Archive for the 'Health Care' Category

Guerilla Health Care - 03

This is the third in a series of contributions to fixing the health care system without breaking the bank

Very simple story of how the health care system got this way

The health care system, continuing a tradition of medicine going back centuries, was propelled forward in the 20th Century by a combination of three factors:  the growth of health insurance, exponential progress in medicine, and the increased role of the federal government in health care.

Health Insurance. Universal health care and national health insurance were proposed as far back as the presidency of Teddy Roosevelt, but were opposed, for a variety of reasons, by organized medicine, organized hospitals and the insurance industry (and their policy spokespersons in government).  There was nothing like private health insurance in the US until 1929.  The reasons are numerous, but in part it was that medicine, in the early 20th Century, was a pretty uncomplicated affair.  Much of it was conducted in the home, fees for service were modest enough they could be paid out of pocket, and there was a tradition of pro bono or charity medicine for those who couldn’t afford care.

The Great Depression spurred the introduction and growth of private insurance, the labor movement accelerated it as health insurance became a negotiable benefit, and by the 1940s it was a not-uncommon commodity.  What emerged, however, was a mish-mash of  coverage, with few or no standards, no coordination and continued opposition to any kind of planned health care system.

Progress in Medicine. In the meantime, there were advances in public health that changed the major causes of death among Americans—we began to live longer—and the same was true of medicine.  There was, for example, a dramatic decrease in the rate at which women died in childbirth as more and more births were attended by physicians in hospitals.  There were advances in the understanding of variations in human blood, making transfusions less risky and enhancing the survival of surgical patients.  Likewise, antibiotics changed what we died of probably more than anything since the introduction of pure drinking water through municipal systems.

Infusion of Government Funds. Still, at the end of World War II, there had been decades in which the supply of hospital beds hadn’t kept up with need.  With rapidly improving medical technology, a general advance in affluence, the existence of affordable health insurance, it was considered necessary by the federal government to intervene by adding to and modernizing hospital facilities.

In 1946 Senators Harold Burton and Lister Hill fashioned a bill to provide federal construction funds for hospitals in areas with shortages of hospital beds.  In California, where I am familiar with the program, the state matched the federal funds and together these amounted to two-thirds of the cost of construction, the other third being raised by bank loans, philanthropic donations or private capital.  At about the same time, the National Institutes of Health and the National Science Foundation began to rapidly increase public monies available for health and biomedical research.  Both root causes of disease and dysfunction as well as therapies aimed at preventing death or long-term disability created another great leap forward.  The focus turned from communicable diseases, which had been tamed largely through public health measures, to the prevention and treatment of chronic diseases, such as cancer.

As we became a predominantly urban society, with a burgeoning middle class, the diseases of affluence plus changes in the people’s expectations increased the demand for health care services as well as the cost of care.  Cost became no consideration in decisions about conditions which, forty years earlier, might have been borne with resignation. With the advent of Medicare in 1966, a class of patient—retired persons of modest means—that had traditionally counted on family and charity to attend the illnesses of advanced age, became a steady source of income for, particularly, hospitals.

Policy makers still had no consistent vision of what constituted a proper health care system, nor what should be the government’s role in operating it.  Some favored federal intervention concentrated on the treatment of catastrophic illness, such as end-stage renal disease; others favored a system that concentrated on preventing illness, and for a time health maintenance organizations were seen as a way to keep ever-increasing costs down while preventing chronic illness and disability.

The question is far from settled.  According to the National Coalition on Health Care, in 2008 we spent more on health care than on defense, or some 17 percent of the nation’s wealth.  We are continually told by organized medicine, hospitals and insurance companies, despite evidence much to the contrary,  that universal health care, with a single payer, is inferior to our laissez faire catch-as-catch-can system because you will have bureaucrats making medical decisions.

In 1929 many Americans were lucky to get any medical care (other than “folk medicine”) between birth and death, and even those defining events might be outside a hospital.  In 1969 by contrast, the average person spent three of his last twelve months of life in an acute care hospital.

And sometime in the ‘70’s, in Los Angeles, Mabel’s friend got her CAT scan because she had a headache.

Guerrilla Health Care - 2

This is the second in a series of contributions to fixing the health care system without breaking the bank

(what system?)

You’ve been running three miles a day since God knows when.  One day you wake up and your knee feels grim.  Days pass; soon just climbing a flight of stairs makes you sweat.  You finally decide to get medical care to put you back in your Nikes and running shorts—you miss the road, you miss the endorphins.

In the process of mending your knee you see your family practitioner, two orthopedists, the radiology department of the local hospital, a physical therapist, the local pharmacy and a podiatrist who designs an orthotic to insert in your running shoe.

For this one condition you interacted with a pretty big swath of the Health Care System:  four doctors, a hospital, a physical therapist, a pharmacy.  But you also had most of your bills paid by an insurance company and there’s the orthotics lab that made the insert, the architect who designed the hospital, the contractor who put it up, the X-ray machine manufacturer, the universities that graduated and trained the doctors and the physical therapist, the manufacturers of the analgesic, the company that designed the hospital’s billing system, the agencies that licensed the practitioners, the boards that certified the physicians’ competency in their specialties, the agency that accredited the hospital and on and on.

AND, most importantly, you, the patient.

Where do you draw the line?  How much of the universe do you encompass within this health care system?

Of course that depends on why you’re taking a systems approach.  If I want to examine the appropriateness of medical care in my immediate medical market area, I’d draw a line on a map enclosing an area along the Interstate 5 corridor from Yreka, California, to Cave Junction, Oregon, with arrows pointing to San Francisco and Portland, where I might go once in a blue moon for super specialty care.

