"They Will Never Really Know"
“THEY WILL NEVER REALLY KNOW”
MY THOUGHTS ON MEDICAL CARE IN AMERICA
First Draft - 31 MAY 2006
Forward:
I am not a political or financial scholar. I know nothing of the fine intricacies of political recourse and leadership necessary to develop the policies and programs that all men need to control primal instincts and insure survival. But I have been deeply immersed in the life of medicine and caring for the mind, body, and soul of others essentially all my life. I am probably one of the last “personal family physicians” this country will produce. Everything changes over time, and to say my service was better than others who come after me, only time will tell. But from what I have seen and heard from those I serve, something seems to be terribly wrong, and perhaps the “new direction and their results” are not the best scenario for the citizens of this country after all.
I had deep admiration and respect for my father, a physician, and heard his council and revelations all my life. I heard of his labors and the sacrifices he made through his training and then watched as he administered the compassionate care that all of his patients so appreciated. I think that all boys, at some point in their lives, want to be like their fathers. That is, if they are fortunate enough to have them around as they grow, and who deserve that respect. This was definitely true in my case and surely what started me on my journey into the medical profession. For me, this desire started at a very early age, and since I had seen how difficult it would be, and many of the sacrifices it would require, it instilled in me a significant amount of discipline from the beginning. I also inherited my father’s compassion for all those who were sick, in need, the poor and in all ways less fortunate. Little did I know how this would also shape my feelings about faith, religion and spirituality, which I feel were essential in dealing with failure, adversity, and many times reality itself. And for this reason, it is very difficult for me not to be judgmental, especially when I encounter what I perceive to be an inequity. For me, the practice of medicine was a “calling”, clearly making it a “profession” to which I would devote all of my time, mind and strength to perfect. It could never be an occupation in which I would perform some predetermined function resulting in an “annual income” or a certain lifestyle. All of these things resulted in my becoming a “family physician”. I wanted to know and experience the myriad relationships of the family and extended family, and the mental and physical disabilities that affected this entire segment of our society. Considering the whole person, I was never interested in focusing on just one organ system or disease entity. I would care for them all.
Fortunately, I had tremendous teachers and a newly developed institution that encouraged me in all my endeavors. Being a man, and realizing all that a family meant to me, I also wanted a family of my own. I wanted to be a part of one. At the time, there was no way I could realize what a tremendous blessing a supportive wife would be. She gave me children, corrected and encouraged me, gave balance to my life, shielded me and greatly increased my faith and spiritual life. My personal family also gave me greater insight into the needs and intricacies of family relationships in my patients. My vision of a family physician was always one in “solo” medical practice, perhaps revealing a romantic version of the “knight in shining armor”, going out to single handedly slay the “dragons” of disease and illness. That instinct may very well be deep in the prehistoric genes of every man. We were taught that we had to be “right and accurate”, not only in our diagnostic decisions, but also in those of proper treatment. Therefore, I was always open to professional associations and interaction, but I could never relinquish my authority to decide who I would treat, how I would treat and care for them, and how I would receive compensation for my services. It would have been much easier to enter a “group practice”, where many of the burdens of office management and financial matters were removed from my control. But, being a loner in my character, I chose not to.
History:
I began my practice in family medicine in 1963, in what was then a small, rural community in a rural state not far from our extended family. The gigantic Medicare Program was just around the corner. It turned out to be a fairly successful program in caring for our elderly population, but in its infancy, it was extremely chaotic and gave me my first taste of subsidized, regulated medicine. Subsidized from the standpoint of “someone else responsible for paying the bills”, and regulated from the standpoint of “someone else telling me what tests or evaluations I could order, and what treatment decisions I could make”. It was the beginning of “benchmarks” whereby your actions were to be compared to those of your peers, not necessarily from the standpoint of quality, but from that of “payment parameters”. All of this led to increased costs, not only for the nation, but for physicians as well. Everything had to be automated, from contact to diagnosis, from treatment to outcome and reimbursement. The “solo physician” would lose his autonomy, not only from a professional standpoint, but from a financial and spiritual one as well, severely challenging his “Hippocratic Oath”. This created a juggernaut of new industries devoted to supply and demand, oversight, accountability, research and development, needs assessment and litigation, and the insurance industry exploded. And in this land of free enterprise, these in turn culminated in the ultimate goal of profits. Profits fueled competition. Competition did not result in increased quality, only quantity. Panels of “experts” were left to decide the definition of quality, and even this fueled competition for profits. The bottom line was, “How do we care for the greatest number at the least amount of cost”. The problem here was, medical care was not a “product” with a debatable “price tag”. To the American public, it became a “right”.
Fueled by the competition and profits, there was an explosion of scientific development and health initiatives. Never before in history was there such an avalanche of new discoveries. Diseases were eradicated. The life expectancy rapidly began to increase. It became possible to relieve the pain and suffering, not to mention the disabilities, of millions more. Along with this came the “expectation” that everyone was entitled to the same “benefits”, the latest and best drug, and the most recent treatment modality. The internet gave people the ability to see all of these and to monitor their progress, diagnose their own conditions from a complex of symptoms, and where the most successful treatment centers were located. All of this then became a “supply” (competition) and a “financial” (profits) issue. And all of these required some type of regulation.
Regulation and supply were slowly shifting from the individual physician to the corporate, state
and federal levels. Supply shifted from individuals to collective efforts of corporations and insurance companies. Quality of care was being regulated more and more by oversight committees and litigation. Expectations and demand for the best created entitlement.
This was a scenario the “former” medical system could not handle. There was neither time, nor resources, for the one-on-one approach to individual medical care. Like the early automobile assembled “one at a time” by skilled and attentive hands, medical care for the individual was entering the age of “mass production” and the “assembly line”. Fixation on quality on the part of the caregiver had to give way to “reasonable outcomes”. But the public demanded even greater quality, almost like a thirty-thousand mile guarantee, but this one was for a life. If this wasn’t delivered, there was always the recourse of litigation. Medical malpractice premiums went through the roof. As physicians became more and more like workers on the assembly line, more were being “bought out” by the large hospitals and corporations providing access to care, and these were also driven by competition. It is known that there are such entities that instruct their physicians on how many patients they will see in an hour, what tests they may order and under what circumstances, and even what limited treatment options are available to their patients. In some of these contracts, if the physician wishes to “opt out”, there is a stipulation in their contract that forces them to move a specified number of miles away in order to practice in their specialty. Thus, the picture of the “modernization of medical care” was becoming complete. Because of the demand for access, profits were ensured. Because of the demand for quality, there was always the prospect of litigation. And who would bear the cost of all this and manage it? Certainly not the old family physician.
Results:
It is strange, but in spite of all this ‘progress”, it seems that very few are content, or satisfied, with the experiences in medical care they have today. Quite often they are not able to have access to a caregiver when they need one, are disappointed in the experience they have, are suspicious of and intimidated by hospitals and are absolutely terrified by many of the medications and medical treatment being offered to them. And they can never justify the costs. It is really surprising that most patients do not understand how, and how much, physicians are being paid today. Most think that physicians can set their own fees, and either the insurance companies or Medicare pay what is charged. This is totally erroneous. When subsidized medical care became the norm, payments to physicians became “regulated”. A large survey reveals that only a small fraction, perhaps two percent, of the population understands how Medicare reimburses physicians for their services. Most think that their insurance covers most of the payment and that their “secondary insurance” covers the remaining payment, up to the limit that the physician charges. This is not so. For example, if a physician charges $120 for a procedure as his ‘customary charge”, Medicare decides what the “prevailing charge” should be for the procedure, say $100, and then pays 80% of this amount, which would be $80. Instead of the secondary insurance paying the difference between what the doctor charged and the amount reimbursed by Medicare, they pay the remaining 20%, or $20, giving a total of $100 for the procedure and the physician is denied the remaining $20. Once Medicare had established all its rules and regulations, and since most of the insurance companies had signed agreements with a huge percentage of the physician clinics and hospital organizations, they then began to set charge limits which were identical to what Medicare would allow for any procedures, even to those patients who had insurance outside the Medicare system and were not Medicare eligible. From that point on, all physicians were denied the ability to set their own fees, even for new procedures developed over the ensuing years. In fact, Medicare payments to physicians have not even kept up with the cost of living, as the original law regulated, and caregivers are once again caught in the limbo of the judicial system. Patients in the Medicare system are usually those with multiple health problems and disease entities. To care for them properly, it takes more time to go over all their complaints and medications at each visit. And yet, this system pays the lowest charges to physicians vs. the amount of time spent for each individual case. There is no way to keep up. Therefore, many physicians are opting out of the Medicare system, or are unable to accept any new such patients into their practices. Physicians are now for the most part “told” what they may charge, and what they will be paid.
