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.

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