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THURSDAY NIGHT IS HEALTH CARE CHANGE NIGHT, a weekly Health Care Series (cross-posted at ePluribus Media)

Two weeks ago my associate, Dr. Michele Gomez, spent hours battling (as of today, still without success) for insurance approval of an MRI for a patient with neurologic symptoms and metastatic lung cancer.  Why this pointless waste of time?  Three managers recognized that although she was insured, it was not their branch which should take responsibility for payment.

Listening to Dr. Gomez’ crusade from across the room, I shook my head.  As the wheels begin to turn on health care reform I’ve agreed with the President's stark diagnosis: "The biggest driver of long-term deficits are the huge health care costs," he warned in his March 24 press conference.  "It is going to be an impossible task for us to balance our budget if we're not taking on rising health care costs."

Yet while I nod in agreement with President Obama’s diagnosis, his treatment seems homeopathically weak and

divorced from the reality I experience every day.

Obama’s proposals for reform, and the variations discussed in recent congressional hearings would add billions to our national expenditures for health care and extrapolate savings, in the long term, through an emphasis on prevention, widespread use of health information technology, chronic disease management, outcome based payment reform (i.e. expanded pay-for-performance), and propagating research findings on cost effective disease management.

Unfortunately, extensive research has shown that although there is some prospect of benefit from these approaches , the benefit is likely to marginal , and many years in the coming.

A recent analysis in the Annals of Internal Medicine subtitled "Hope vs. Reality" emphasizes these points and concludes that to control cost we must "embrace price restraint, spending targets, and insurance regulation."

Nevertheless, from my seat as a primary care physician in clinical practice, I can’t embrace this diagnosis, either.  It doesn’t fit with my experience. And the solution my experience suggests would require a simpler, but more fundamental reform than that proposed by President Obama or by Marmor and his colleagues in the Annals.

To illustrate this, I chose to go to the office one random morning and analyze each case I encountered in an effort to find opportunities and direction for cost control efforts.....  

Late in the evening, home after finishing a short day at work (eight appointments, a dozen phone calls, medication refills, etc), getting my younger son off on a sleepover weekend, watching The San Francisco Giants win a rare 2-0 shutout, and tucking in my older son I returned to the task at hand.

It was difficult, in the hubbub of a busy clinic, to keep track of each patient visit and call for the purpose of this examination of possible routes towards heath care cost control, but I think what follows provides the gist of thoughts brought on by a rather ordinary day:

"I don’t know what I have to pay for with the insurance I’ve got," bemoaned my first patient, holding back sobs.  "It’s a big shock for me, a big worry."  The 22 year-old unemployed mother of a six week-old infant, was suffering from post-partum depression and topping the list of issues which had led her to see me was anxiety about health care costs, and stress in dealing with the hassles of her complex insurance.  This kind of concern is no surprise.  Indeed, the April 18 business section of the Las Vegas Sun headlines "Rising health care costs spur more anxiety than job loss."  

Perhaps to treat that anxiety, Aetna is pushing in its advertising a new book, Navigating Your Health Benefits for Dummies.   How ironic!  Aetna, which is in the middle of a big campaign to sell more individual health policies, bare-boned policies which feature large deductibles and co-pays and offer their corporate sponsors fat profit margins, is using health insurance premiums to push a book that helps patients manage the complexities created by the insurers own activities! (Interestingly, this book is not listed on the website nor is it available elsewhere except through Aetna-connected sources.)

John Pizelle (names have been changed for confidentiality) , my next patient, spurred in by the fact that his wife had recently been treated for potentially serious disease, greeted me warmly, "How’s the economy treating you?!"  His wife had recently lost her job and they were contemplating the possibility of securing health coverage through C.O.B.R.A., the option created by the federal government which "gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances."  

He was considering becoming one of the only 10% of Americans eligible for COBRA benefits who actually enroll, as the qualifying circumstance, unemployment, makes most unable to afford to pay the premiums. Mr. Pizelle made his appointment to see me, fundamentally an unneeded one, because he was worried about what lurked in his health care future and was undertaking an individual cost-benefit analysis about the value of paying for COBRA.

Those who oppose making health coverage more widely available often express concern that lowering economic barriers to care might result in an excessive increase in visits to the doctor. Maybe, but the "Please-order-every-test-and-make-every-referral-because-I'm-about-to-lose-my-insurance" visits will surely decline.