We seem to be losing our designation as the nation that offers the “best medical treatment in the world”. Some of this may be well founded, or at least understandable. The United States has the most expensive health care system in the world. In 2005, health care cost $6000 per person, or in excess of 16% of the gross domestic product. It is now close to 20%. Switzerland spends $4077, or 11.5% of its GDP, Norway spends $3,966 (9.7%), Germany $3043 (10.6%) and South Korea $1149 (8.2%). But in spite of this, life expectancy in our nation is 78 years, and ranks 45th in the world, well behind Switzerland, Norway, Germany and even Greece, Bosnia and Jordan. The infant mortality rate of 6.37 per 1000 live births is higher than almost all other developed countries, including Cuba. According to “Save the Children”, in 2007, the United States tied with Hungary for 26th. place for childhood mortality. Even for white individuals, the death rate of 5.7 is more than double the rate in Singapore, Sweden and Japan. Obesity in this country has reached epidemic proportions and, like smoking, has continued to underline the problem we have in the realm of “self-discipline” and “being somewhat responsible” for our own actions and health. Childhood obesity is at epidemic proportions and will lead to thousands of new cases of diabetes mellitus. Overweight children become overweight adults leading to all the other problems and disabilities such as arthritis diabetes and heart disease. A recent report indicated a drop in the percentage of women receiving mammograms, and thus a drop in the percentages of breast cancer. One wonders if there is a percentage of these women carrying undiagnosed breast cancer, and that the rate will suddenly shoot up again in the future when these undiagnosed cases become clinically apparent. Individual responsibility has been denied, and it permeates our whole society. And if we believe we are the very safest when we enter one of our pristine, well equipped hospitals, the Institutes of Medicine has just reported that there are 100,000 deaths in America each year just from medication errors in the hospital. It is obvious that throwing more money at the problem is not going to be of any benefit. We have already tried that on a grand scale, and have failed the American people. In this scenario, when all else seems to have failed in this daunting clash of wills, we always seem to look to a “national” solution, because the desires and demands seem insurmountable, at least on a “local” or “regionally collective” basis.
Addressing costs in our system today, there are enormous opportunities to make a profit. Our great American system of free enterprise has stepped in to provide a “solution”, and thereby generated the profits afforded to stockholders. Health and medical liability insurance companies are not in their business for “good will”. They are attempting to “meet a need”. They are providing coverage for the possibility of catastrophic losses based on a calculated risk factor, and their competitive success lies in their ability to ensure a greater return on their investment. Thus, it requires a “minimum reimbursement”. One way to accomplish this is to market their products specifically to the “healthier” segment of our population. Another is to deny coverage to the sickest patients, or at least greatly increase their premiums. Many horror stories abound about companies that “drop” patients from their insurance coverage because they are no longer deemed “insurable”, sometimes occurring after a serious illness that has required considerable expense. It may not be well known, but many of these companies hire other companies to challenge any and all claims for payment, and thereby deepening the well of “costs”. This is exemplified in many situations where insurance companies are spending larges sums to other companies to find ways to reduce their payouts. At the same time, large amounts are being spent by healthcare providers to fight the insurance companies to insure “maximum payments”. It has been estimated that it would take approximately $78 billion dollars to insure every American citizen that is not now insured. By eliminating the extra administrative costs paid to private and corporate health insurers, along with reducing the exorbitant amount paid for medications and devices on a scale more like that charged to other countries, this sum could easily be afforded. What if these “profits” could be funneled into medical care and research? Many hospitals are becoming competitive healthcare conglomerates, again providing profits for shareholders. To guarantee profits, they are creating contracts with physicians and groups of physicians. In some cases, these contracts demand a certain level of “production” in the form of the number of patient encounters, the time spent with patients, patient admissions to specific hospitals and the number and quality of tests ordered and medical treatments offered. A consulting firm, McKinsey and Associates, has released a report indicating we spend $98 billion dollars a year in excess administrative costs, more than half of this accounted for by marketing and underwriting, costs that don’t appear in a single-payer system. It was reported in August 2007 that United Health Care, the second-largest health insurer in the nation, added $31 million dollars to their second quarter earnings because of “Medicare adjustments”. It is also estimated that we pay $66 billion dollars a year in excess drug costs and the costs of medical devices. Here it is sufficient to say, as Paul Krugman of the New York Times reflects, “The larger problem isn’t the behavior of an individual company, it’s the ugly incentives provided by a system in which giving care is punished, while denying it is rewarded”. What if all these profits could be funneled into a fund to build state-of-the-art, regional institutions with a great number of well-equipped satellite clinics staffed around the clock with qualified caregivers?
Because of the tremendous fear of catastrophic loss, physicians today are devoting an ever-increasing percentage of their income to insurance against potential litigation. Fueled by a necessity to order the “most recent and right tests”, and in sufficient quantity to ensure an “optimal outcome”, the need for this coverage has become even more essential. As individuals in our society have heard more and more about huge judgments being made against physicians and other entities, insurance rates have skyrocketed. We have become a “litigious society”, expecting nothing but a “guaranteed outcome” in spite of our inability, or will, to be a part of that solution
by taking a greater responsibility for the outcome. A whole industry has sprung up just to address the notion of “best outcomes” and “appropriate care”. What value can be placed on any human life, or on any part thereof? We must come to some consensus about what is appropriate and deemed necessary. Why couldn’t we direct all this extra “charge’ or “compensation” into a national pool that would cover everyone who faces medical litigation, or everyone who has a valid complaint? These complaints could be adjudicated by a panel of “experts” or “judges” selected by the people or appointed by collegiate panels of experts, similar to the way our Supreme Court does for our national laws. Surely this could be totally funded and accepted by a large enough segment of our population to make it work.
Some Solutions:
Addressing access and availability, it is becoming increasingly clear that not every patient requires the same level of care by the current providers, even when they expect or demand what they perceive to be their “rightful outcome”. For adequate and appropriate medical care, the human condition requires a “human” and humane intervention. The day of the computerized robotic evaluation, examination and treatment decisions is not yet here. Illness is, and always will be, a very personal experience, and only a human intervention will ever succeed or be deemed acceptable to mitigate the fear and anxiety that results from ailments of the human mind and body. Fear of the unknown is the cause of a great part of this anxiety, and only aggravates an already tenuous situation. What has been taken away from many of our medical interventions is that “personal” contact, and this creates enormous anxiety and frustration. To address this need, it is not necessary that a physician with eight or more years of medical training be the “first contact” for a patient with any given illness or injury. But it must be a person with appropriate skills and level of knowledge necessary to assess the condition. This level of care-giving can be provided on an immediate basis, twenty-four hours a day, and in any location. With the quality of transportation in our country today, any patient requiring a more judicious level of care can be transported expeditiously to one of the more regional facilities. This is provided today by
some “quick clinics”, and is essentially the same scenario that has been in place for many years in our county health offices and clinics and many other “community health” clinics throughout our nation. Qualified nurse practitioners, physician assistants and others have already proved that this type of care is not only more affordable, but the outcomes in patient care and satisfaction are often exemplary. Many years ago, the need for medical care in more remote regions of some states led to the certification of “midwives”. Many would be amazed at the number of children these persons have delivered, and at what level of competence they have practiced. With the massive number of responsibilities placed on our nurses today, the rapidly increasing population, the number of senior citizens coming into retirement age and thereby requiring more medical attention, the strain on our nurses will be close to the breaking point. It is imperative that we renew our efforts to train more nurses and ancillary personnel, but with the added intent of training them for new levels of patient care, with more autonomy in their decision making and opportunities for financial and professional advancement. Inappropriate demands for certain “procedures” and levels of care should be reduced. Emergency rooms were designed for just what they are called – emergencies – and most of these cases would require hospitalization or advanced levels of care. Serious accidents and injuries could be included. To provide the level of care these required, they are usually inside hospitals, or close by, where they can utilize all the resources and medical treatment provided by a hospital – x-rays, laboratory procedures, and medications. This requires enormous costs even without the specter of litigation. Many are now receiving care for ailments requiring only outpatient treatment, while others, requiring more urgent care, are left to “wait their turn”, sometimes with drastic and litigious results. With the massive amount of equipment and resources required to maintain a certified, quality approved hospital today, the emergency room, which has access to all these resources, should never be utilized as the “first point of contact” for medical care. It must be maintained and made available only for those requiring a higher level of medical care, and the decision to admit should be made by trained, primary caregivers. This requirement alone would surely reduce current and future emergency room costs by over sixty percent. And because of this, sadly, some physicians, or groups of physicians, are purchasing very expensive equipment to use in their own offices where some of these profits will be returned to them and where they will be readily available for their use.
