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Monthly Archives: September 2007

After talking to my girlfriend (who is taking a health policy course) and two of my good friends who are also active webloggers, I decided it would make sense for me to jot down a few hypotheses of mine regarding health care. These have also been on my mind because my current, greatest professional interest is in intensive care, a highly expensive form of care that avid supporters of preventive medicine sometimes believe is incompatible with their mission of improving healthcare for all. I believe they’re wrong on that account. Here’s why:

studies.jpeg

Hopefully, there are (or will be) studies out there that support these ideas.

1. Although health care provided for a small percentage of the general population disproportionately accounts for the majority of spending on patients, this small percentage group is not constant and individuals may enter and leave the group through improved health status or death.

Many people will cite a statistic that approximates that health care for 2-5% of the U.S. population accounts for 50-80% of health care expenditures on patient care in a given year. Without looking further, many assumptions are made: that these people are negligent and delinquent about seeking preventive care, that these people are poor and/or uninsured, and that these people are a problem that need to be corrected. If there is truth in any of these assumptions, I suspect that it is only partial. The most expensive parts of patient care are specialized procedures (e.g. surgeries, stent insertions, etc.) and intensive care, typically care that is provided as interventions when someone is very sick and has a very large chance of dying (or having their deaths hastened). However, the majority of people go through these procedures, survive, and often achieve good qualities of life (according to their own post-catastrophic-event perceptions, even though they may have disabilities) for some years more. So, those individuals in the 5% group will then move back into the rest of the 95%, perhaps only needing supportive mediations (e.g. statins, aspirin, fish oil, and others for someone who had and survived a heart attack). Others might die after an expensive effort to save their life (e.g. weeks in the ICU, blood bank resources, etc.). However, those people are the minority, and they are also removed from the equation.

In short, the population is dynamic, so the 5% group is constantly in flux. Putting that 5% on a desert island isn’t going to help anyone. Similarly, focusing entirely on improving preventive care isn’t going to eliminate that 5%. There will always be people dying: that’s one of the few things that all people must do (it’s a free country, right?). Our society values life, and we try our hardest to delay death, which necessitates a significant degree of expenditure on end-of-life care, specifically intensive care. If people are at risk of dying, we’re going to try our best to stop it from happening suddenly and unexpectedly: we want them to have a chance to tie loose ends, enjoy their lasts, and say good-bye to their loved ones. As a profession, we’re now beginning to find better ways of communicating clearly with patients and families at the end of life, particularly when the sick loved one has made the choice to die and would die without life support. For better or worse, these are the steps that our society requires of people to take when they are going to die. And because of our society’s high value on life, we try to preserve life at all costs – and those costs are necessarily expensive.

2. Intensive care is often a profitable venture for hospitals, because third party payers (insurance companies, the government, etc.) reimburse well for its services. This is because people buy insurance with catastrophic health events in mind, not preventive care.

People don’t pay for insurance to help them take care of their diabetes, or heart disease, or cancer, and so on (if they knew they had those diseases before getting insurance, their insurance premiums would be very expensive). They pay for insurance because they believe there is a risk of something bad happening, and that mental image is typically a life-threatening event, such as a heart attack, a stroke, a car accident, etc. If insurance companies did not reimburse physicians and hospitals for these expensive, life-saving treatments and care regimens, then the word would get out, and people would not buy insurance. So, insurance companies don’t mind paying for acute, life-threatening problems, but they don’t like paying for the long-term treatment of chronic diseases or lengthy, less expensive end-of-life care outside of the ICU.

Many people might think that they can simply “move” the money that pays for intensive care to pay for preventive care. That’s not going to happen for at least two reasons: (1) People will still get very sick, and there’s no way in hell that they’re not going to get treatment in a country that demands high quality and values life as much as the U.S, and (2) patients are not (yet) in control of money allocation.

3. In order to institute quality assurance and improve health care outcomes, the authoritative power of payment must be shifted from insurers to patients.

Most people don’t pay for health care. They either receive health insurance from employment or the government (Medicare, Medicaid, SCHIP, etc.), or they may receive free health care for lack of insurance (often from Emergency Departments, compounding the congestion and overuse of EDs). Some people with the financial means pay for their own health insurance, but they aren’t directly paying for health care. Instead, they are paying for a service (i.e. health insurance) that purportedly manages their health by conveniently connecting them with physicians and other health services. Unfortunately, since individual people don’t pay directly for health care, they have no say or control over the quality of services delivered or the prices of services.