If  I were curious to know whether medical specialists in the Rogue Valley used the latest in medical knowledge in their practices, I might have to go very far afield, since specialty boards are national in scope and there is no telling where a physician was trained before he entered practice in the Rogue Valley.  I’d want to know what Oregon’s licensing agency requires in the way of continuing education.  I’d probably consult Oregon affiliates of national professional organizations.

If I were all wise and President Obama’s health care guru, I’d be looking at the whole shebang:  enabling factors, such as health insurance, dental insurance, Medicare and Medicaid; predisposing factors, such as life style, education, income, genetic predisposition to disease, and religious proscriptions; facilitating factors, such as the number and distribution of medical care resources, the public health sector, the state of biomedical research; system regulators, such as the Food and Drug Administration, the Department of Agriculture, the GAO, the Department of Justice, OSHA, the Department of Consumer Affairs, the antifraud unit of the Centers for Medicare and Medicaid Services.

Most of all I’d be looking for an accurate model of how the health care system operates, it’s inputs and outputs, its processes, and equally important, how its accomplishments (or lack of them) are monitored, where it’s out of kilter and where it’s outstanding.

In the process of constructing this model, I’d want to know what the system actually costs, not just in big numbers but in specifics, such as what it costs to treat a case of a certain variety of cancer.

I would also want to model the consequences of changes in the inputs and processes of the system.

What if, for example, doctors could prescribe membership in a fitness center for obese persons?  What if a doctor could prescribe not only nutrition counseling for the undernourished but also food?  Would investments in these products and services change the inputs to the system (e.g., obese persons or otherwise malnourished persons) sufficiently to reduce the costs of medical care?  Would old, infirm persons get more preventive health care if Medicare ponied up for taxi fare to the doctor’s office?

The health care system is vast, expensive, secretive and self-protective, inherently inefficient and, overall, under-regulated.  In coming posts I’ll speak to places where a systems approach can be fashioned to work within these constraints.

Guerilla Health Care - 1

(Potshotting the health care system)

If there’s something in this world I know something about, worry about the Obama administration getting right and feel compelled to opine about, it’s health care—both medical care services (narrow) and the people’s health (broad).  Hence a new category of posts: Guerilla Health Care.   — Angus, 3/6/09.

I got a glimpse of the real problem as I rode the elevator to my twelfth floor office.  As Director of Planning for the Los Angeles County Health Planning Council, my job was to create a fact-based plan that identified medical care resource needs for the county’s seven plus million residents five years in the future.  How many doctors of what kind would we need?  How many emergency rooms?  Where should they be located?

I shared the elevator that day with two women—middle-aged, affluent suburbanites—oblivious of my presence.  One or both had come downtown to visit her physician.  I stood quietly watching the floors go by as I eavesdropped on their conversation.

“Mabel,” one woman asserted, “I told my doctor if he didn’t get me a CAT scan for my headaches, I was going to sue his ass off.”

The other woman applauded her pluck.

It happens I’d been pondering, for days if not weeks, why LA County, with seven million residents, should have sixty-three CT scanners, while Great Britain, where the contraption had been invented and with roughly eight times the population, had only three.

Now I knew why.

The real problem was the pseudo-quasi-free market model of the health care system envisioned by the system’s decision-makers, because of which every hospital that can remotely justify it gets the latest medical imaging devices.  (Five years later I’d meet a lawyer whose radiologist wife actually had a scanner in a trailer she pulled around the county doing curbside tomography.  Hey, driving downtown is such a drag.)

You have consumer demand, you have a payment system that permits payment-for “usual and customary” diagnosis and treatment-for pretty much whatever the consumer demands and the doctor okays.  You have a public who fervently believes in the health care system’s ability to ward off death, cure ills that a hundred years ago would have put you in your grave, make up for unhealthy lifestyle choices, and alleviate pain and the fear of pain.  -Or else.

Oh, and give us Cadillac health care at Chevrolet prices—without government meddling (except for approving drugs, licensing health care providers, funding most biomedical research, keeping the environment healthy and footing the bill when we get old, disabled, or indigent).

So why not, you ask?

Because, if we make sure every citizen has access to Cadillac health care, someone’s got to pick up the part of the bill that you or I can’t personally afford.  There simply is no cut-rate health care.  If a CAT scan for Mabel’s friend becomes “usual and customary,” you’re not going to get your headache treated without a CAT scan first.  Your doctor’s already paying more for his malpractice insurance than he is for his mortgage.  He definitely doesn’t want to risk your suing his ass off.

Hence the cry for “health care reform,” as if this will suddenly make everything better.  Health care reform, alas, is a shibboleth that has a righteous ring but a devilish price tag.

In the coming year I plan to explore what’s possible and what’s not in bringing effective health care services to the people, and what effect universal heath care will have on the people’s health.

Update: Coincidentally, the New York TIMES recently published an article (”Good or Useless, Medical Scans Cost the Same,” by Gina Kolata, NYT, 3/1/09) in which the author asserts, quoting a GAO study and radiologists on the staff of medical schools around the country, that perhaps half of all medical imaging procedures are useless, even though private and government insurers foot the bill for these.  It seems some scanners are past their prime, or some persons interpreting their images aren’t competent.  And the motive, in both cases, is economic.  She states that 95 million scans are done each year, costing $100 billion, of which Medicare pays $14 billion.  There are no standards for judging the appropriateness of most scanning procedures.

I’ll address some of the issues raised in this article in subsequent posts.