Another area where quality and cost issues should be addressed is in the arena of the purchase of pharmaceuticals. These companies are again large corporations seeking to make a profit for their shareholders. Complaining that costs should remain high because of the expenses associated with research and development, there is considerable evidence available to dispute this claim. They also contend that the risk of litigation is so high, they must maintain measures that guarantee high quality. Again, the litigation issue resurfaces, as it does permeating all of society. However, over the past five years or more, many of these companies have spent more on marketing and advertising than they have on the research and development of new drugs. They do this because it has been shown that marketing directly to the general public results in increased requests for specific medications from their caregivers, and sadly, these in turn increase prescribing. It is so advantageous it has permeated all the media and print publications, including radio, television, magazines, newspapers and even professional journals. This was at one time available only to certified professional caregivers, reportedly for “informational” purposes. In the public interest, the advertising and marketing of medications requiring a prescription directly to the public through “any media” should be abolished, and pharmaceutical “representatives” should be barred from physician’s offices and those of other caregivers. Caregivers can today get very adequate and up-to-date information on any and all pharmaceuticals from the internet and other professional media, which they already readily use. One single website could be established revealing every new medication or agent released, and updated daily. This would allow all caregivers to keep abreast of the most recent developments, even in their respective specialized fields, and not just “prescribing physicians”. This process would negate any attempt at undue influence on the prescribing habits of physicians by doing away with the reported perks and outside ‘benefits” that have been reported in the past.
The patent system is also radically flawed. The patents on new drugs are in place to ensure that the developing company is adequately compensated for its expenses in research and development. In their present state, they are more than adequate. Some patents last for a period of seven years whereby one company can manufacture and distribute the medication and thereby control the price structure. However, due to some changes in the patent law, at the end of this period, these companies can then apply for and receive “extensions” on these patents, and thereby ensure that no other company can produce a competing, generic product. In this manner, they can control an elevated price for the drug for nine years or longer. In other countries, if a manufacturer wants to distribute a cheaper, generic product, they do so at the peril of infringing on United States patents. There is often very inappropriate review of these practices.
Most pharmaceuticals sold in the United States are also sold in other countries, many times in identical packaging and redistributed through the pharmaceutical licensing bodies of the other countries. In many of these countries, these same medications are sold at a much cheaper price than they are in this country. Our FDA has ruled that citizens of the United States cannot purchase these drugs in these foreign countries and have them shipped here for “safety concerns”. Stating they “cannot guarantee their safety and quality”, they are in essence intimating that these drugs may not be “safe”, when in actuality many are still in their original, identical packaging. This also implies some people in these other countries, such as Canada, may be taking “unsafe” medications. How can we tolerate a person having to choose between medication and food in order to survive? A large percentage of the medicines taken by the American consumer are made in foreign countries, such as Puerto Rico and Ireland, and are sold through “subsidiaries’ of the original company. Any pharmaceutical company that has manufacturing facilities or sales in other countries, for whatever reason, whether it is for cheaper labor and manufacturing costs or because of costs of litigation in this country, should be required to sell the same medications, for the same indications, in any other country and at the same cost. As it is now, they are free to charge according to what the “market will bear”. Insurance companies offering pharmaceutical benefits will give large discounts where a generic version of a drug is used. But this will make little difference in the present situation where people want the best and very latest drugs, and this is again reflected in the pharmaceutical marketing campaigns. Again, it’s all about profits.
With the slow drift again toward a national health system of “universal care”, the debate is again focusing on “excessive treatment”. Because of the laws in many areas, and the specter of litigation, the “right to die” and let “nature take its course” has again been removed from the judgment and prerogative of the personal physician, the caregiver closest to the circumstances of the patient and their attendant loved ones. There is no “legal action” requiring the maintenance of life for its own sake. This should always be in the hands of the patient, his family and the caregiver. In spite of “living wills” and “advanced directives”, it is common knowledge that in the majority of situations, every effort is made through medications and equipment to maintain “life”, regardless of the quality of results. The determining factor is not the patient’s best interest. It is the fear of litigation.
If we, as the richest and most “advanced” nation in the world, are to live up to our obligations as citizens of humanity, we must face some serious but necessary realizations and solutions. As products of the Nature around us, we all require food, clean water, and shelter from the elements. If we are to advance beyond this level of basic necessities, we must be as healthy as possible to advance to the higher levels of learning and physical, mental and social development. We have been blessed to live in a country where all possibilities can be addressed and, through trial and error with our natural resources and intellect, come to sound judgments concerning how we choose to live, in what condition, and under what circumstances. Our ultimate survival will depend not just on our own personal endeavors, but in our understanding of the need to address the whole. We have established a system of public schools, where every person is afforded the opportunity of an education. We have laws and policing organizations on a local and national level to protect the individuals in our society, no matter what race or condition. We have organized municipalities to give us safe drinking water, food and clean air. We have houses of worship in which we can practice whatever basis of faith we wish to express. Because of our empathy, we have countless organizations attempting to meet the many needs of those less fortunate with food, clothing and shelter. We have developed recreational facilities to satisfy almost every aspect of the desire for physical activity and wellbeing. But the question then remains, what good is all of this if we do not have our basic health to take advantage of it all.
There could be a healthcare system covering all our citizens based upon a model of the Medicare system we have today. The overhead for Medicare is about 1.5 percent, whereas in the private sector it is more like 14 percent. It has been reported that the overhead of health insurers in 2006 came to $120 billion and of that, $40 billion was profit. To cover all of the uninsured in the United States today would cost $54 billion. This is the also very much like the system in France, where all citizens are covered and the cost was only 11 percent of the gross domestic product, whereas we spend over 16 percent. And the other European countries offering full coverage spend even less. As noted previously, health-outcome is not sacrificed. Think of the other means of saving if we could “negotiate” prices for pharmaceutical products, rid ourselves of some of those huge profits, and put some type of “cap” on outlandish rewards in litigation. This is also being accomplished in the Medicare “Part D” Program. Citizens do have access to medical care in our country today, but because of the lack of coverage, they wait until it is too late to get anything but emergency treatment, and then it’s a visit to an overcrowded emergency room. The only ones receiving preventative care and care as needed are the ones who can “afford it”. Even if our overall taxes go up, this increase would probably be less than what we are paying out-of-pocket in the private sector now. One objection to this proposal has been one of “timely access” to the care needed. Even in other countries, there is no ‘wait’ for urgent care. An elective procedure may have a “waiting period”, but in some cases this is necessary, but not a burden on the system. Waiting for appointments for routine care is still grossly unacceptable in this country, and the only country with a worse record is Canada. Many other countries that offer universal care report no problems with waiting periods at all, including France, Belgium, Germany and Japan.
