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.

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