Indeed, data on the frequency with which patients forego needed care, miss doses of medication, or otherwise avoid care which is their own best interest has revealed over and over again the economic wisdom of reducing barriers to care.

I am reminded about another patient of mine, a "non-compliant" diabetic whose lifetime of complications had cost tens (if not hundreds) of thousands of dollars, who returned from an extended trip overseas with his diabetes finally under control.  "What happened?" I asked, incredulous.  And he matter-of-factly replied, "Medicine is free in Tonga."

Of course nothing is "free."  But in a system where a societal judgment has been made to pay for health care through a system of central financing, reducing barriers to care at the "retail" level,  patients and their physicians make health care decisions based upon need, resulting in a greater focus on preventive care and leading to improved management of chronic conditions. As a study commissioned by the Robert Wood Johnson Foundation published in the scholarly journal Health Affairs concluded, fully insuring all Americans under such a plan would not increase overall health spending because increased costs from covering the underinsured and uninsured would be offset through the reduction in administrative costs.

The next two patients of my morning failed to show.  One called, saying she was "too sick" to make it in.  I spoke with her, finding her to be not really that ill, but in need of a prescription for an antibiotic for a sinus infection.  My thoughts drifted to the possible role of the co-pay in preventing her visit and brought to mind how the structure of physician payment, based upon face-to-face encounters, may push up the costs of providing care.  Paid in this way, physicians are encouraged to see patients whom they might have managed equally well over the phone or through an online interaction.

After two "physicals," the next two patients, one requiring a rather large excisional biopsy, the other (Mary) with a non-displaced distal radial fracture, pointed to the beneficial role of an extensive primary care infrastructure in the battle to reduce costs.  As I removed the cyst from Mr. Martinez’ axillary fold I recalled my brother-in-law’s experience in New York City, a locale dominated by specialty care.  He presented to his dermatologist (family physicians are few and far between in New York) with a small mole on his upper arm.  Rather than remove it herself, biopsy a section, or conclude that it was benign (it was) based upon clinical features, she referred him to a plastic surgeon who, more than a thousand dollars later, removed the lesion.

Finally, arranging for Mary’s late Friday referral to the Emergency Room for splinting of her fracture (no orthopedists available for patients with her health coverage), I recalled the days when I used to manage such fractures and considered the systemic savings to be had if we operated within a system dominated by widely competent primary care providers working in a more integrated system which did not distinguish among patients based upon the source of their health benefit payment.  Rather than Mary’s moving from me, to the emergency room, to the orthopedist, she might have gotten all her care in one place, saving resources for other public needs.

It’s clearly not so much my fees (or even those of my more richly rewarded specialist colleagues), but the associated costs of the care we direct and the increasingly complex, balkanized, and bureaucratic system within which we all operate which feels like the driver of the explosion in health care costs which threatens to sink business and government.

President Obama understands and has articulated the risk that uncontrolled costs impose on our government and society.  But physicians understand best from where this risk derives and where we must turn.

A fundamental transformation of our health care system is required, away from the confusion and profit-maximizing bureaucratic buck passing of the private health insurance system, and towards a new system which is defined by centralized funding and universal enrollment of everyone living in this land.  With this change we will waste no more resources on achieving a favorable risk selection, marketing, underwriting, investor relations, product development, nor profits. Providers will spend virtually no revenue on billing and we will all operate within a clear cut set of rules that applies to all patients.

It is a dream, but it is a dream that can be realized now, if we can only get going and act. Politics, and political change, has been described as the art of the possible.  But what is possible only comes about when those who believe in the need for change act upon that belief.  Possibilities can be created.  Hope can lead to change.

This has also been cross-posted at TPM

Originally posted to doctoraaron on Thu May 07, 2009 at 04:31 PM PDT.

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Comment Preferences

  •  tips (56+ / 0-)

    tonight belong to the heroes who put themselves at risk by protesting yesterday at the Senate hearings on health reform:  
    Russell Mokhiber, v=G5vhTtxad30
    Margaret Flowers, MD & Katie Robbins v=1zOShsL4UJo
    Carol Paris, MD v=RdIUcrVxGwA
    Mark Dudzic v=r1nl32aAh7M
    Adam S v=I26EkvnjZuQ
    Pat Salomon, MD & Kevin Zeese v=iDHJH7W-ZEo

    The Thursday Night Weekly Health Care Series is published every Thursday. It is meant to provide a forum and encouragement for people organizing for positive health care change.
    The following upcoming diaries are scheduled:

    May 14: losanjalis- Topic TBA
    May 21: boatsie- Topic Direct Marketing of Pharmaceuticals

    If you would like to contribute to the series, please contact TheFatLadySings at tflsster/at/gmail/dot/com.