We have the resources, and the opportunity, to offer the best healthcare in the world to all of our citizens. Without this, none of us will be able to take full advantage of all the freedoms and opportunities our country offers. To accomplish this, I could imagine a series of opportunities and initiatives:
1. Establish a “ladder” of healthcare organizations that would supply needed services on a level based on “medical need”. Require that all requests for medical encounter follow the order of needs assessment from first encounter to final resolution. “First contact” would be with an adequately trained caregiver who would evaluate the necessity for a given level of medical care. This could be afforded in small, regional clinics, open twenty-four hours a day, in essentially every community but readily accessible to a higher level of treatment. This would alleviate the “requirement” that everyone must go to an emergency room for care, and would free these resources for the very function for which they were established. An available clinic of physicians would be the next level of expertise in the judgment of need for further care, and this staffed by licensed physicians trained in “primary care”. In the case of a condition truly requiring a more focused level of care, the patient would be referred directly to a specialist trained for that purpose. Thus, the hospital would be reserved for true emergencies requiring “urgent” care, and receive those who require “inpatient” care. Some individuals today have entered training in a field of “specialty training” because of the fear of litigation and workload. The field of specialty in emergency medicine has generated great numbers of physicians who are trained to treat the most urgent of conditions and trauma, but who spend much of their time treating patients who require only a low level of medical expertise. The vast majority of persons seeking initial medical care do not require the services of a “specialist”, but we have forced them to “self refer” because they do not know where to begin. They “refer” themselves according to an “organ symptom”. They should be urged, or instructed or required, to first consult a “primary caregiver”. This would result in huge savings for the medical system and would likewise result in a marked improvement in patient satisfaction.
2. Litigation, and the fear that it generates, must be addressed. There will never be a circumstance in which there is no possibility of “medical error”. All cases of potential litigation should be referred to a panel of experts, both legal and medical, who would render an initial assessment of culpability. If it is found that there are sufficient grounds, the case should be referred directly to a jury to decide an award for injustice. Since there is no way a statement of specific value can be placed on an organ, function, or the life of every individual, there should be specific guidelines set out for the award of financial
compensation in all cases. Only when willful intent or gross negligence is proved should
larger awards be given. The present situation in which large sums are required for the
defense of litigation, and the reckless and massive awards that have resulted from legal
and unwarranted patient expectations must be remedied.
3. The issues addressed above would go far toward relieving the huge levels of insurance
coverage required by physicians, not only against potential litigation, but also for that
covering patient services. A great deal of these savings could then be directed toward
better patient care and the availability of that care. In some instances, the necessity of
having insurance to afford care has generated a greater need for services, and these
services are then rendered only to those with the highest level of “insurance coverage”.
But first, we must admit that the appropriate care is “justified”, or deserved.
Until we accept that healthcare is a benefit of our society and the American way of life,
someone else must manage the “financing” of our medical product, and in the case of
insurance today, that is based on risk and profit.
4. One of the greatest examples of the waste and misdirection of financial resources today is
in our care of the elderly and the incapacitated. With the anticipated influx of retiring and
aging seniors in our country, in some reports as high as seventy-million people, we are
facing a crisis of huge proportions in our ability to adequately care for these individuals.
The institutional model we have today will be markedly inadequate to provide the
appropriate care. We must focus more on home-based care, caring for people in a
homelike setting which may afford much higher levels of patient-care outcome and
satisfaction with services. Litigation issues in these institutions has also skyrocketed, and
could be dealt with in a similar fashion. After World War Two, it became possible for
physicians to actually cure many illnesses and diseases because of the advent of
antibiotics. As medical improvements continued, there was a greater need for hospitals,
and since the only available model was one of a military quonset hut, hospitals were
constructed on that design. As the care improved and more patients were able to be
discharged, and began to live longer, there was a need to care for them in some type of
inpatient setting. Thus, “nursing facilities” were constructed on the same model as
the hospital, with a nurses’ station and patients isolated in individual rooms, sometimes
with one or perhaps two roommates. Today, in our mobile and occupational society, the
primary reason a person enters a nursing home is because they do not have a daughter in
the immediate vicinity to care for them, like it was done for hundreds of years in small,
rural societies. Very few of the “healthier” seniors of today require a high level of
intensive medical care. They need a “daughter”, and a person can be trained to meet that
need. It has created a whole new industry of caregivers, and the satisfaction of residents is
markedly improved, not to mention the level of “personal” care they receive. This alone
has the potential to drastically reduce the costs in long term care. The recently developed
Green House model is a case for verification. There has been a rapid influx of “in-home”
caregivers into our medical system. The problem here is that there are no national
standards with which to judge the competence of these individuals. Almost anyone can
hang out a “shingle” and start recruiting people to send into homes to care for our elderly
and frail. Charges are sometimes astronomical and obscene, primarily because there are
no alternatives for choice in families where quite often both spouses are working fulltime,
and their parents are in need. A recent study by the Schmieding Center revealed that
of the people who had caregivers caring for someone in their family over the age of 65,
78% thought that the caregiver had had formal training of some type, just because they
were advertised as “caregivers for seniors”. In reality, experts believe that only 20% of
these “caregivers” actually have had any kind of training at all, and even these have had
no formal training that would be certified by national standards. Sadly, at this time, there
are no “national standards”. But this may soon change, thanks to the efforts of Dr. Larry
Wright, Director of the Schmieding Center for Senior Health, and Dr. Robert Butler with
the International Longevity Center, USA, in New York and Washington.
Ethical issues form the core of clinical decision making, and challenges are
becoming more complicated as clinicians face an increasing and expanding range
of diagnostic, therapeutic, and palliative options for care. At its core, medicine
emphasizes compassion and caring for others: the needs of the patient are the
primary concern. In the past few decades, however, when the core values of
medicine have come into conflict with the values of the marketplace, the core
values of medicine appear to have been compromised. Likewise, there is a
perception among doctors as well as patients nationwide of erosion in the doctor-
patient relationship. Economic realities are impossible to ignore, but they also
serve as a convenient excuse. Nevertheless, such an excuse is never acceptable to
patients. Excellent geriatric care requires reaffirmation of medicine's core values
and emphasizes patience, compassion, and caring. Unfortunately, this may be
increasingly difficult for clinicians, particularly those involved in primary care,
who feel competing tensions between this professional ethic and increasing
administrative complexity, demands for improved productivity, and more and
greater pressures that seem to get in the way of what it means to be a medical
doctor.
Postlude:
Many may feel that my writing this is nothing more than the “sour grapes” of an old family doctor after his retirement. But it is not that at all. It is my attempt to relay to those coming after me what it has been like to be a “family doctor” over the past forty years, and what some of my observations have been about the condition we are in today, how we got here, and possibly some of the solutions for going into the future. At least they are only my observations, my feelings, and my “solutions”. I am amazed at the great possibilities facing us today, and pray they will be utilized to their fullest extent, and for the right reasons. It has been a privilege and an honor to “suffer” this centuries-old profession, and there could never be any better. I have prevailed, and I still have the Faith.
To my patients and those I might have met and cared for in the years to come, and to those who will actually care for them, I would say:
There was a time I would sit beside the bed of your grandfather and watch with you as physical life left his body, and to be there to console your grief and that of your grandmother and her entire family. Over many years, I would treat the myriad illnesses of you and your family, and even deliver your children. If so blessed, I might even deliver your grandchildren, and theirs, and care for their extended families too. No other human on this earth was ever as close to you as I was, or knew more about you physically, mentally or spiritually than I have. Not even your pastor.
But no more, and I fear that this ‘closeness and dedication” between a physician and his patients will become a thing of the past, like all things “modern”. No one knows what the future holds, but for me to think on it, I am fearful for you. But in the long scheme of things, it may turn out to be even better than any of us dreamed possible. Only time will tell. God has blessed me with the opportunities I have had to care for entire families and all that entailed. It has truly been a unique and gratifying experience. No one could ever ask for more. As to the type and quality of care your children and grandchildren will ultimately experience in the future, no one can predict. As compared to that I have offered to you…they will never really know.
