Medicine and Money, Part 1 of Many

When the term "Health Care Reform" is mentioned, the first issue that comes to most minds is cost. The most common reasons people say "Our health care system is broken" are economic. Insurance companies, socialized medicine, tort reform, formularies...the arguments really are all too often about the exchange of money.

There is an assumption that health care is expensive, so expensive that no one is expected to be able to pay out of pocket at the time of specific need. Truly, very few have $100,000 laying around in the event of a serious automobile accident requiring surgery, hospitalization, and weeks of rehab. Most don't have $15,000 laying around if they need their gallbladder out. The assumption continues that we MUST pool resources so that the money is there when the need arises.

Wait a second, isn't that socialism? Of course it is, depending on your definition. The only question that's really being debated is who gets to collect and distribute the money (which for fun I'm going to refer to as the "pot of gold"). Private organizations (still commonly grouped under the label "insurance companies") perform that function for many of us, and their dynamics are different than when the government adminsters the pool. But regardless of who takes care of the books, the reason any of us are willing to put our gold into the pot is that we expect to be able to get medical care when we need it, especially if something really big and scary happens.

But there's a problem. Pots of gold are tricky things. It is virtually impossible to look at a pot of gold and avoid thinking "Wow what I could do with that!" Pots of gold tend to make people do things they wouldn't otherwise do, ranging from bending the truth a little about why some of that gold belongs in my pocket to outright thievery (or worse). The bigger the pot of gold, the further people are willing to go.

The economy of modern medicine in America is one of the biggest pots of gold in history. It has attracted thieves and scavengers. Good people tell lies large and small to make sure their part of the gold is secure. In a classic example, the hospital charges us $5 for a Tylenol, and tells us it's to pay for the uninsured patient in the ICU. We grumble but accept this, another de facto socialization of medical economics. Different patients are charged radically different amounts for the same service based on who is managing the pool of money to which they contribute. Many medical providers won't release their prices, because the amount of money changing hands is so fluid that the word "price" is meaningless. Insurers try to trick patients into paying bills they don't owe, and try to avoid paying what they've contractually agreed to pay. Medical providers in turn further distort "prices" to try to compensate.

This is not a free market. This is not an open economy finding the most efficient way to distribute resources. This is people telling each other lie after lie after lie as they shuffle around shares of the pot of gold. And the greatest lie is the one that we all tell ourselves so often. That the pot of gold is infinite, that in MY case (whether it's a lawsuit, an expensive medication, my company's business practice, my personal salary, or one more test on a dying loved one), I can ignore the system as a whole.

This may seem to be belaboring the obvious, but I think getting to the basics is essential if we're going to modify the leviathan social organism that is American medicine.

More thinking to do...

Brainstorming Health Care Change

I have done more than my share of complaining about how broken our health care system is, and have made the claim that health care reform has been my personal #1 issue when I vote. I've bemoaned the failure of the Clinton Administration's attempt to reform our system, and done my share of criticizing the 2010 Affordable Health Care Act. At the same time, I've also been vocal about my relief that we're at least doing SOMETHING.

All of that is rather vanilla opinion that probably isn't detailed enough for someone who takes comfort in the fact that I work in a Community Health Center. As I've been reading about efforts within the environmental movement to create change from the ground up, I've decided to explore, at minimum, what I really think health care should look like. At the same time, I want to welcome comments from friends and colleagues so that my views can grow. The hope is that I can form a vision for an intentional practice in the future, and perhaps all who enter here might help each other develop a more nuanced conception of our mutual problem.

So I start with some really basic observations from the exam room.

1. Patient priorities and provider priorites are quite different. Patients seek out care for pain and illness, hoping to be relieved of suffering. Providers / doctors want to diagnose and treat. Obviously there is a lot of overlap, but it is extremely common for my time in the exam room to involve me wanting to optimize blood pressure and blood sugars while the patient wants their chronic knee pain fixed.

2. Neither one of us really wants to deal with the money. Patients rarely know the details of their coverage, and I also avoid learning specific formularies, copay structures, etc. Always looming is the expectation that care is payer blind but in reality almost every single patient encounter is affected by cost.

3. Most everyone feels overwhelmed and powerless. The pressure to see more patients with less cost leaves both provider and patient unhappy. Patients know that their access to most modern healthcare technology must go through a trained gatekeeper. I hate being a gatekeeper. I would rather be an advisor and a guide.

So I'm sitting here staring at this list, just another bit of complaining. The inspiration for this blog was reading a book (NO IMPACT MAN) where a guy who was really upset about a problem just jumped off to try to make his part better.

What can I do today? Now?

After staring at the screen for 15 minutes, I realized that what I want most of all is to have meaningful encounters. Where I walk out and the patient walks out feeling something was accomplished. Time well spent.

So this afternoon, I am going to ask myself for each visit. Do I feel satisfied with that encounter? Do I think the patient did? Why?

We'll see where it leads.