    Dr. Aaron Roland is a family physician in Burlingame, CA.

    by doctoraaron on Thu May 07, 2009 at 04:40:35 PM PDT

  •  Amen to this (15+ / 0-)

    A fundamental transformation of our health care system is required, away from the confusion and profit-maximizing bureaucratic buck passing of the private health insurance system, and towards a new system which is defined by centralized funding and universal enrollment of everyone living in this land.  With this change we will waste no more resources on achieving a favorable risk selection, marketing, underwriting, investor relations, product development, nor profits. Providers will spend virtually no revenue on billing and we will all operate within a clear cut set of rules that applies to all patients.

    Yes, yes, yes

    Tipped and recced for hope, even if forlorn.

    Yes we did, yes we will. President Obama

    by marketgeek on Thu May 07, 2009 at 04:59:08 PM PDT

  •  Ah, the built-in extra costs of "managed" care! (24+ / 0-)

     When I was insured through Humana, I had two, count 'em - two - "managed care" experts who would call me once a month to make sure my care was properly managed.  Both were nice ladies, R.N.'s with a background in oncology, and I'm sure that Humana paid each of them a nice, tidy sum of money to make sure I wasn't wasting any of theirs.
     What did they do?  We talked about my care, of course, and the weather, gardening, children...nice little social calls, as I knew as much or more about cancer care than they did - I am an oncologist, after all - a fact I'd shared with them from day one.
     But they continued to call me, costing Humana $$ each time, while wasting my dollars and my time.
     Don't get me started on the fallacy of the primary care physician as a gate-keeper....
     Thanks for the diary, doctoraaron

    "Respect for the rights of others means peace" Benito Juarez

    by drchelo on Thu May 07, 2009 at 05:01:02 PM PDT

    •  How are you feeling today? (8+ / 0-)

      You sound pretty chipper.

    •  What about (6+ / 0-)

      What about the primary care physician as a medical home? (Or am I using the term correctly?)

      Want to be a living kidney donor? I need one from someone with a bloodtype of B or O. Drop a note at

      by Kitsap River on Thu May 07, 2009 at 06:53:51 PM PDT

      [ Parent ]

      •  The medical home is a great concept (9+ / 0-)

        and will be of significant value in reducing costs of care if implemented.  Unfortunately, medical students can do the math, and knowing that primary care doctors get paid a fraction (25% is about right) of what many specialists earn, they are choosing to specialize.  Without general internists and, especially, family practitioners, the hopes for a medical home will never get realized.

        Dr. Aaron Roland is a family physician in Burlingame, CA.

        by doctoraaron on Thu May 07, 2009 at 06:57:32 PM PDT

        [ Parent ]

        •  Which is why (8+ / 0-)

          I am going into primary care, one way or another. I can do the math, too. I can figure out just how few primary care physicians we will have for the growing population. Some of the family practitioners and internists ought to take a course in geriatrics; we are going to need doctors trained in that field.

          Given that I am starting off as a college freshman at 49, it will be a very long time before I am in practice in any form. I am still, nonetheless, keeping my options open as to how that will take shape. If I attempt medical school, I won't get out until I'm 63 or so (including residency and fellowship) at the earliest, and nearly ready for Medicare based on age myself! This is, of course, assuming I get a kidney or survive on dialysis for that long. It can certainly be done either way; I know people who have been on dialysis since the mid-60s who had to go before the Life and Death Committee, also known as the God Squad.

          I figure that however I do it, I have at least a good 15-25 years at minimum in which to practice. PA or ARNP may be the way to go, but a large part of me really does want to go to medical school...

          Want to be a living kidney donor? I need one from someone with a bloodtype of B or O. Drop a note at

          by Kitsap River on Thu May 07, 2009 at 07:12:45 PM PDT

          [ Parent ]

          •  Kudos to you (2+ / 0-)
            Recommended by:
            samddobermann, Larsstephens

            for having the courage and determination to go to med school at your age.  I'm also middle aged and just got accepted to nursing school, so your story inspires me.  I'm hoping my third career will be my final career.  Good luck to you.