Donald L. Cohagan, M.D., FAAFP
31 May, 2006
MY THOUGHTS ON MEDICAL CARE IN AMERICA
First Draft - 31 MAY 2006
Forward:
I am not a political or financial scholar. I know nothing of the fine intricacies of political recourse and leadership necessary to develop the policies and programs that all men need to control primal instincts and insure survival. But I have been deeply immersed in the life of medicine and caring for the mind, body, and soul of others essentially all my life. I am probably one of the last “personal family physicians” this country will produce. Everything changes over time, and to say my service was better than others who come after me, only time will tell. But from what I have seen and heard from those I serve, something seems to be terribly wrong, and perhaps the “new direction and their results” are not the best scenario for the citizens of this country after all.
I had deep admiration and respect for my father, a physician, and heard his council and revelations all my life. I heard of his labors and the sacrifices he made through his training and then watched as he administered the compassionate care that all of his patients so appreciated. I think that all boys, at some point in their lives, want to be like their fathers. That is, if they are fortunate enough to have them around as they grow, and who deserve that respect. This was definitely true in my case and surely what started me on my journey into the medical profession. For me, this desire started at a very early age, and since I had seen how difficult it would be, and many of the sacrifices it would require, it instilled in me a significant amount of discipline from the beginning. I also inherited my father’s compassion for all those who were sick, in need, the poor and in all ways less fortunate. Little did I know how this would also shape my feelings about faith, religion and spirituality, which I feel were essential in dealing with failure, adversity, and many times reality itself. And for this reason, it is very difficult for me not to be judgmental, especially when I encounter what I perceive to be an inequity. For me, the practice of medicine was a “calling”, clearly making it a “profession” to which I would devote all of my time, mind and strength to perfect. It could never be an occupation in which I would perform some predetermined function resulting in an “annual income” or a certain lifestyle. All of these things resulted in my becoming a “family physician”. I wanted to know and experience the myriad relationships of the family and extended family, and the mental and physical disabilities that affected this entire segment of our society. Considering the whole person, I was never interested in focusing on just one organ system or disease entity. I would care for them all.
Fortunately, I had tremendous teachers and a newly developed institution that encouraged me in all my endeavors. Being a man, and realizing all that a family meant to me, I also wanted a family of my own. I wanted to be a part of one. At the time, there was no way I could realize what a tremendous blessing a supportive wife would be. She gave me children, corrected and encouraged me, gave balance to my life, shielded me and greatly increased my faith and spiritual life. My personal family also gave me greater insight into the needs and intricacies of family relationships in my patients. My vision of a family physician was always one in “solo” medical practice, perhaps revealing a romantic version of the “knight in shining armor”, going out to single handedly slay the “dragons” of disease and illness. That instinct may very well be deep in the prehistoric genes of every man. We were taught that we had to be “right and accurate”, not only in our diagnostic decisions, but also in those of proper treatment. Therefore, I was always open to professional associations and interaction, but I could never relinquish my authority to decide who I would treat, how I would treat and care for them, and how I would receive compensation for my services. It would have been much easier to enter a “group practice”, where many of the burdens of office management and financial matters were removed from my control. But, being a loner in my character, I chose not to.
History:
I began my practice in family medicine in 1963, in what was then a small, rural community in a rural state not far from our extended family. The gigantic Medicare Program was just around the corner. It turned out to be a fairly successful program in caring for our elderly population, but in its infancy, it was extremely chaotic and gave me my first taste of subsidized, regulated medicine. Subsidized from the standpoint of “someone else responsible for paying the bills”, and regulated from the standpoint of “someone else telling me what tests or evaluations I could order, and what treatment decisions I could make”. It was the beginning of “benchmarks” whereby your actions were to be compared to those of your peers, not necessarily from the standpoint of quality, but from that of “payment parameters”. All of this led to increased costs, not only for the nation, but for physicians as well. Everything had to be automated, from contact to diagnosis, from treatment to outcome and reimbursement. The “solo physician” would lose his autonomy, not only from a professional standpoint, but from a financial and spiritual one as well, severely challenging his “Hippocratic Oath”. This created a juggernaut of new industries devoted to supply and demand, oversight, accountability, research and development, needs assessment and litigation, and the insurance industry exploded. And in this land of free enterprise, these in turn culminated in the ultimate goal of profits. Profits fueled competition. Competition did not result in increased quality, only quantity. Panels of “experts” were left to decide the definition of quality, and even this fueled competition for profits. The bottom line was, “How do we care for the greatest number at the least amount of cost”. The problem here was, medical care was not a “product” with a debatable “price tag”. To the American public, it became a “right”.
Fueled by the competition and profits, there was an explosion of scientific development and health initiatives. Never before in history was there such an avalanche of new discoveries. Diseases were eradicated. The life expectancy rapidly began to increase. It became possible to relieve the pain and suffering, not to mention the disabilities, of millions more. Along with this came the “expectation” that everyone was entitled to the same “benefits”, the latest and best drug, and the most recent treatment modality. The internet gave people the ability to see all of these and to monitor their progress, diagnose their own conditions from a complex of symptoms, and where the most successful treatment centers were located. All of this then became a “supply” (competition) and a “financial” (profits) issue. And all of these required some type of regulation.
Regulation and supply were slowly shifting from the individual physician to the corporate, state
and federal levels. Supply shifted from individuals to collective efforts of corporations and insurance companies. Quality of care was being regulated more and more by oversight committees and litigation. Expectations and demand for the best created entitlement.
This was a scenario the “former” medical system could not handle. There was neither time, nor resources, for the one-on-one approach to individual medical care. Like the early automobile assembled “one at a time” by skilled and attentive hands, medical care for the individual was entering the age of “mass production” and the “assembly line”. Fixation on quality on the part of the caregiver had to give way to “reasonable outcomes”. But the public demanded even greater quality, almost like a thirty-thousand mile guarantee, but this one was for a life. If this wasn’t delivered, there was always the recourse of litigation. Medical malpractice premiums went through the roof. As physicians became more and more like workers on the assembly line, more were being “bought out” by the large hospitals and corporations providing access to care, and these were also driven by competition. It is known that there are such entities that instruct their physicians on how many patients they will see in an hour, what tests they may order and under what circumstances, and even what limited treatment options are available to their patients. In some of these contracts, if the physician wishes to “opt out”, there is a stipulation in their contract that forces them to move a specified number of miles away in order to practice in their specialty. Thus, the picture of the “modernization of medical care” was becoming complete. Because of the demand for access, profits were ensured. Because of the demand for quality, there was always the prospect of litigation. And who would bear the cost of all this and manage it? Certainly not the old family physician.
Results:
It is strange, but in spite of all this ‘progress”, it seems that very few are content, or satisfied, with the experiences in medical care they have today. Quite often they are not able to have access to a caregiver when they need one, are disappointed in the experience they have, are suspicious of and intimidated by hospitals and are absolutely terrified by many of the medications and medical treatment being offered to them. And they can never justify the costs. It is really surprising that most patients do not understand how, and how much, physicians are being paid today. Most think that physicians can set their own fees, and either the insurance companies or Medicare pay what is charged. This is totally erroneous. When subsidized medical care became the norm, payments to physicians became “regulated”. A large survey reveals that only a small fraction, perhaps two percent, of the population understands how Medicare reimburses physicians for their services. Most think that their insurance covers most of the payment and that their “secondary insurance” covers the remaining payment, up to the limit that the physician charges. This is not so. For example, if a physician charges $120 for a procedure as his ‘customary charge”, Medicare decides what the “prevailing charge” should be for the procedure, say $100, and then pays 80% of this amount, which would be $80. Instead of the secondary insurance paying the difference between what the doctor charged and the amount reimbursed by Medicare, they pay the remaining 20%, or $20, giving a total of $100 for the procedure and the physician is denied the remaining $20. Once Medicare had established all its rules and regulations, and since most of the insurance companies had signed agreements with a huge percentage of the physician clinics and hospital organizations, they then began to set charge limits which were identical to what Medicare would allow for any procedures, even to those patients who had insurance outside the Medicare system and were not Medicare eligible. From that point on, all physicians were denied the ability to set their own fees, even for new procedures developed over the ensuing years. In fact, Medicare payments to physicians have not even kept up with the cost of living, as the original law regulated, and caregivers are once again caught in the limbo of the judicial system. Patients in the Medicare system are usually those with multiple health problems and disease entities. To care for them properly, it takes more time to go over all their complaints and medications at each visit. And yet, this system pays the lowest charges to physicians vs. the amount of time spent for each individual case. There is no way to keep up. Therefore, many physicians are opting out of the Medicare system, or are unable to accept any new such patients into their practices. Physicians are now for the most part “told” what they may charge, and what they will be paid.
