they were happy with their system.

I reacted to this bloggers post because it involved a cancer patient and timing is of the essence with that disease...or so I thought. We have an aunt that has been aggressively battling cancer since Sept. 2007 and her doctors are very particular about all of her treatments/schedules.

My questions, etc, are to anyone not just the 2 people I responded to.

Dr Schwab...or anyone else in the know...I have another question. not being one who is savvy with economics...I thought the plan that President Bush (I know I said the "B" word here... is that"oops" allowed?)traveled around the country promoting to help save social security and insure that people would have something to retire with sounded feasible. It involved giving everyone the option to leave their money just as it is OR they could opt to put their retirement funds into a secure stock investment fund which yielded higher interest rates and therefore more to retire on. It was successful somewhere in South America (if I remember correctly)and somewhere else. Anyway...no one was interested and he tried. It seems people are apathetic and even though they grumble they would rather live with the status quo then make changes. Then of course the politicians worry about keeping their jobs, don't want to ruffle feathers and nothing changes. Just wondering. And sorry so long.

Anonymous said...

Seaspray, to me a routine GI referral would be, you turn 50 and your PCP says "its time to get that colonoscopy." The one that everyone is supposed to get at age 50 or there about. This was a referral to RO colon cancer. She had melena (black coffee ground stools) Her PCP also told us that he did a CEA as part of her blood work becuase he suspected colon cancer, and it was elevated to the range that is consistent with colon cancer. This was all part of the referral. The problem I do see with it all, is that he (the PCP)initially didn't make personal contact himself with the GI. He instead left it in the hands of office staff. When they couldn't get past the office staff at the GI office, to get an earlier than 7month appointment, and we returned to the PCP thats when he called the GI personally. It should have happened from the beginning. Insurance or ability to pay had nothing to do with it.My parents were well insured and financially secure.

Like I said, once she became an established patient there has never been any problem getting in to see him. But, it absolutely was not a routine visit and was initially scheduled for 7 months out.

A big problem is lack of communication between providers. They leave to much in the hands of staff, and particularly when it is a cancer R/O, or in my mom's case it ended being a cancer R/I, they ought to be getting on the horn talking to each other from the get go..

SeaSpray said...

Hi Anonymous 11:14 - I misunderstood because you had (before her diagnosis) in parentheses.

That is awful that they did that. I have never worked in a doctor's office but I think if i saw/heard that...I would inquire to the office mgr or doctor and not just blow a patient off. Maybe it was an inexperienced person handling the appointment.

Regardless...I wholeheartedly agree with you. As a pt I would be willing to schedule myself but if i hit a wall like that knowing it "could" be cancer...i would immediately call my PCP back and ask to speak with him.

I do believe that pts need to be proactive with their health care. Respectfully...of course. Everyone is so busy today and unfortunately people that never should fall through the cracks sometimes do.

i am glad she is being so well taken care of by her doctor now. :)

Anonymous said...

An interesting article about the British Health care system.

http://www.nytimes.com/2008/02/21/world/europe/21britain.html?pagewanted=1&hp

Sid Schwab said...

Yes, that is interesting. Thanks.

Branch said...

Sid I know you are for some kind of national health. It scares me to death considering the mess that government makes of everything.(Postal service is an outstanding example). I have had some experience with Canadian Health while vacationing there and it sure as hell isn't the answer here. (maybe because I wasn't a citizen there but my Canadian friend said it was par for the course). I Don't know the answer and our insurance is over 12,000 per year for two people. It would be wonderful if someone would come up with a simple answer.

Sid Schwab said...

Branch: of course, there are no simple answers, even though many politicians would like you to think there are ("market forces.") And, for what it's worth, I don't have much complaint with the postal service. It seems a pretty good deal, actually; for many things quite a lot cheaper than the alternatives, generally reliable, six days a week. Not that that's really relevant.

I don't think "national health" and "single payer" are necessarily the same, in terms of comparing Canada to the US. Medicare, a single-payer system, would be the model here, and is quite different from the Canadian system.