            "My wife is a big green person." - Tweety on Hardball, 5/5/09

            by Maudlin on Fri May 08, 2009 at 08:04:14 AM PDT

            [ Parent ]

            •  Thanks! (0+ / 0-)

              Good luck to you, too! Nursing school is no walk in the park; I have checked out the curriculum at my community college for the RN program; it requires the student to take a more-than-full-time program. To even be considered you have to have a 3.7 GPA or better in a class called Dosage Calculations, and I have to have a 3.7 GPA or better and complete all my prerequisite courses in four quarters (including summer, in my case, which is a short quarter) to get the maximum number of points towards admission in my first year of application. You can get one more point if you've been held over a year, for a total of 14. They're only admitting applicants with 13 and 14 points now, and not all of the applicants with 13 points get admitted. The courses you have to take are English, Psychology, a 5-credit elective from one of several disciplines (I'm taking Archaeology, since it's under the Anthropology heading and thus allowed), Chemistry, Organic Chemistry, 2 quarters of Anatomy and Physiology, Microbiology, Dosage Calculations, and Pharmacology. I have a bit of an edge, having already taken English and Psychology and gotten a 4.0 in each, but I also have a prerequisite of math before I can get into the Chemistry class this summer, and I'm taking that math class now. For me, these all have to be completed by the end of Winter 2010, which is the middle of March, in order to qualify to apply for admission.

              And that is how I am approaching this career shift. I will start as a nurse, get my BSN, take all the sciences I need to enter medical school at the same time I'm taking all the sciences I need to finish the BSN program, and then see where I want to go, where I can get admitted, and, of course, what I can obtain in the way of financing to do it. The local med school is the #1 school for primary care in the U.S. and I hope that if I try to enter medical school, that I can get in there.

              One thing that concerns me is the hours required - for nurses, for interns, for residents. I need that 9 hours a night on my machine plus time to set it up (about 0.5 to 1 hour) and get off, do my record-keeping, and get it back to its initial state (about 0.3 to 0.5 hour), plus, of course, time to go home and come back, or a place at the facility to do my dialysis if I bring my machine and supplies with me (easily doable). Is having the need for dialysis a protected disability when it comes to things like education, or does that only count for employment? Will whatever program I train in have to let me use my machine when I need to, or had I better make sure that I either have a kidney or have switched to home hemo by then? I'll still need daily dialysis time if I switch, but it won't necessarily have to be as long (though it is better for me if it is).

              Want to be a living kidney donor? I need one from someone with a bloodtype of B or O. Drop a note at

              by Kitsap River on Sat May 09, 2009 at 12:06:26 PM PDT

              [ Parent ]

        •  Medical home (7+ / 0-)

          Our local community health center is working to develop a "medical home" model for our patients. The staff is divided into care teams, and the patients into panels that are associated with a care team. Instead of 8000 patients somewhat randomly accessing our 4 MDs and 8 mid-levels (not all of these are full time), we will have panels of about 2000 patients attached to each care team of one MD, two mid-levels, and dedicated support staff. The idea is that the care teams will become personally familiar with the patients, facilitating continuity and coordination of care, and reducing time wasted in having patients repeat their stories to a new provider for each encounter.

          I am optimisitic that this system will deliver very positive results for our patients. But in a larger frame, it can't work unless the primary care docs are there. We have to improve compensation and reduce net cost of medical education for primary care.

        •  I've never understood that (2+ / 0-)
          Recommended by:
          samddobermann, Larsstephens

          Doctors have skills. A good PCP has as many and as challenging skills as a specialist. They see a much wider range of conditions and have to be much cleverer about figuring out the whole picture.

          Of course, then there's veterinarians. I know a vet who might do five surgeries in a day - on animals of markedly different physiology... a bird, a reptile, a dog, a cat... and a fish. She runs the anaesthesia, too. Ironically, she's even more affordable than a GP.

          Fry, don't be a hero! It's not covered by our health plan!

          by elfling on Fri May 08, 2009 at 08:25:06 AM PDT

          [ Parent ]

  •  Excellent blog. (9+ / 0-)

    If you think we should join Dr. Dean or any other organization's efforts, please let us know how we should proceed. Thank you.

  •  This was a really great diary (10+ / 0-)

    thank you for sharing.  I have a chronic condition that requires regular visits to two different specialists.  About once or twice a year I get swimmers ear and have to my regular doc, and every time my wait to see the gp is way longer than my wait for the specialist, so I'm definitely for phone support or online support.  I just need some drops, my ears, they hurt, a lot.