We seem to be losing our designation as the nation that offers the “best medical treatment in the world”. Some of this may be well founded, or at least understandable. The United States has the most expensive health care system in the world. In 2005, health care cost $6000 per person, or in excess of 16% of the gross domestic product. It is now close to 20%. Switzerland spends $4077, or 11.5% of its GDP, Norway spends $3,966 (9.7%), Germany $3043 (10.6%) and South Korea $1149 (8.2%). But in spite of this, life expectancy in our nation is 78 years, and ranks 45th in the world, well behind Switzerland, Norway, Germany and even Greece, Bosnia and Jordan. The infant mortality rate of 6.37 per 1000 live births is higher than almost all other developed countries, including Cuba. According to “Save the Children”, in 2007, the United States tied with Hungary for 26th. place for childhood mortality. Even for white individuals, the death rate of 5.7 is more than double the rate in Singapore, Sweden and Japan. Obesity in this country has reached epidemic proportions and, like smoking, has continued to underline the problem we have in the realm of “self-discipline” and “being somewhat responsible” for our own actions and health. Childhood obesity is at epidemic proportions and will lead to thousands of new cases of diabetes mellitus. Overweight children become overweight adults leading to all the other problems and disabilities such as arthritis diabetes and heart disease. A recent report indicated a drop in the percentage of women receiving mammograms, and thus a drop in the percentages of breast cancer. One wonders if there is a percentage of these women carrying undiagnosed breast cancer, and that the rate will suddenly shoot up again in the future when these undiagnosed cases become clinically apparent. Individual responsibility has been denied, and it permeates our whole society. And if we believe we are the very safest when we enter one of our pristine, well equipped hospitals, the Institutes of Medicine has just reported that there are 100,000 deaths in America each year just from medication errors in the hospital. It is obvious that throwing more money at the problem is not going to be of any benefit. We have already tried that on a grand scale, and have failed the American people. In this scenario, when all else seems to have failed in this daunting clash of wills, we always seem to look to a “national” solution, because the desires and demands seem insurmountable, at least on a “local” or “regionally collective” basis.
Addressing costs in our system today, there are enormous opportunities to make a profit. Our great American system of free enterprise has stepped in to provide a “solution”, and thereby generated the profits afforded to stockholders. Health and medical liability insurance companies are not in their business for “good will”. They are attempting to “meet a need”. They are providing coverage for the possibility of catastrophic losses based on a calculated risk factor, and their competitive success lies in their ability to ensure a greater return on their investment. Thus, it requires a “minimum reimbursement”. One way to accomplish this is to market their products specifically to the “healthier” segment of our population. Another is to deny coverage to the sickest patients, or at least greatly increase their premiums. Many horror stories abound about companies that “drop” patients from their insurance coverage because they are no longer deemed “insurable”, sometimes occurring after a serious illness that has required considerable expense. It may not be well known, but many of these companies hire other companies to challenge any and all claims for payment, and thereby deepening the well of “costs”. This is exemplified in many situations where insurance companies are spending larges sums to other companies to find ways to reduce their payouts. At the same time, large amounts are being spent by healthcare providers to fight the insurance companies to insure “maximum payments”. It has been estimated that it would take approximately $78 billion dollars to insure every American citizen that is not now insured. By eliminating the extra administrative costs paid to private and corporate health insurers, along with reducing the exorbitant amount paid for medications and devices on a scale more like that charged to other countries, this sum could easily be afforded. What if these “profits” could be funneled into medical care and research? Many hospitals are becoming competitive healthcare conglomerates, again providing profits for shareholders. To guarantee profits, they are creating contracts with physicians and groups of physicians. In some cases, these contracts demand a certain level of “production” in the form of the number of patient encounters, the time spent with patients, patient admissions to specific hospitals and the number and quality of tests ordered and medical treatments offered. A consulting firm, McKinsey and Associates, has released a report indicating we spend $98 billion dollars a year in excess administrative costs, more than half of this accounted for by marketing and underwriting, costs that don’t appear in a single-payer system. It was reported in August 2007 that United Health Care, the second-largest health insurer in the nation, added $31 million dollars to their second quarter earnings because of “Medicare adjustments”. It is also estimated that we pay $66 billion dollars a year in excess drug costs and the costs of medical devices. Here it is sufficient to say, as Paul Krugman of the New York Times reflects, “The larger problem isn’t the behavior of an individual company, it’s the ugly incentives provided by a system in which giving care is punished, while denying it is rewarded”. What if all these profits could be funneled into a fund to build state-of-the-art, regional institutions with a great number of well-equipped satellite clinics staffed around the clock with qualified caregivers?
Because of the tremendous fear of catastrophic loss, physicians today are devoting an ever-increasing percentage of their income to insurance against potential litigation. Fueled by a necessity to order the “most recent and right tests”, and in sufficient quantity to ensure an “optimal outcome”, the need for this coverage has become even more essential. As individuals in our society have heard more and more about huge judgments being made against physicians and other entities, insurance rates have skyrocketed. We have become a “litigious society”, expecting nothing but a “guaranteed outcome” in spite of our inability, or will, to be a part of that solution
by taking a greater responsibility for the outcome. A whole industry has sprung up just to address the notion of “best outcomes” and “appropriate care”. What value can be placed on any human life, or on any part thereof? We must come to some consensus about what is appropriate and deemed necessary. Why couldn’t we direct all this extra “charge’ or “compensation” into a national pool that would cover everyone who faces medical litigation, or everyone who has a valid complaint? These complaints could be adjudicated by a panel of “experts” or “judges” selected by the people or appointed by collegiate panels of experts, similar to the way our Supreme Court does for our national laws. Surely this could be totally funded and accepted by a large enough segment of our population to make it work.
Some Solutions:
Addressing access and availability, it is becoming increasingly clear that not every patient requires the same level of care by the current providers, even when they expect or demand what they perceive to be their “rightful outcome”. For adequate and appropriate medical care, the human condition requires a “human” and humane intervention. The day of the computerized robotic evaluation, examination and treatment decisions is not yet here. Illness is, and always will be, a very personal experience, and only a human intervention will ever succeed or be deemed acceptable to mitigate the fear and anxiety that results from ailments of the human mind and body. Fear of the unknown is the cause of a great part of this anxiety, and only aggravates an already tenuous situation. What has been taken away from many of our medical interventions is that “personal” contact, and this creates enormous anxiety and frustration. To address this need, it is not necessary that a physician with eight or more years of medical training be the “first contact” for a patient with any given illness or injury. But it must be a person with appropriate skills and level of knowledge necessary to assess the condition. This level of care-giving can be provided on an immediate basis, twenty-four hours a day, and in any location. With the quality of transportation in our country today, any patient requiring a more judicious level of care can be transported expeditiously to one of the more regional facilities. This is provided today by
some “quick clinics”, and is essentially the same scenario that has been in place for many years in our county health offices and clinics and many other “community health” clinics throughout our nation. Qualified nurse practitioners, physician assistants and others have already proved that this type of care is not only more affordable, but the outcomes in patient care and satisfaction are often exemplary. Many years ago, the need for medical care in more remote regions of some states led to the certification of “midwives”. Many would be amazed at the number of children these persons have delivered, and at what level of competence they have practiced. With the massive number of responsibilities placed on our nurses today, the rapidly increasing population, the number of senior citizens coming into retirement age and thereby requiring more medical attention, the strain on our nurses will be close to the breaking point. It is imperative that we renew our efforts to train more nurses and ancillary personnel, but with the added intent of training them for new levels of patient care, with more autonomy in their decision making and opportunities for financial and professional advancement. Inappropriate demands for certain “procedures” and levels of care should be reduced. Emergency rooms were designed for just what they are called – emergencies – and most of these cases would require hospitalization or advanced levels of care. Serious accidents and injuries could be included. To provide the level of care these required, they are usually inside hospitals, or close by, where they can utilize all the resources and medical treatment provided by a hospital – x-rays, laboratory procedures, and medications. This requires enormous costs even without the specter of litigation. Many are now receiving care for ailments requiring only outpatient treatment, while others, requiring more urgent care, are left to “wait their turn”, sometimes with drastic and litigious results. With the massive amount of equipment and resources required to maintain a certified, quality approved hospital today, the emergency room, which has access to all these resources, should never be utilized as the “first point of contact” for medical care. It must be maintained and made available only for those requiring a higher level of medical care, and the decision to admit should be made by trained, primary caregivers. This requirement alone would surely reduce current and future emergency room costs by over sixty percent. And because of this, sadly, some physicians, or groups of physicians, are purchasing very expensive equipment to use in their own offices where some of these profits will be returned to them and where they will be readily available for their use.