Instead, insurers and the government pay for care, and thus, they set the incentives for payment. At this time, the equation is this: High Performance = High Patient Volume. This is not ideal for patients (or doctors) in most cases, except maybe with ICUs (which actually improve patient outcomes when they have higher annual patient numbers). As patients, we would like to spend more time with our primary care doctors, we would like them to have a good patient-doctor rapport, and also be as competent as possible. We would like our surgeons and interventionalists to perform their job in a way that achieves the best possible patient outcomes as much as possible. With the “payer’s authority” in the hands of the insurance companies, there aren’t effective ways of changing priorities throughout the health care system in ways that don’t produce “perverse incentives.” The customer is always right, and in this case, the customers are the third party payers.

Logically, one might follow the line of reasoning to the notion that patients should pay for their health care. Perhaps this is the answer. However, people have many irrational takes on this idea. For example, some believe that raising co-pays on insurance plans will help people be more “cost-conscious” and use fewer resources. This is true: people will be aware that the health insurance is not helping attenuate their health care costs, and they will be using fewer health care resources. But this won’t necessarily help improve health care quality: it will “cut expenditures,” but actually might gut preventive care and funnel more money into intensive care because more people will be getting very sick from lack of use of primary care.

One thing I do think is important is that primary care physicians, in improving preventive care, should help patients develop health care cost consciousness and emphasize spending a little now in order to save a lot later. Everyone should have health insurance (or some other coverage), hopefully insurance coverage that is relatively standardized and not convoluted (as plans are now) so that doctors can actually advise generally. At the same time, insurance companies should move towards a model of funding more preventive care so that they don’t have to spend as much on intensive care. Even if that 5% doesn’t disappear entirely, it might at least be reduced by a couple of percentage points which would represent a much larger benefit with respect to reduced spending. Although I may become a critical care physician someday, it would make me happy not to see patients in the ICU who didn’t have to be there or could have avoided a life-threatening crisis prematurely.

So, to recap, you can’t just magically “move money from intensive care to preventive care”: you need to shift disease incidence from expensive, life-threatening crises to lower-cost, preventable indications for care. Diseases don’t change overnight and may take decades to develop, so rapidly shifting large amounts of reimbursement from intensive care to preventive care will jeopardize the protection of the health of an entire generation: our parents, or ourselves. Instead, the change needs to be more gradual and have measures in place to insure that the preventive care works.

[I’m a big supporter of better health education in the U.S. school system: by helping young people develop good healthy habits early, we can prevent substantial amounts of chronic diseases and also infectious diseases such as AIDS and hepatitis. Additionally, with respect to preventive care, one thing I’d like to see are opt-in courses where people, healthy or sick, can learn about standard preventive health measures. By taking these courses, particularly when people are in their 20s and 30s, these people would be eligible for universal fee deductions for health insurance coverage, so their premiums would become cheaper the more they learn about preventive measures and healthy habits. Even better, it would be ideal if they were tested (as in driver’s education) and their performance was also measured by long-term measures of health, with matching rewards in the form of cheaper premiums or other pro-health incentives. I don’t think this should be mandatory, though, as many people might not want to or might not have the time to do this. However, introducing this program early in life (such as in grade school) might help insure that the program isn’t just for rich people.]

4. Lastly, in order to reset priorities so that higher performance is marked by improved patient health outcomes, patients and physicians need to work together to assign values on services.

I don’t think insurers should have much of a role in this discussion. It should be a focused, in-depth discussion between physicians and patients. While quality ultimately is for the sake of the patient and we would like to think that patients should determine the measures of quality, patients do not know the full extent of quality in the delivery of medicine. To that effect, physicians are the best advocates for patients. Some patients love their doctors, but those doctors may not be competent in medicine. Some patients might not like their doctors very much, but those doctors may be very competent despite their less ideal rapport with their patients. The quality of medical care in the U.S. is better than it is elsewhere in the world; the quality of health care in the U.S. is not. In other words, the expertise and capabilities of physicians in the U.S. are better than anywhere else in the world (which attracts foreign medical graduates to train here, and also to remain here so that they get paid more for their superior training as compared to jobs they might find in their home countries where medicine is not as good or even as valued), but the delivery of health care (including medicine, its main component) is not ideal in the U.S. Many aspects of health care impede the delivery of 100% of the quality of medical care that can be provided by a given physician: shortened visit times, malpractice forcing doctors to practice “defensive medicine” at great financial expense and expense to their potential as physicians (i.e. they don’t reinforce excellent training with excellent practice, because ordering every test when many possibilities can be ruled out with good history-taking and a good physical exam is not good medical practice), general distrust of doctors by patients, poor compliance on the part of patients, and more. At the same time, patients need to assert themselves in a manner that is not threatening to physicians: doctors are not their enemies, but rather, their potential best allies, if the profession is not crippled by politics, malpractice lawsuits, and financial restrictions and disincentives. In order to achieve the best quality of medical and health care possible, physicians and patients must work together to make it happen.