    Secondarily, my specialists both take half a day a week for negotiating with insurance companies to cover meds for their patients, that's just not right.

  •  Thanks, doctoraaron (8+ / 0-)

    Great diary.

    I have a fantastic primary care physician. I rarely have to wait more than a day for an appointment if I need one. He insists on seeing me once a month. he's not only my GP, he does my diabetes care. I went to another primary care physician after my GP changed practices to a practice which is NOT a preferred provider on our insurance. One visit to the new clinic and the new GP and it was back to the old GP. The new GP was in a drive-thru doc clinic where we waited for an hour and half (despite having scheduled appointments) for less than 5 minutes with the doc. He didn't even ask me about my diabetes, despite the fact that diabetes was all over my intake form and I had brought my meter with me. He didn't even ask me about my ESRD! That was all over my intake form, too. Back to the first GP I went. We will have to pay 30% of the cost because of his office not being a preferred provider on our insurance, but it is worth it.

    Dr. I. is the one inspiring me into going into primary care. I don't know whether it will be as an ARNP, a PA, or actually trying to get into medical school (at my age! and on dialysis to boot), but one way or another, I am going to wind up in primary care.

    That is, if I can get admitted to the programs I need. They are awfully competitive, and I'm still struggling.

    Want to be a living kidney donor? I need one from someone with a bloodtype of B or O. Drop a note at

    by Kitsap River on Thu May 07, 2009 at 07:02:45 PM PDT

  •  Excellent diary. I came over from the Ed one on (10+ / 0-)

    the rec list and I'm glad I did.  There are really some compelling stories there.

    The bottom line is that health care shouldn't be a profit driven industry.

  •  They want it to be revenue neutral (3+ / 0-)

    That means that the subsidies are not there. Adverse selection will make any public option that functions as an insurer of last resort very expensive, like the high risk pools.

    The money is going to Wall Street instead.

    Guess we might get lucky in 2016, huh?

    "Obama’s proposals for reform, and the variations discussed in recent congressional hearings would add billions to our national expenditures for health care and extrapolate savings, in the long term, through an emphasis on prevention, widespread use of health information technology, chronic disease management, outcome based payment reform (i.e. expanded pay-for-performance), and propagating research findings on cost effective disease management."

  •  My story (12+ / 0-)

    My husband had to have double hernia surgery a couple of years ago.  He was about 65 at the time.  The surgery took over 2 hours, I seem to remember.  The pre-surgical instructions, by the way, emphasized that someone would have to pick him up afterward, and they would not begin the surgery until they checked that I was there.  The reason for this will become clear later.

    After the surgery, he went to the first recovery room, and I was allowed to join him in the second recovery room, the one where he was sitting up in a huge chair, eating crackers.  The regulations set by the insurance industry dictated that 90 minutes after surgery - a surgery that took longer than 90 minutes - he had to leave the hospital.  He was not really ready, but he was given his clothes and he started to walk to the bathroom.  He passed out and I managed to catch him.  The nurses helped me get him to a bed, and he then spent the next 4 hours in the higher level of care, with all functions being monitored, with a nurse sitting at the end of the bed watching everything, and a neurology consultation.  There was nothing wrong with him.  He just needed another half an hour in the chair.  Maybe a 30-year-old can jump up 90 minutes after 2+ hours of general anesthesia, but my husband couldn't.

    It was clear that the nurses hated making him get up.  They knew that he was not ready to leave, but they could do nothing about it until he passed out. I told him to complain to the surgeon when he had his post-op visit.  He did mention it, and the doctor confirmed that the insurance companies were dictating these things, and there was no room for judgment on the part of the nurses.

    How much do you think it cost for the hours of high-level care and the neuro consult, compared to half an hour in the chair?  All completely unnecessary.

    •  I gave birth at 8:29 am. (6+ / 0-)

      They waited long enough to sew me up, let me have a shower, and let the epidural wear all the way off before sending me home with the baby; 5:30 pm I was home. No support of any sort, just "see your doctor if x, y, or z happen."

      Right now I'm sitting with my foot up again. I need a midfoot fusion. But since I have to arrange for my own home care afterwards, let alone find the money to pay for it, it's not going to happen this year unless I win the lottery.