Another area where quality and cost issues should be addressed is in the arena of the purchase of pharmaceuticals. These companies are again large corporations seeking to make a profit for their shareholders. Complaining that costs should remain high because of the expenses associated with research and development, there is considerable evidence available to dispute this claim. They also contend that the risk of litigation is so high, they must maintain measures that guarantee high quality. Again, the litigation issue resurfaces, as it does permeating all of society. However, over the past five years or more, many of these companies have spent more on marketing and advertising than they have on the research and development of new drugs. They do this because it has been shown that marketing directly to the general public results in increased requests for specific medications from their caregivers, and sadly, these in turn increase prescribing. It is so advantageous it has permeated all the media and print publications, including radio, television, magazines, newspapers and even professional journals. This was at one time available only to certified professional caregivers, reportedly for “informational” purposes. In the public interest, the advertising and marketing of medications requiring a prescription directly to the public through “any media” should be abolished, and pharmaceutical “representatives” should be barred from physician’s offices and those of other caregivers. Caregivers can today get very adequate and up-to-date information on any and all pharmaceuticals from the internet and other professional media, which they already readily use. One single website could be established revealing every new medication or agent released, and updated daily. This would allow all caregivers to keep abreast of the most recent developments, even in their respective specialized fields, and not just “prescribing physicians”. This process would negate any attempt at undue influence on the prescribing habits of physicians by doing away with the reported perks and outside ‘benefits” that have been reported in the past.
The patent system is also radically flawed. The patents on new drugs are in place to ensure that the developing company is adequately compensated for its expenses in research and development. In their present state, they are more than adequate. Some patents last for a period of seven years whereby one company can manufacture and distribute the medication and thereby control the price structure. However, due to some changes in the patent law, at the end of this period, these companies can then apply for and receive “extensions” on these patents, and thereby ensure that no other company can produce a competing, generic product. In this manner, they can control an elevated price for the drug for nine years or longer. In other countries, if a manufacturer wants to distribute a cheaper, generic product, they do so at the peril of infringing on United States patents. There is often very inappropriate review of these practices.
Most pharmaceuticals sold in the United States are also sold in other countries, many times in identical packaging and redistributed through the pharmaceutical licensing bodies of the other countries. In many of these countries, these same medications are sold at a much cheaper price than they are in this country. Our FDA has ruled that citizens of the United States cannot purchase these drugs in these foreign countries and have them shipped here for “safety concerns”. Stating they “cannot guarantee their safety and quality”, they are in essence intimating that these drugs may not be “safe”, when in actuality many are still in their original, identical packaging. This also implies some people in these other countries, such as Canada, may be taking “unsafe” medications. How can we tolerate a person having to choose between medication and food in order to survive? A large percentage of the medicines taken by the American consumer are made in foreign countries, such as Puerto Rico and Ireland, and are sold through “subsidiaries’ of the original company. Any pharmaceutical company that has manufacturing facilities or sales in other countries, for whatever reason, whether it is for cheaper labor and manufacturing costs or because of costs of litigation in this country, should be required to sell the same medications, for the same indications, in any other country and at the same cost. As it is now, they are free to charge according to what the “market will bear”. Insurance companies offering pharmaceutical benefits will give large discounts where a generic version of a drug is used. But this will make little difference in the present situation where people want the best and very latest drugs, and this is again reflected in the pharmaceutical marketing campaigns. Again, it’s all about profits.
With the slow drift again toward a national health system of “universal care”, the debate is again focusing on “excessive treatment”. Because of the laws in many areas, and the specter of litigation, the “right to die” and let “nature take its course” has again been removed from the judgment and prerogative of the personal physician, the caregiver closest to the circumstances of the patient and their attendant loved ones. There is no “legal action” requiring the maintenance of life for its own sake. This should always be in the hands of the patient, his family and the caregiver. In spite of “living wills” and “advanced directives”, it is common knowledge that in the majority of situations, every effort is made through medications and equipment to maintain “life”, regardless of the quality of results. The determining factor is not the patient’s best interest. It is the fear of litigation.
If we, as the richest and most “advanced” nation in the world, are to live up to our obligations as citizens of humanity, we must face some serious but necessary realizations and solutions. As products of the Nature around us, we all require food, clean water, and shelter from the elements. If we are to advance beyond this level of basic necessities, we must be as healthy as possible to advance to the higher levels of learning and physical, mental and social development. We have been blessed to live in a country where all possibilities can be addressed and, through trial and error with our natural resources and intellect, come to sound judgments concerning how we choose to live, in what condition, and under what circumstances. Our ultimate survival will depend not just on our own personal endeavors, but in our understanding of the need to address the whole. We have established a system of public schools, where every person is afforded the opportunity of an education. We have laws and policing organizations on a local and national level to protect the individuals in our society, no matter what race or condition. We have organized municipalities to give us safe drinking water, food and clean air. We have houses of worship in which we can practice whatever basis of faith we wish to express. Because of our empathy, we have countless organizations attempting to meet the many needs of those less fortunate with food, clothing and shelter. We have developed recreational facilities to satisfy almost every aspect of the desire for physical activity and wellbeing. But the question then remains, what good is all of this if we do not have our basic health to take advantage of it all.
There could be a healthcare system covering all our citizens based upon a model of the Medicare system we have today. The overhead for Medicare is about 1.5 percent, whereas in the private sector it is more like 14 percent. It has been reported that the overhead of health insurers in 2006 came to $120 billion and of that, $40 billion was profit. To cover all of the uninsured in the United States today would cost $54 billion. This is the also very much like the system in France, where all citizens are covered and the cost was only 11 percent of the gross domestic product, whereas we spend over 16 percent. And the other European countries offering full coverage spend even less. As noted previously, health-outcome is not sacrificed. Think of the other means of saving if we could “negotiate” prices for pharmaceutical products, rid ourselves of some of those huge profits, and put some type of “cap” on outlandish rewards in litigation. This is also being accomplished in the Medicare “Part D” Program. Citizens do have access to medical care in our country today, but because of the lack of coverage, they wait until it is too late to get anything but emergency treatment, and then it’s a visit to an overcrowded emergency room. The only ones receiving preventative care and care as needed are the ones who can “afford it”. Even if our overall taxes go up, this increase would probably be less than what we are paying out-of-pocket in the private sector now. One objection to this proposal has been one of “timely access” to the care needed. Even in other countries, there is no ‘wait’ for urgent care. An elective procedure may have a “waiting period”, but in some cases this is necessary, but not a burden on the system. Waiting for appointments for routine care is still grossly unacceptable in this country, and the only country with a worse record is Canada. Many other countries that offer universal care report no problems with waiting periods at all, including France, Belgium, Germany and Japan.