Across each time zone, hidden from the light of day, hundreds, perhaps thousands, of people lie awake, unable to fall asleep. Some suffer from insomnia. Others are light sleepers and have their sleep interrupted by the loud TV or stereo downstairs. Some made the mistake of drinking an extra-large latté after dinner. A handful might even be on the run, whether from the police, a rival gang, or assassins sent by a mysterious power broker. And then there’s me, lying in bed with a throbbing, swollen thumb, cursing my own tired stupidity.

Just a few hours earlier as I was getting settled to sleep, I quickly reemerged from my comfortable bed and the warmth of my girlfriend’s company to close more doors in my suite and muffle the loud, rumbling bass of my neighbor’s music. As I slammed the door with disapproval, contempt, and weariness, I didn’t notice that I had placed my thumb between the door and the frame. It’s often said that paper cuts, however small, are so much more painful than large gashes and scrapes on much less sensitive parts of the body, like one’s shins or arms. If paper cuts expose the nerve endings in the fingers to the harsh air, imagine what it is like to have those nerves crushed and dozens more compressed by rapid, internal hemorrhaging.

Despite the pain, I decided not to go to the off-hours, college Urgent Care facility. The last time I went there, I had been punched in the face during an intramural soccer match, leaving a wide enough gash on my eyebrow to require stitches. However, I had to wait four hours before I received any care, even though I was one of two patients in the facility. I was not pleased. I ended up disinfecting the wound myself in the men’s room and using paper towels to stanch the bleeding while the nurses chatted the hours away. This time, I decided that it would be better to wait for the normal outpatient service to return in the morning.

Yet, here I was, lying on my back, restless, frustrated, and angry at just about everything that popped into my head. Angry that the urgent care facility was a joke (e.g. I wouldn’t be surprised if the first question they asked was, “Were you drinking?”, closely followed by “Are you pregnant?”). Angry that it was too ridiculously cold outside to venture out in the middle of the night to seek substandard care. Angry that despite my excruciating pain in my hand that felt like it was throbbing as loudly as the bass next door, my girlfriend was sound asleep beside me, oblivious to my state of misery. I started feeling sweaty and feverish and had difficulty deciding whether to keep the covers on to stave off winter’s bite or shrug them off to cool the delirium.

By the next morning, my nail bed of my thumb was, in full, the darkest shade of violet. My anger had subsided, but my feeling of stupidity was reinforced by my girlfriend’s concern and question, “Sweetie, why didn’t you wake me?” Somehow, biting my tongue about a jammed thumb didn’t seem so manly as it might have at 3 in the morning. We immediately went to the student health center as soon as the evening shift was over, and I was promptly seen by a doctor who came up with a quick solution: a cauterizer. He explained that the trauma to my thumb broke blood vessels that were pouring their contents under my nail. He was going to relieve the pressure on the nerves in my thumb by burning a small hole into the nail to drain the blood. If there was no damage to the nail matrix, it would simply grow out and my thumb would be back to normal in a couple of months. My girlfriend, in a more keen and cheerful mental state than myself, asked the doctor, “What is the Matrix?” I smiled in appreciation of the joke, but sadly the doctor didn’t recognize it and instead answered with a quick medical explanation. Well, at least I was in a stable enough mental state to appreciate jokes now. The procedure went without a hitch, and the pain was relieved instantly. For the next several weeks, I occasionally stared at the hole in my nail with the comforting observation that it was progressing forward to the edge and would soon be gone. And also, I would think to myself, “Well, that was easier than expected.”

I can deal with people making mistakes that negatively impact me: mistakes happen. However, there is one thing that I simply cannot tolerate: people not owning up to their mistakes and shifting the blame onto others. In the context of medicine, I just can’t believe that this would happen, but it does.

The Cyst Saga or How I Learned to Stop Worrying and Love the Remains of the Abscess on the Side of My Head

For more than a month, I have been trying to schedule an appointment with a dermatologist. At the beginning of this time period, I spoke with the dermatologist’s nurse, and after discussing a few dates, we agreed to schedule an appointment at the end of August. When I called in shortly before the appointment, I was told that I had no appointment: rather, I had an appointment in the middle of August, and I had missed it. I was told that the nurse would call me back to reschedule. She didn’t. I sent an e-mail to the doctor explaining that there had been some miscommunication because I was told the appointment was for the end of August, and that I’d like to reschedule. I called back a week later since no one had contacted me. The receptionist said the nurse would call me back that afternoon. She did this time, and claimed that the dermatologist didn’t want to reschedule my appointment, implying that since I had “missed my appointment,” I didn’t deserve to receive care from him, a busy physician with a full schedule with other patients who do show up for their appointments. (EXCUSE ME? said a voice screaming in my head.) I tend not to complain, but this was just ridiculous. After finding out the name of the person with whom I was speaking (who happened to be the nurse who was supposed to have scheduled my appointment), I insisted that there had been some miscommunication or mistake since I had been told that my appointment was for the end of August. In fact, the date my “appointment” was scheduled for would have been the best date possible for me (since I had nothing scheduled for that afternoon), but she had never even offered that date as a possibility (leaving me to choose between possibly having surgery the day before an exam or the day before I flew out of town for a weekend trip). She then discovered that I had not received an appointment (reminder) slip, which seems to imply that she (or someone else between her and the appointment schedule) seriously dropped the ball. With an enormous THUD. She subsequently rescheduled my appointment for a month from now. I don’t like getting people in trouble, but the fact that the blame was shifted onto me and would have removed my ability to seek treatment from this dermatologist is a serious breach of responsible conduct. I’d like to think that she simply didn’t remember making a mistake when the dermatologist discovered that his patient (me) was a no-show for my mid-August “appointment”: that would suggest incompetence rather than gross negligence due to dishonest irresponsibility.