    •  My experience (5+ / 0-)

      I had minor surgery a few times last year. In two cases, I had to have a balloon angioplasty in my left arm to try and clear up a couple of stenoses that were hampering development of an AV fistula. (Which remains undeveloped, by the way, but my vascular surgeon says to give it time.) My surgeon determined that the best way to access my arm was to go in from my groin and go up, across, and down. That's what he did both times. I had to stay lying down in the recovery room until many hours had passed afterward just to make sure I wasn't going to bleed out. Regulations. (He made such a small hole that I could not find the mark the next day when I took a shower; I wasn't really worried about bleeding out.) I went in at something like 10 am and didn't get out of the hospital until after 10 pm. Just the opposite of what happened with your husband. I am appalled that he was expected to be ambulatory that soon.

      On the other hand, when I had my dialysis catheter implanted, they kicked me out after something like 90 minutes post-surgery. I had an abdominal incision fairly low on the left, another higher up where my new catheter tube exited my body, and one hell of a lot of pain. I could barely put my clothing on and required quite a lot of assistance to stand. I was immediately put into a wheelchair, required by some regulation or other, and wheeled out to the parking garage by my husband, accompanied by a hospital staff member who stayed with me until my husband came around with the car. I then faced a long trip (over 1 1/2 hours including ferry waiting time) back home to our side of the Sound before I could go to bed and lie down. As was the case with your husband's experience, this may well have been mandated by insurance. It would have been nice if I had had a little more time in the recovery room to actually recover.

      Want to be a living kidney donor? I need one from someone with a bloodtype of B or O. Drop a note at

      by Kitsap River on Thu May 07, 2009 at 09:47:08 PM PDT

      [ Parent ]

  •  Trying to keep hope alive here... (2+ / 0-)
    Recommended by:
    bthespoon, Larsstephens

    ...we need to mount a big protest in Warner Center, in the West San Fernando Valley. This is where a lot of health insurance companies have their West Coast HQs, and where Anthem BCBS has their HQs.

    Can I get some love for this idea? I'm doing everything else you are asking.

  •  I added the 'teaching' tag (5+ / 0-)

    so that this will go into Daily Kos University, which opens every Saturday at 9 AM Eastern, but stays open all week.

    No fees, no tests, no grades .... just learning!

  •  Super diary, and so true! (3+ / 0-)
    Recommended by:
    CatJab, ludlow, Larsstephens

    The big cost savings are not in increased computerization or more efficiency, the big cost savings are in taking out the 30% or so that the insureres take off the top.

  •  Reinventing the wheel (3+ / 0-)
    Recommended by:
    CatJab, Larsstephens, doctoraaron

    If a group inventing the wheel was analogous to the group holding hearings on health care reform, the proposed wheel would be square, with no spokes.  Ironically, this wheel wouldn't be invented in ancient times but in modern times, with wheels everywhere to copy that work wonderfully.  That is the case with our health care.  We don't have to invent it.  It is working all over the world and all we have to do is copy the features we like best -- chrome, rubber, whatever.

    The wheel and good health care share certain things in common no matter what their model.  Round for the wheel and non-profit for the health care. Hubs for the wheel and government set prices for health care. I could go on but I'll have mercy.  In any case, I am sick to death of these bad, unworkable ideas that keep us in the same cruel morass we are in with health care when all we have to do is copy any one of the existing universal health care programs around the world to incredibly improve our awful system.  Then if we want to improve on that, we can but at least we'll save lives and stop suffering now.

  •  A Concise, Forthright Precis Of Today's System, (1+ / 0-)
    Recommended by:

    Along with some concrete ideas for reform.

    I appreciated the effort.

    And like the drowning man, who, in despair, Doth clutch the frail and weakly straw --Thomas Horatius Delpho

    by terry2wa on Fri May 08, 2009 at 09:25:50 AM PDT

  •  Nothing beats info right from the trenches! (1+ / 0-)
    Recommended by:

    Keep up the amazing work, Dr. Aaron!

  •  Media needs to step up in health care debate (2+ / 0-)
    Recommended by:
    Larsstephens, doctoraaron

    Bravo! Another great post that underscores the urgent need for single-payer. Thanks Dr. Roland. This is the kind of personal reporting (and advocacy) we sorely need in the health care reform debate. I'm posting a link (and excerpt below) to a recent flap over a PBS "Frontline" series documentary that ignored addressing single-payer.  Thankfully, the PBS Ombudsman took "Frontline" to task for this oversight and pointed out a startling fact: the mainstream media's complete lack of help in educating the public on single-payer.

