As I caffeinated myself last Sunday morning, I came across the L-T-E section of the NY Times. Here I found letters responding to the anemia drug story the Times broke last week, detailing how competing Big Pharma companies have, to politely put it, "incentivized" cancer docs to preferentially prescribe their respective drugs. The section is bookended by readers decrying the influence of greed in medicine. No facts were offered, though, to support claims (there’s a word limit, but seriously). One of the readers misleadingly states that the medicines have been proven harmful, which one could easily retort with a quick Medline search. Sandwiched between these letters is a response from a prominent MD who is past president of America’s largest clinical oncology organization and is the dean of U Michigan’s medical school. By word count his letter was the longest, and yet said the least. Something about how cancer doctors care about their patients and should study the relevant issues and, and, and.....oh, dude, I just passed out reading an academic physician sounding like a politician. The worst of all possible boredoms....
I turned my attention to my favorite Vulcan's "Ode to Peter Rubens". Between subsequent jaw drops I still kept thinking about those letters. Well, I am a cancer doctor. And I care about cancer patients. These letter writers obviously care about cancer patients. People care. But if such an upscale marketplace of ideas is this banal and trite when it comes to healthcare, then does it matter how much we care? Maybe the editors care about appearing evenhanded and pick letters with boilerplate sentiments. Or maybe we all care and talk about the wrong things? Or not enough things? Or discuss them in the wrong venue? With the wrong people? I’m writing this all out here on Daily Kos for a reason. This is an exemplary public forum where providers, policy wonks, and intelligent health care consumers who are smart enough to be liberals (or don’t mind talking to liberals) could actually talk like humans to each other. But what about? Where to start? What could we actually get done? Healthcare is so complicated.
Healthcare is not a force of nature we have no control over. It is complex in the way an overbuilt jungle gym of freeway ramps and exchanges would be. Cars keep fendering each other and an occasional vehicle careens off an edge, but not enough to set off panic amongst the commuters. Enough providers and companies make enough money. Enough customers get enough of what they want (and some even get great care). Any cursory American history lesson will tell you that this country will not preemptively resolve social policy issues which remain in equilibrium, no matter how tenuously. It reactively responds to pain and confrontation (more than what we’re sensitive to here). We’re getting there. How should people who care prepare? (will put in non-competing bid to sell this jingle to HSA)
So, I was originally going to write about the problems with long-term health care/rehabilitation for the disabled in America, at the suggestion of another Kossack. Then I read nyceve’s diary Monday about "medical holidays", which just flipped a switch for me. We live in a country where people fly to third world countries to get affordable surgeries. Even at the encouragement of their health plans. I’ll suppose they include the iodine tablets they throw in the IV fluids. Sonofabitch, I’m a doctor, and hell if I knew that crap was going on. After that stinky one sank to the bottom of the bowl, I wanted to take a step back and present an overlying thesis, that the problems with American Healthcare are themselves more of a symptom than an actual disease. They reflect a national community and lifestyle that is, simply put, out of balance with itself. Gee, I’m such a genius, pointing out the obvious. Uh, then why don’t we talk (and care) about the obvious?
In the case of Healthcare there really is hope for future, because many of the root causes are unwise policy and fiscal inertia (as for the rest of America’s personality and lifestyle issues, go consult a genie or "Bowling Alone"). To give you some hope, sprinkled with a little outrage, let’s rattle off some colorful examples of complex yet fixable problems, one of which may look completely unrelated to health care at first glance. Notice that they all interconnect with healthcare but from different points of origin, and would be well suited to a holistic approach towards societal and physical health. One may not even be a problem, depending on your perspective.
- The Farm Bill. Forget child health care coverage for a second. The same NY Times Op-Ed page I described above highlighted child hunger as its lead editorial. Up to 12-13 million US children involuntarily skip or areat risk for skipping meals each day. International statistics would only serve to mortify. Children who don’t eat well are not healthy. They are at risk for poor cognitive, social, and professional development. Thus, they are at risk for crime, drug use, and thus, prison internment. The prison "industry" is a growing, profitable service sector, and it is not in the business of promoting health. The Farm Bill feeds poor children through food stamps and the editorial makes a good case for straightforward ways to improve on this. Weirdly enough the Bill worsens international hunger by putting third world farmers under tremendous price pressures while subsidizing over-nutrition in the rest of us through support of US corn production (cheap corn syrup, the bedrock of Fast Food Nation). But this is legislation. Legislation reflects collective choice. Legislation can change. Verdict: Fixable. Level of Difficulty: $$$$
- The "Dually Eligible" (aka Poverty). These are the 7 million indigent elders who qualify for both Medicare and Medicaid. These are the truly frail, with a high incidence of mental illness, dementia, nursing home placement, and limited advocacy. Medicaid used to pay for these patients’ meds. Medicare Part D now provides coverage of this population’s drug premiums. The switch to Part D gave people 6 weeks to choose a plan. Notification was by mail. So, demented people living in nursing homes literally got letters telling them to head down to Walgreen’s or wherever to sign up for a Part D card. In early surveys from Kaiser, some patients have found their previous access to drugs of choice either denied or delayed, especially if their medicines were not listed on their Part D formulary. Switching plans, while supposed to be free and easy, has proven cumbersome. Those who "spend down" income to become Medicare eligible have had problems as well. While some states have jumped in to help cover formulary gaps, others have not. Like Florida. Do any old people live in Florida? But, hey, this is a result of public policy and legislation which abandons our most vulnerable. Legislation reflects collective choice (or perhaps collective ignorance or collective loss of community). Legislation can change. Verdict: Fixable. Level of Difficulty: $$$$ to elect politicians who aren’t dicks. And who inspire community at all levels, not just for health coverage.