We have the resources, and the opportunity, to offer the best healthcare in the world to all of our citizens. Without this, none of us will be able to take full advantage of all the freedoms and opportunities our country offers. To accomplish this, I could imagine a series of opportunities and initiatives:
1. Establish a “ladder” of healthcare organizations that would supply needed services on a level based on “medical need”. Require that all requests for medical encounter follow the order of needs assessment from first encounter to final resolution. “First contact” would be with an adequately trained caregiver who would evaluate the necessity for a given level of medical care. This could be afforded in small, regional clinics, open twenty-four hours a day, in essentially every community but readily accessible to a higher level of treatment. This would alleviate the “requirement” that everyone must go to an emergency room for care, and would free these resources for the very function for which they were established. An available clinic of physicians would be the next level of expertise in the judgment of need for further care, and this staffed by licensed physicians trained in “primary care”. In the case of a condition truly requiring a more focused level of care, the patient would be referred directly to a specialist trained for that purpose. Thus, the hospital would be reserved for true emergencies requiring “urgent” care, and receive those who require “inpatient” care. Some individuals today have entered training in a field of “specialty training” because of the fear of litigation and workload. The field of specialty in emergency medicine has generated great numbers of physicians who are trained to treat the most urgent of conditions and trauma, but who spend much of their time treating patients who require only a low level of medical expertise. The vast majority of persons seeking initial medical care do not require the services of a “specialist”, but we have forced them to “self refer” because they do not know where to begin. They “refer” themselves according to an “organ symptom”. They should be urged, or instructed or required, to first consult a “primary caregiver”. This would result in huge savings for the medical system and would likewise result in a marked improvement in patient satisfaction.
2. Litigation, and the fear that it generates, must be addressed. There will never be a circumstance in which there is no possibility of “medical error”. All cases of potential litigation should be referred to a panel of experts, both legal and medical, who would render an initial assessment of culpability. If it is found that there are sufficient grounds, the case should be referred directly to a jury to decide an award for injustice. Since there is no way a statement of specific value can be placed on an organ, function, or the life of every individual, there should be specific guidelines set out for the award of financial
compensation in all cases. Only when willful intent or gross negligence is proved should
larger awards be given. The present situation in which large sums are required for the
defense of litigation, and the reckless and massive awards that have resulted from legal
and unwarranted patient expectations must be remedied.
3. The issues addressed above would go far toward relieving the huge levels of insurance
coverage required by physicians, not only against potential litigation, but also for that
covering patient services. A great deal of these savings could then be directed toward
better patient care and the availability of that care. In some instances, the necessity of
having insurance to afford care has generated a greater need for services, and these
services are then rendered only to those with the highest level of “insurance coverage”.
But first, we must admit that the appropriate care is “justified”, or deserved.
Until we accept that healthcare is a benefit of our society and the American way of life,
someone else must manage the “financing” of our medical product, and in the case of
insurance today, that is based on risk and profit.
4. One of the greatest examples of the waste and misdirection of financial resources today is
in our care of the elderly and the incapacitated. With the anticipated influx of retiring and
aging seniors in our country, in some reports as high as seventy-million people, we are
facing a crisis of huge proportions in our ability to adequately care for these individuals.
The institutional model we have today will be markedly inadequate to provide the
appropriate care. We must focus more on home-based care, caring for people in a
homelike setting which may afford much higher levels of patient-care outcome and
satisfaction with services. Litigation issues in these institutions has also skyrocketed, and
could be dealt with in a similar fashion. After World War Two, it became possible for
physicians to actually cure many illnesses and diseases because of the advent of
antibiotics. As medical improvements continued, there was a greater need for hospitals,
and since the only available model was one of a military quonset hut, hospitals were
constructed on that design. As the care improved and more patients were able to be
discharged, and began to live longer, there was a need to care for them in some type of
inpatient setting. Thus, “nursing facilities” were constructed on the same model as
the hospital, with a nurses’ station and patients isolated in individual rooms, sometimes
with one or perhaps two roommates. Today, in our mobile and occupational society, the
primary reason a person enters a nursing home is because they do not have a daughter in
the immediate vicinity to care for them, like it was done for hundreds of years in small,
rural societies. Very few of the “healthier” seniors of today require a high level of
intensive medical care. They need a “daughter”, and a person can be trained to meet that
need. It has created a whole new industry of caregivers, and the satisfaction of residents is
markedly improved, not to mention the level of “personal” care they receive. This alone
has the potential to drastically reduce the costs in long term care. The recently developed
Green House model is a case for verification. There has been a rapid influx of “in-home”
caregivers into our medical system. The problem here is that there are no national
standards with which to judge the competence of these individuals. Almost anyone can
hang out a “shingle” and start recruiting people to send into homes to care for our elderly
and frail. Charges are sometimes astronomical and obscene, primarily because there are
no alternatives for choice in families where quite often both spouses are working fulltime,
and their parents are in need. A recent study by the Schmieding Center revealed that
of the people who had caregivers caring for someone in their family over the age of 65,
78% thought that the caregiver had had formal training of some type, just because they
were advertised as “caregivers for seniors”. In reality, experts believe that only 20% of
these “caregivers” actually have had any kind of training at all, and even these have had
no formal training that would be certified by national standards. Sadly, at this time, there
are no “national standards”. But this may soon change, thanks to the efforts of Dr. Larry
Wright, Director of the Schmieding Center for Senior Health, and Dr. Robert Butler with
the International Longevity Center, USA, in New York and Washington.
Ethical issues form the core of clinical decision making, and challenges are
becoming more complicated as clinicians face an increasing and expanding range
of diagnostic, therapeutic, and palliative options for care. At its core, medicine
emphasizes compassion and caring for others: the needs of the patient are the
primary concern. In the past few decades, however, when the core values of
medicine have come into conflict with the values of the marketplace, the core
values of medicine appear to have been compromised. Likewise, there is a
perception among doctors as well as patients nationwide of erosion in the doctor-
patient relationship. Economic realities are impossible to ignore, but they also
serve as a convenient excuse. Nevertheless, such an excuse is never acceptable to
patients. Excellent geriatric care requires reaffirmation of medicine's core values
and emphasizes patience, compassion, and caring. Unfortunately, this may be
increasingly difficult for clinicians, particularly those involved in primary care,
who feel competing tensions between this professional ethic and increasing
administrative complexity, demands for improved productivity, and more and
greater pressures that seem to get in the way of what it means to be a medical
doctor.
Postlude:
Many may feel that my writing this is nothing more than the “sour grapes” of an old family doctor after his retirement. But it is not that at all. It is my attempt to relay to those coming after me what it has been like to be a “family doctor” over the past forty years, and what some of my observations have been about the condition we are in today, how we got here, and possibly some of the solutions for going into the future. At least they are only my observations, my feelings, and my “solutions”. I am amazed at the great possibilities facing us today, and pray they will be utilized to their fullest extent, and for the right reasons. It has been a privilege and an honor to “suffer” this centuries-old profession, and there could never be any better. I have prevailed, and I still have the Faith.
To my patients and those I might have met and cared for in the years to come, and to those who will actually care for them, I would say:
There was a time I would sit beside the bed of your grandfather and watch with you as physical life left his body, and to be there to console your grief and that of your grandmother and her entire family. Over many years, I would treat the myriad illnesses of you and your family, and even deliver your children. If so blessed, I might even deliver your grandchildren, and theirs, and care for their extended families too. No other human on this earth was ever as close to you as I was, or knew more about you physically, mentally or spiritually than I have. Not even your pastor.
But no more, and I fear that this ‘closeness and dedication” between a physician and his patients will become a thing of the past, like all things “modern”. No one knows what the future holds, but for me to think on it, I am fearful for you. But in the long scheme of things, it may turn out to be even better than any of us dreamed possible. Only time will tell. God has blessed me with the opportunities I have had to care for entire families and all that entailed. It has truly been a unique and gratifying experience. No one could ever ask for more. As to the type and quality of care your children and grandchildren will ultimately experience in the future, no one can predict. As compared to that I have offered to you…they will never really know.
Donald L. Cohagan, M.D., FAAFP
31 May, 2006
posted by Dedok at 2:34 PM
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