    "As I looked further, I found a brief but fascinating study last month by the media watchdog group FAIR (Fairness & Accuracy In Reporting) that documented how rarely major newspaper or broadcast or cable television stories actually mention the idea of a single-payer system as a part of the national dialogue, despite considerable support in polls and among a fair number in Congress. Only 18 out of hundreds of stories surveyed in one week dealing with health care reform mentioned it."

  •  If Mary's insurance would have paid for it, (0+ / 0-)

    would anything else have prevented you from managing her fracture rather than referring to an emergency room?  If Mary had been on Medicare or Medicaid, could you have billed for your management services and/or time?  Could you have set the fracture yourself?  

    In what way does the integrated service model you are describing differ from the old HMO model?

    This diary was well worth the read, by the way.

    •  Payment was not the issue (2+ / 0-)
      Recommended by:
      panicbean, rhutcheson

      The problems were multiple. I'm in clinic now so hard to respond fully, but here's a summary:

      --although I was trained to set fractures, I have done so so rarely over the years that I don't really feel comfortable doing so anymore
      --in an integrated, Kaiser-type, HMO Mary's care would have been much more easily accomplished at the lowest possible cost.  That being said, although I see value in this type of model, I know it is not an ideal for all care.  This was just one musing on potential for cost reduction.
      --Mary has Medicare and Medicaid (she's a developmentally delayed adult) and I did bill for my visit but
      --very few orthopedists outside of the public hospitals accept her insurance and so costs "to the system" overall were increased by the lack of coordination possible in this case.

      Dr. Aaron Roland is a family physician in Burlingame, CA.

      by doctoraaron on Fri May 08, 2009 at 01:18:28 PM PDT

      [ Parent ]

      •  One of my questions has to do with (0+ / 0-)

        reimbursement rates.  By rights, had you referred to a specialist, you should have gotten a payment for your 'management efforts', but I don't know whether you can get that kind of reimbursement currently.

  •  The health reform discussion is a national disgra (0+ / 0-)

    John Edwards warned in last year's debates that you don't give corporations a seat at the table.
    And what did Obama do?
    They own the table.

    The man featured in the video below is not a leader.
    He can't even follow a large national majority.

    He says in this video:
    "I happen to be a proponent of single payer..."  Then he denied he said this to Meredith Veiera right after she played it!

    Obama used to be for single payer before he came out against it.

    by formernadervoter on Fri May 08, 2009 at 04:02:58 PM PDT

  •  Lots of good stuff in here, doc. (1+ / 0-)
    Recommended by:

    As you nicely illustrate, our current patchwork non-system of health care is chock full of perverse incentives that increase costs even as they worsen quality.

    You hit on one of the most promising ways to reduce medical costs: a greatly expanded role for primary care physicians. Well trained family physicians can take care of many straightforward minor surgical and orthopedic problems at far lower cost than the subspecialists can. Primary care has a proven track record of providing higher quality care and greater patient satisfaction at lower cost. Yet today primary care in America is on the verge of collapse. Our aging, rapidly shrinking primary care base is being replaced by fragmented subspecialty care, where each organ system is 'managed' by a different consultant providing intensive and absurdly expensive care, yet no one is in charge. That's just nuts, and to his credit Obama appears to "get it". Whether substantive policy changes will be forthcoming remains to be seen; the subspecialty push-back is already gathering steam.

    Next, it's obvious to many of us that single payer is virtually imperative if we're to successfully provide high quality care to all Americans at an affordable cost. The colossal 30%+ overhead/waste associated with commercial for-profit insurance must be captured to fund expansion of care to the uninsured and underinsured. The efficiencies of scale, simplicity of billing and ease of data management in a unified system are compelling. But how we get there is the rub. Right now we have perhaps a unique political opportunity to get a 'public option' on the table to start the process; but the lobbyists and corporate sharks already have their knives out.

    In my experience no one wants to hear the last piece of the puzzle; that's the "R-word".