- Pharma R&D. I am jaded by drug companies. But, I like new medicines and I’m using them to treat cancer at an academic center (uh oh, I sound like a drug company PR release. But have no fear). The federal government is abandoning much of its remaining direct support of clinical trials and shifting the burden to industry R&D. If done "responsibly", is this bad, good, or neither? Not long ago, the NIH would support basic and preclinical development of a drug. Successful academic drug developers would be totally hosed out a making anything to supplement their underwhelming academic salaries (this changed with the Bayh-Dole Act of 1980). Is psychic pay a good way to stimulate drug development? Now academics can license their work to (typically small) companies which are designed to do certain things well. Such as make clean, consumable medicinal chemicals and navigate the regulatory waters to bring them to customers. As for clinical trials, I have personally been supported by large drug companies to test cancer drugs. I did these trials at a VA hospital, and they raised the level of military veteran’s care at this facility. How’s that for irony? I could never have done these trials without these companies, they interacted honorably with me, and I give them credit. Verdict: Is this really a problem, or are we unfairly putting certain companies on the defensive in an era when all of corporate America has been given access to the cookie jar. Level of difficulty: a half-gainer’s worth of ambivalence. Note to trolls—I am not an apologist for this industry. Like the rest of corporate America, they have done whole lot to screw people. The MMA of 2003 sucks. Uncontrolled profit motive without protective regulation is terrible for healthcare, and Pharma makes huge profits (which put health care plan profits to shame). But complete elimination of profit motive and competition also make no sense to me, and I am just trying to stimulate debate, so don’t piss me off. Stay away.
- Greed. Not the kind you’re thinking. Your greed. Greedy patients who ignore good advice. You think Big Pharma and health plans are greedy? Well, US patients are literally trained to be greedy, because their bills get handled for them by third parties. Increased premiums and reduced coverage are relatively recent phenomena. Patients eat crappy food, smoke, ignore common sense advice, and don’t show up for appointments, and then expect to be fixed when it all blows up in their face. It’s not easy to study this, but up 50% of patients, adults and children, are routinely non-compliant with treatment for chronic conditions. Ask me some time for my favorite example of noncompliance—it has to do with family planning. Yes, health plans do their best to ration and control prices at the expense of patients, many times heartlessly. But they have to contend with patient and provider-driven expenditures and billing, plenty of which is wasteful if not downright futile (end of life care, especially in ICUs, is some of the most expensive and is frequently futile). I have personally been compelled to provide potentially futile care via the exhortations of patients. Verdict: Fixable. Level of Difficulty: Price of a sturdy bull whip....uh, actually I don’t really know. Ok, this is a complicated one, and is worthy of discourse. In other countries (Japan, Europe, Canada) patients don’t get bills either, yet costs don’t spiral as in the US. How hard would it be to improve the collective educational level, consumer expectations, and gym membership of the American public? Or would it be easier to compensate for the unique foibles and fallibilities of Americans by making health care advice more accessible and user friendly through increased access to nurses and mid-level practitioners for preventative management? Or to force patients to directly pay medical bills or to take direct responsibility for budgeting their health care (oh beware, this is a major rationale behind the flawed approach towards "consumer-driven health care", best exemplified by health savings accounts.
Have oodles of examples, but let’s stop because the emphasis should be on two things. 1) Health is deeply integrated into all of our community’s decisions. If we make socially unhealthy decisions, we will lead physically unhealthy lives. Overlook this, and we will not "solve healthcare". Saying "single payer system" a million times fast will not change this (and I say this as a supporter of a single payer system). 2) Everything made by humans is fixable. Things are "complicated" really because of two things: inertia and money. I am not being starry-eyed, nor am I being particularly original—Fast Food Nation is a great example of this line of thought and it has change attitudes towards an industry which screws our country’s health. There has been plenty of talk of healthcare here. nyceve, dr.steveb and others are quite active on this site. Remarkably thoughtful summary statements have been published—please check out jd in nyc’s Magnum Opus. (will try to highlight other Kossacks as I stumble on their work). The real aim is to push the envelope and to think about how to weave together individual strands of specific issues into a comprehensive tapestry (including issues which impact health only indirectly), rather than getting repeatedly pissed at individual examples of idiocy. If a health plan executive, a midlevel practitioner, a patient/poverty/immigrant advocate, a health economist, and a doctor all got stuck a dark room, would they screw in a light bulb faster together or alone? (no jokes, please—just a metaphor) Got a feeling in my gut our time is coming in January 2009--could this community fuel a comprehensive healthcare policy statement, something like Energize America? Won’t speculate, but I got some hope. Now I’ve got to go research a diary about long term health care issues in America. Apply sunscreen generously and eat your spinach....see you soon.