As Americans, for the most part we feel entitled to good health care. There are plenty of problems with the system, but at the end of the day, we like to think that as Americans, we do not ration health care.
We believe as Americans we get what we need. Anyone watching the COVID disaster, knows a lot about rationing. Who would have ever thought we would have to ration masks in the USA?
In fact, we do a lot of rationing. The majority of the healthcare dollar for Medicare patients is spent in the last year or so of life. So, do we keep elderly patients’ alive in their last year, spending billions of dollars. Or do we use this money to support preventive care, vaccines, childhood nutrition, etc. This is a difficult decision to make for any doctor or any human being.
We all assume that by taking better care of ourselves and achieving lower weights that we will be healthier and be less of a burden on the health care system.
However, there is an obvious problem with this logic; if these obese patients lose weight and take good care of themselves, they LIVE LONGER AND COST MORE! So, the issue of cost control in medicine is extremely complicated.
In a Canadian Report, the author muses over the cost savings achieved when patients choose “Euthanasia”. They state that patients are not “encouraged” to commit suicide, but the patients are under social pressure to not waste resources and are sort of socially pressured to just die.
In the USA, it is very different. As we age, as I have aged, I feel that I have now paid into the system and deserve anything I can get no matter how old and decrepit I have become. I PAID FOR IT!!
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In the early 80’s, some very interesting Medicare billing policies changed. “Right to die” legislation passed, allowing nurses and doctors to support end of life care and allow patients to die in the hospital.
The other piece of legislation attached to this “right to die”, was tied to how Medicare would reimburse the hospitals. With these new changes, the payment from Medicare to the hospital was based upon the patient’s diagnosis and comorbidities. There might be adjustments, but a “stroke” was a fixed fee. If you added in pneumonia to the stroke, it was a different and higher level code, but a fixed fee.
With fixed fee hospitalizations, the hospitals no longer had incentives to provide excessive care. The hospitals would get the up-front payment determined by the diagnosis and complications, and then were “ok” if the patient wanted to die. Patients, for sure, are very aware of when they are to be dismissed from good care or placed into Hospice too soon.
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Listen to what I personally experienced in the early 80’s as HMOs first came on the scene. They were brilliant and I studied them and went to any physician meeting where they told us how much better our lives would be if we just “signed up” with the HMO.
The HMO’s would take 20% or so off the top of the Medical Dollar and leave the 80% to be fought over – and fights did take place. Everyone fights for a piece of the pie after 20% is taken by the HMO.
It seemed to me at the time that I would be working harder and making less money and be forced to see more patients daily than I was comfortable seeing. I loved and still love the luxury of spending 60 minutes or more with a new patient. 90 minutes would be perfect.
My daughter is a UCLA Professor of Endocrinology.
She is always struggling to find more time to spend with patients. I never wanted to do that. It takes time for a patient to develop trust; 20 minutes is just not enough time. Also, it takes more than 15 or 20 minutes for a good doctor to formulate the treatment plan. Then perhaps 5 minutes of the 15 min is done charting and billing. So, if you include saying hello to the patient, you might be down to 7 or 8 minutes while having the ability and likelihood, that thousands of dollars are to be spent on more tests that could be avoided.
Inadequate patient-doctor time, leads to the ordering of more expensive tests that often can often be avoided by spending an extra 15 minutes with a patient. I was always relieved and terrified when I realized I finally “got it” in the last few minutes of a 60 minute visit. The more a physician must “shotgun” testing, the less likely a true diagnosis will be made.
So, the testing system does contribute a lot of harm with both false positives and false negatives. In many situations, particularly with uncommon diseases, the false positive tests combined with the false negative tests, makes the predictive value of the test very, very poor. This can be calculated, if you are remotely interested by using Bayes Theorem
Let’s take resource distribution to the level of the insane.
We should cancel all helmet laws – sure more head injuries, but most will die young and save money.
Perhaps the government should subsidize McDonald’s oil rather than the oil companies? IF the patients begin dying younger, they will use less medical resources and less petroleum products in their lifetime and die younger having contributed less to carbon pollution; what a double win!
So, it seems that preventive healthcare may kill the system. Let’s take it to the final level of insanity. Read on. Perhaps over the top, but perhaps not so much!
The short-term costs of the COVID-19 Pandemic will be made up over the years by having less citizens to take care of. In fact, is it a coincidence that patients of color are dying much faster? Coincidence? I don’t know. We are cleaning out the nursing homes and the old are dying much more than the young.
If one could control this a bit better, you could alter society in ways that are way too scary to contemplate.
Let us digress. Are the above activities serious issues? Yes, and the more you dig, the more you will see rationing. Blue States vs. Red States. Rich vs. the poor. Black vs white vs Brown. HMO vs PPO
What a mess, so what is the solution? Over many years, I have developed a concept that I believe would greatly improve the HealthCare system.
All patients need access to medical care at a reasonable cost. This is true regardless of who pays for it. So, how do we avoid excessive waste while taking better care of patients.
I would set up a clinic, perhaps next to a University medical clinic. The difference is that in this clinic, the primary care doctors are given 90 minutes for new patients and 30 min for every follow up.
The physicians are trained to use physical exams and detailed history taking to figure out a diagnosis with a limited number of tests. Again, this is critical, as the more tests that are done, the more false-positives you will have. Sadly, the system encourages tests much of the time, so avoiding “unnecessary” tests is never discouraged. Only a good physician with adequate time can do better than much technology.
These false positive tests often lead to more tests and more consultants and before you know it, $100,000 is spent to diagnose appendicitis. We can do better. We need to go back to the History and the Physical exam. We need to do a much better job during patient visits and we need 60-90 minute initial visits. I know that I do require this
Pretty much all the information a physician requires, can be obtained from the history, physical and the family. The exam and tests do add to the diagnosis, but are generally confirmatory.
I know that when I have extra time with the patient, I can calmly decide whether I even need the special and very, very expensive tests. So, if you give a good doctor all the time they need, the professional fee may be some hundreds of dollars, but scans, lab work, consultations, etc become less needed. The tests are far more expensive than the physician fees and often complicated with false positives and negatives requiring more tests.
Patients are very smart. They know when a good physician is barking up the right tree as in making a solid working diagnosis. Patients, in the clear majority of situations, will trust a doctor who is smart, caring and knows how to screen patients without spending a million dollars on an extensive work up. All patients want physicians who listen to them and who gives them hope.
Would it not be great to have two clinics, side by side? Patients were sent to Clinic A or Clinic B in a random way. One clinic works like all clinics work now, but in the other clinic, “The Clinic of Hope”.......
Doctors can spend any time needed with the patient
More frequent 30 min follow up visits are needed
Get to know the patient very well
Order tests when truly needed
Order consultations only when needed.
If we have enough time, many tests will not be needed
Then, after five years, you examine patient satisfaction, money spent and outcomes. I would bet the “kind” clinic would be much cheaper and have better outcomes and patient satisfaction.
I would love to be the medical director of this clinic.