    Yet, unless we grasp the nettle and address this honestly, any reform effort is doomed to fail. The potential cost of medical care as our population ages and technology advances is literally mind-boggling. It will eat not just the entire Federal budget, but our entire economy, unless some realistic constraints are applied. Currently we ration via cost and access- patients with Medicaid can't find anyone willing to see them, the uninsured get virtually no care, the underinsured are forced to forego care when copays or deductibles bankrupt them. This is morally atrocious, but it surely limits cost. Meanwhile the very well insured are often treated to insane levels of intensity even when a terminal outcome is imminent.
    If we succeed in providing access to care for the uninsured and underinsured without effectively addressing this issue, exploding costs will destroy us. Hell, that'll happen even if the uninsured are left out in the snow to freeze.

    This is not a problem that can be solved painlessly via 'savings' from preventive care, electronic health record 'efficiency'or shaving 20% off the cost of meds through competitive bidding. This will require a serious, adult discussion about what we expect from health care- what's essential, what's reasonable, what's excessive, and where we as a society decide to draw the line. Should we routinely provide hemodialysis to profoundly impaired 83 year old patients with Alzheimer's disease or cancer if it means eviscerating school funding for our children? Because that's what we're doing now.

    This kind of rational and paradoxically compassionate thinking is routine overseas. In England or France, no one is ever bankrupted paying for medical care; no one has to die for want of medical care because they're uninsured. But the British National Health Service for example foregoes ultra-aggressive treatment with limited benefit. It's going to take a long time for Americans to wrap their heads around this concept. But until we do, we're headed for a crash.

    •  I'd love to see an expanded diary (0+ / 0-)

      about rationing.  

      Of course we already ration, but based upon income and other inappropriate criteria.

      Oregon, in their Medicaid program, I recall tried a form of overt rationing which didn't work very well...

      Dr. Aaron Roland is a family physician in Burlingame, CA.

      by doctoraaron on Fri May 08, 2009 at 07:53:42 PM PDT

      [ Parent ]

      •  Ah, John Kitzhaber's experiment. (1+ / 0-)
        Recommended by:

        A very interesting idea indeed. Governor Kitzhaber (a family physician, by the way) tried to greatly expand coverage of Oregon's poor by ranking procedures and treatments by cost and cost-effectiveness, and limiting Medicaid's coverage to the higher ranking treatments. The number of poor Oregonians covered was (I believe) roughly doubled, while coverage of procedures that were very expensive but of limited effectiveness (like bone marrow transplant for AML) was ended.

        Kitzhaber's idea was radical in concept but compassionate in reality. Treatments were ranked, and if State funding was increased, coverage would be extended farther down the list. Unfortunately it collided with two unrelated problems. First, Republicans in the legislature simply despised Kitzhaber, and did everything they could to hamper or sabotage the program. Republicans were politically ascendant at the time, and their revulsion for the program was part of their sales pitch. Second, a combination of economic downturn and taxpayer 'revolt' (eagerly stoked by Republicans) whittled away at the program's funding. As the dividing line between covered & uncovered services regressed, the program became more difficult to defend.

        This was just a taste of what's in store for us when we finally confront the reality of rationing. It's an issue that attracts vile demagoguery like iron filings to a magnet, and politically it will be absolutely toxic. But unless we deal with it, we're doomed.

  •  This is an excellent summary of the real problems (0+ / 0-) health care, and it's the primary doctors who are in the trenches dealing with the nightmare day after day...

    I harken back to Clinton's 1994 State of the Union address, where he held up that National Insurance Card... If was had only done the right thing the first time around...

    Thanks for the diary, and I'm glad it's getting attention at TPM... I read it there first, actually...

    DARTH SPECTER: I am altering the deal! Pray I don't alter it any further!
    LANDO REID: This deal keeps getting worse all the time!

    by LordMike on Fri May 08, 2009 at 08:58:03 PM PDT

  •  Thank you for being a caring doctor (0+ / 0-)

    And thank you for taking the time to delineate just how messed up things are.

    I feel insurance company profits are the main barrier, both to cost control and making single payer happen.

    Insurance companies also squish promising new treatments, regardless of cost, even when it would be cheaper.

    Look at the Lyme Disease controversy, where everyone is assumed to be handled by a short course of antibiotics, which only works when someone is diagnosed quickly. Yet they rig the system to make it less and less likely someone is diagnosed quickly.

    They are the ones messing up health care; rationing, restricting doctors, and throwing people out of the hospital too quickly.

    Pootie fan? Me too! Check out my cat advice blog.
    The Way of Cats

    by WereBear on Sun May 10, 2009 at 04:15:27 AM PDT

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