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April 16, 2009

Health Care Reform Part 1

Patricia A. Kelly

Barack Obama is not the only one who believes that health care reform is essential to the economic and personal well-being of Americans. Technically, we can’t be beat, but our system is a mess.


People come to this country for second opinions and specialized treatments unavailable elsewhere. We, meanwhile, are flying to India for surgery, or going without care or prescriptions for lack of money. Go figure!


In his speech February 25, 2009, while nominating Kathleen Sebelius as Secretary of Health and Human Services, President Obama made a number of excellent points about the present state of our health care system.


He said that one fourth of our health care expense is administrative, due to our antiquated record keeping system.


He named drug and insurance companies as the biggest obstacles to health care reform. These companies have spent $1 Billion in lobbying over the past 10 years. So much for their claim that they need to recover funds spent on research by inflating drug prices during the patent period.


Per the president, General Motors pays seven times what it would cost a Japanese auto maker to provide health insurance to employees.


Price gouging of uninsured patients by hospitals, and the estimated 100,000 annual deaths due to medical errors were also mentioned.


The president definitely scratched the surface, but there is so much more.


Considering our wealth and technical skill, our life expectancy and infant mortality statistics are pretty bad, compared to many other countries. The bulk of our health care dollar is spent in the last six months of life, often on futile care. This means that, for all the money we spend, we don’t get very good value.


Physicians generally fail to police themselves. In my personal experience as a nurse reporting egregious physician behavior to the hospital medical staff, what I got was a thank you note. What the physician got was a letter, and the right to continue to practice freely.  What the patient got was a ruined heart.


Patients fail to take responsibility for themselves. We show up like little sheep at the physician’s office, take what we’re given, and ask few questions. We want a pill that will quickly fix us without requiring the work of diet or exercise, or better lifestyle choices. Just give us a pill. We don’t even check to make sure it’s the right pill when we get it.


If a drug representative convinces our doctor that a new pill is better than our old one, we’ll often get it prescribed for us. If we’re insured, we may not even notice that this new pill costs $200 per month vs. $10 for the old one, and that there may be little or no actual evidence that it works better. Sometimes, our new pill has been pushed through the FDA so fast that dangerous side effects remain undiscovered.


Merck, the pharmaceutical giant, actually knew that Vioxx was dangerous, but hid the data. In the end, after enough patient deaths, Vioxx was proven to be, not only dangerous, but no more effective against pain than ibuprofen or acetaminophen.


If the doctor – whom we have not questioned – makes an error, we and our lawyers think we should be paid a lot of money. If the doctor amputates the wrong leg, I agree. If he misses a diagnosis that’s complicated, in spite of appropriate testing and checking, I don’t.


Malpractice suits have dramatically increased the cost of physician insurance, and actually driven many out of private practice. There‘s a serious shortage of neurosurgeons in Maryland. That’s very bad news if you start bleeding around your brain.


My son fractured his ankle in an accident just after moving to California and letting his health insurance expire, as his COBRA payment was high. To mention only one of his bills, the hospital charged him $29,000 for outpatient surgery that took one to one and a half hours of operating room time. This didn’t include the doctor or anesthesiologist. The hospital then offered him a 50% discount for payment within 30 days!


The same operating room time for an insured person in Maryland would have cost about $5,000.


I don’t know the reason for price gouging the uninsured, but I imagine the write-off for a very large unpaid bill would considerably benefit the hospital bottom line. The hospital in my son’s case undoubtedly expected him to be unable to pay. As it happened, he negotiated the price, got a little state help and worked many, many hours of overtime to pay his medical bills, after spending much of his recovery period negotiating by phone.


It just doesn’t seem right that cash on the spot payment would cost two to five times more than the insurance company would be charged.


Medical, nursing and pharmacy errors are huge in our country, with 100,000 unnecessary deaths reported each year. Not infrequently, nurses are assigned eight patients, even without an assistant. Although better nurse/patient ratios have been demonstrated to reduce errors and save lives, our health system leaders resist paying for reasonable staffing.


California has mandated ratios. Nurses actually move there to work because of them. A friend of mine returned to Maryland after spending some time working in California and told me that life was amazing for her there. She could actually do a good job and still have time to take a break, or eat lunch. She couldn’t believe what a difference it made.


Primary physicians don’t have it easy, either. Their income, controlled by insurance reimbursement, is a numbers game. They can make good money only by increasing their patient numbers. They don’t even have time to know their patients, so they send them to the Emergency Department. They’re quitting, or, at least discouraging their children from going into medicine.


In many hospital settings in this country, it is dangerous to leave a helpless patient at the mercy of the overworked staff. From bedsores, catheter-related or other hospital-acquired infections, to dangerous medication errors, hospitals are minefields.


All the two-story atria, baby grand player pianos and trickling fountains in the world don’t make much difference to a person who needs to be turned every two hours to prevent skin breakdown, if his nurse doesn’t have time to do it, not to mention to provide him with proper ongoing assessment.


There isn’t enough coverage for non-acute, preventive care for the under-insured. These same patients, after their condition has deteriorated into serious, life-threatening illness, become eligible for Medicaid and end up in ICU. Compare the cost: thousands per day in ICU, or two hundred or less for a regular physician appointment.


If you live in Frederick, you might be able to get a liver transplant, but you would have to get into a Mission of Mercy clinic to get regular, preventive care as a member of the working poor. That means we spend millions of dollars per year snatching people from the brink of death to live in a state of chronic illness instead of providing adequate preventive care.


Physicians, lawyers, patients, insurers and legislators all share some responsibility for our present crisis.


Next time, I’ll offer some ideas for solutions.


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