Reply to "America's Health Care System"

Wow! I am really impressed with the thoughtful, intelligent replies. I do feel a little guilty for putting this out there in light of the fact that I don't have a grand scheme or any great ideas how to fix these problems.

This is an incredibly complicated situation that goes to the core of our belief system in the US. We have to figure out how we are going to come to a resolution that is palpable and safe for all of us. One way or another there are going to be some big societal changes from this problem whether we like it or not. I think this realization has to be the first step in deciding how we are going to proceed as a country.

We can't begin to solve these problems until we decide, as a country, what our belief is about the system of health care. The first decision we have to make is whether health care is a privilege (you can have it if you work hard, earn it and pay for it), or a right (any person living in a society as rich as ours should be able to expect to not have to worry about such a basic necessity as medical care). Do we believe that the more money you have to spend, the better your care should be, and the better the outcomes you can expect from treatment? Or should we all be able to expect the same high level of service as we do from our highway system, firefighters, police officers and other public safety systems? I think it is some kind of poetic justice that one of the systems described above is basically the Canadian system (where many of my family live), and the other is realistically the Mexican system (that living in South Texas I deal with the shortcomings of on a daily basis). How ironic that we are literally and figuratively "in between"?

My best guess on how this is all going to play out is something in the middle, as practiced in the past in the UK (where my wife grew up). Greatly simplified-a basic expected level of care that, if you can afford it, can be enhanced with your own supplemental insurance/money. Does this ensure equal care for all citizens? Absolutely not, but you are guaranteed a certain level of care and freedom from the threat of financial ruin from medical bills. Is there rationing involved? Absolutely, you are not guaranteed the latest wonder drug or procedure.

Even without government intervention I believe we are headed this direction. Many medical specialists are now banding together and building there own for profit hospitals to get out from under the government regulations required when you accept governmental insurance. You get what you pay for at these sites. One of the hottest trends in medicine today is "boutique care" where you pay extra money to have improved access to your physician (and often their home/cell phone number that you are encouraged to use if needed) and longer scheduled appointments in what is usually a nicer, less busy office.

Will this UK type of system fly in the US where we feel like we are entitled to and expect the newest, fastest, most technologically advanced everything available "because we are Americans"? That remains to be seen. There would have to be a change in attitude about the whole system. Whose job is it to tell someone they are not entitled (sorry, I love that word) to the most advanced, specialized treatment available? Unfortunately, I think the only entity that could pull it off would be the government. I think it works in the UK because of different expectations and history of a strong class based societal system.

Why don't we just give in and do it that way? To many people have to much at stake. Many of us are not comfortable turning even a basic level of our medical care over to our government control even though realistically we already do. With exception, and to greatly simplify it, everything in medicine today including private insurance reimbursment rates and approval of procedures/treatments is based on Medicare/Medicaid standards. Do we think multi-billion dollar profit making insurance companies or hugely profitable hospital systems (of which there are more than you might expect) are agreeable to this? Do we believe the people who can't afford extra "boutique care" will accept this inequality? Do we think the many private physicians that would essentially become government employees (even though practically they already are) would accept it? Do we think the lawyers will agree not to sue if the basic accepted care was rendered but the latest state of the art cutting edge treatment was not given? Do we think the politicians up for election are going to be able to tell their constituents, "I'm sorry, you can't have everything but this is the best for all of us in the long run"? I think you can see how big of a shift in societal attitude this would require. I'm not sure we're ready for it, but something is going to happen whether we are ready or not.

To just respond to some of the excellent comments you guys have made:

Larry-Medicare is a great idea, the first problem is that it is going broke. Without a huge influx of money and/or limiting of benefits it is unsustainable. Problem 2 is that it is so laden with regulation and complexity that it is impossible to fulfill all the requirements without using more costly resources. We have to have people (called "coders") whose only job is to look at our charts and determine the proper codes to submit to get paid for the care we provide. If you put in the wrong code you don't get paid. If you get paid for something that wasn't supported by your chart you can be subject to prosecution for fraud and have to pay back 2-3 times the money the government paid you on demand. Sorry, given that I practice Emergency Medicine I am somewhat blissfully ignorant of the many intricacies of the coding/reimbursment particulars. I'm lucky enough to be in a specialty that has people to do it for us. I'm sure some of the other docs on the forum can give you way more info on this than you will ever care to know. Think about the forum discussion we had on the paperwork for "cash for clunkers" and multiply it by all the possible diagnoses and patients that are taken care of every day.

Kelly-some of the worst business people I have ever met are doctors. In 4 years of college, 4 years of medical school and 3 years of residency I never had a class in business. We are trying to change that now in Emergency Medicine by including lectures in our residency program regarding the business aspects of medicine. It is the medical profession's own fault that we got taken advantage of by insurance/lawyers/government. In the past the profession saw itself as a calling. We thought we were "above" the business/legal/political aspects of medicine and let others deal with those aspects of practice since we felt our job was to just take care of the patient. Obviously this was incredibly short-sighted and arrogant or naive of us and we eventually let other people/government/organizations tell us how we had to treat the patient instead of what we knew needed to be done. Unfortunately that genie is out of the bottle. Organized medicine is not that organized, and like everything else today there are huge political forces at work.

Once again, I appreciate all your thoughtful comments. Thanks for listening. I'm glad there are people out there that can see through the political posturing and reactions and realize this is actually important and will affect all of us in the long run.

As Jack says, my 2 cents worth.

I promise not to burden the forum further with too many off topic musings.

Mike

P.S. My wife stumbled on these postings on my computer and said "Oh my God you got started on it again, didn't you".