I Must Not Tell Lies

I used to be somewhat self-conscious about my teeth. My lower incisors are somewhat crooked: my jaw just doesn’t have quite enough space for them. When I was a teenager, like so many others, I had braces for a couple of years. However, mine didn’t work. Rather, the braces worked fine, but the retainers didn’t. When I went to see my orthodontist, he took a look at my teeth and very quickly jumped to his conclusion. “Why aren’t you wearing your retainer?” (Excuse me? – I was too timid to talk back in ALL CAPS at that point in my life.) The thing is, I had been wearing my retainer, exactly as he had instructed. I explained such. He looked at me condescendingly and said, “You need to wear your retainer as I instructed.” As one might imagine, I was quite angry that I was being accused of being a liar when I wasn’t. He seemed completely incapable of adapting to an unfamiliar situation or an outcome he didn’t expect. He was unable to believe that the treatment he provided didn’t work. Of course, it had to be my fault.

I kept wearing my retainer after that, but I was very disenchanted by the condescension bestowed upon me by this person with the initials “Dr.” in front of his name. Months later, I was fairly negligent with my retainer use, partly because it was clear that the retainers were not strong enough to hold my teeth in place. However, it was mostly because he had destroyed my trust in him. Ironically, as I watched him with some degree of defiance in my eyes, the orthodontist examined my teeth and said, “I see you’re wearing your retainers. Good.” I said nothing.

Today, it remains as my scar, my reminder of honesty as I continue on my road to becoming a healer: in order to treat others well, I must be honest with myself, particularly about my mistakes. I must not tell lies – especially to myself.

Fall Guy

Without going into too much detail about the case of Dr. Anna Pou and the deaths of a number of patients at Memorial Hospital in the chaotic days following Hurricane Katrina, there is one thing that I found meaningful about the case. Despite the dreadful consequences and the end of her career, Dr. Pou did at least one thing quite admirable that no one can deny: she took responsibility for the deaths of the patients under her care. Ironically, she was getting nailed for taking responsibility, exactly what we want our doctors to be doing. By pursuing so doggedly in trying to put Dr. Pou behind bars, Louisana Attorney General Charles Foti publicly, nationally, and severely damaged the patient-physician relationship by making it harmful for doctors to take responsibility, admit mistakes, or show signs of remorse for undesired patient outcomes. At one point, the Attorney General even convinced the other two defendants, both nurses working with Dr. Pou, to testify against her in exchange for having the murder charges against them dropped.

I found this quote (from the Wikipedia article on Dr. Pou) remarkable:

The investigation apparently began after Dr. Bryant King, a physician working at Memorial following the hurricane, publicly charged that one or more health care workers had killed patients. King told CNN that when he believed, based on conversations with other health care workers, that a doctor was about to kill patients, he boarded a boat and left the hospital. King explained his actions in terms of his opposition to Pou’s alleged actions, arguing “I’d rather be considered a person who abandoned patients than someone who aided in eliminating patients.”

In the midst of the chaos, with no sign of rescue or aid, with everyone trying to adapt to an unfamiliar situation with unfamiliar needs, this doctor thus justifies his decision to abandon patients. Way to give up the responsibility to save lives and ease suffering.

Concluding Thoughts

Responsibility is an incredibly important component of the medical profession. As far as I have witnessed and heard, it seems that physicians often feel or take greater responsibility for conduct and outcomes than other health care professionals, or perhaps just other people in general. At least in my case, orthodontists and nurses. Don’t get me wrong, I love nurses and have worked extremely well with many, but the buck stops with the physician. The physician is the team leader, and upon the shoulder of leaders, we place the responsibility and the blame. If anything, our society should make it easier for physicians to take responsibility, learn from mistakes, and improve care rather than continue in its punishment of one of the few groups of people that actually feels compulsion to be responsible and act on that internalized moral code.

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