Sunday, February 03, 2008

How Nate Would Fix U.S. Health Care

I'm not running for President in 2008 but have been thinking a lot about how royally f'ed up the U.S. health care system currently is. Although I do enjoy helping people deal with their kidney disease on a day-to-day basis and can point to numerous instances of success, there are certain cases I am involved with duI'ring which I can't help shake the feeling that I am also helping propagate this ridiculous health care system which is not sustainable in its current form.

Three things I would do to improve the system:

1. Universal Medical Records. I have talked about this on my blog before. One computer information system for everybody. Eliminate paper charting. This would save oodles of dough and improve communication between doctors, resulting in less duplication of expensive medical tests and overall better clinical care. I heard Hillary Clinton speaking about moving towards a universal medical records system recently and I couldn't agree more.

2. Limit care in medically futile situations. One of the reasons our medical costs are so astronomical is that our resources are allocated so poorly. Specifically, we are spending too much money on patients with advanced medical illnesses in a misguided attempt to prolong their lifespan at the expense of a reasonable quality of life, and too little on preventable disease. I can point to numerous examples of this since starting my renal fellowship, the most obvious one being an elderly man who underwent a heart valve replacement surgery and had a very difficult post-operative course which involved, among other things, kidney failure and low blood pressure requiring him to be hooked up to a special dialysis machine which was running 24 hours a day and required the presence of a single nurse to be with this patient at all times. He was on this kidney machine every day, 24 hours a day, for a period approaching 4 months before he expired. I feel guilty when I think about (a) the suffering this patient likely endured over this extended period of time, and (b) the amount of vaccines, antihypertensive agents, and pediatric checkups which could have been paid for with this single individuals' medical bills.

I think most physicians involved in this case probably felt that this had gone on for too long, but for whatever reasons, these concerns were not voiced until the very end. Why did this happen? Some of the fault lies with us doctors: there is a culture of not giving up at any costs, which in a sense is noble, but at the same time our degree of medical sophistication has evolved to the point where we need to realize that just because we can do something for a patient doesn't necessarily mean that it is appropriate. Second, our country has moved too far towards giving the patient decision-making autonomy and away from the traditional paternalistic model during which the physician makes the "best decision" for a patient. This is accomplished in the transplant community--there are only so many liver transplants to go around, for instance, and it is up to a panel of physicians and other health care providers to decide who is eligible and who is not--because the organ supply is seen as a limited resource. At some point, high-priced medical procedures should also be categorized as "limited resources" since our medical funding is not unlimited. Finally, I think another reasons doctors are reluctant to limit outrageous medical spending in helpless medical cases is that they are concerned about the possibility of a lawsuit which could destroy their medical career, resulting in the current practice of "defensive medicine" in which many unnecessary tests are ordered. Which leads me to my next point:

3. Put a cap on medical lawsuits. I agree that we must preserve the right for patients to sue doctors for gross negligence--I would be nieve if I stated that all doctors are altruistic and cannot be held accountable for obvious mistakes such as sawing off the wrong leg or missing an obvious diagnosis of a treatable cancer. However, for the most part doctors are a hard-working bunch who sacrifice a great deal of personal time in order to help achieve a good outcome for their patients, and it really bothers me to see "good samaritans" such as these to be scape-goated and sued. Furthermore, million-dollar lawsuits results in driving up malpractice rates for doctors and health care insurance premium for patients. If there were a "cap" on the amount somebody could sue for, this might help limit these expenses. I know it is impossible to put a value on human life, but at the same time such large sums of money are a huge burden to society.

So there you have it. Three easy-as-pie steps to fix the U.S. health care system.

On a lighter note, GO PATS. They play in the Super Bowl in about an hour.

Here is the all-too-short list of professional sports teams who have won a championship while I was living in that city:

1987 Minnesota Twins
1991 Minnesota Twins
2000 St. Louis Rams
2007 Boston Red Sox
2007 New England Patriots?


Blogger Eric said...

Great post=

We've moved to the Health Savings Account plan at work, which was predicted to lower the cost of premiums in the future. It didn't, though it may have mitigated the increase a bit. Hard to tell.
What I find interesting is the health care system's lack of interest in participating in the free market. Ask a doctor/nurse/front desk worker how much this appointment will cost - and you get a blank stare. "You have insurance..."
The hospital bill that Joey received for Mason's birth pretty much said "Birth - $18,995" (4 days under the "bili-lights" gets costly). We asked for a more detailed receipt, and they were somewhat annoyed and reluctant. Once we received it, we found she was charged $2000 for an epidural, after an exhausting 18 hour natural child birth! We contested on behalf of our insurance company.

I think the HSA is good in theory, and a free market for hospitals, doctors, procedures, and insurance companies will drive up efficiency and drive down costs. But, everyone has to play by free market rules. I sound like a conservative. If there was one running, I might even vote for them.

9:10 PM  
Blogger nathanhellman said...

It's true that most doctors (including myself) dont' always have a good grasp of how much something is going to cost for a patient. But this is also partially due to the complexity of the system--something which might be a $10 copay for you might be hundreds of dollars for somebody else.

Also, regarding the epidural's cost being hidden in the bill--you only picked up on that because you asked--I would guess that the vast majority of patients do not have either the time or educational background to delve into the bill details--that certainly sounds a little shady, you wonder how often extra charges like this slip through!

5:30 PM  
Anonymous Jeff said...

Nate: Your comments deserve mention.

I agree with the Universal EMR. That day is of course coming.

I could not agree more that futile and absurd care at the end of life is sucking the lifeblood out of the American economy and healthcare system. You offer some suggestion that part of the blame lies with doctors, but then you shift to blaming patient autonomy and the lawyers.

The blame lies almost entirely with us. We created this culture. There is nothing noble about flogging someone for 4 months before they die, and if everyone knew this was futile (I wager that is true) then it is cowardice to have not spoken up and acted on this knowledge.

There is a compelling piece by Kuttner in this weeks NEJM about the roots of this: We have had this perverse system driving a creation of the standard of care that has explcitly and persistently rewarded docs, hospitals and systems that do more and more and more. We have trained in this model, and the public has come to think of it as an appropriate standard of care.

Fixing the mess requires docs to have the courage to say "Enough." And we have to teach and model that courage, and be recognized (with promotion, awards, etc) for having that courage.

It also requires a reordering of incentives in the payment system. I guarantee you that if insurers stopped paying hospitals for that care, we would have task forces, panel discussions, Associate Deans for Palliative Medicine arising within weeks to months. But the system works for the most powerful voices in the process: Pharma, Big AMCs, Big Tech, the specialist-heavy AMA.

Do not cite malpractice as a driver. A lawsuit is a fact of life in modern practice. It is a pain in the neck, but does not ruin your career; and the honest empathic doctor who withholds care is less likely to be sued than the arrogant uncaring doc who tests and tests and flogs and flogs. The concept of defensive medicine is a crutch for docs who are not willing to do the hard work of delivering appropriate care (and it is hard work).

OK, back to work. Fight the good fight and I'll see you at the polls.

9:37 AM  
Anonymous Dan said...

I have a few suggestions.

First, we need to dramatically cut salaries for nephrologists; they're making way too much money.

Second, we need to cut out the insurance companies with a single payer, medicare for all system with a sliding scale co-pay based on income.

Third, we need to do everything Nate says.

9:18 AM  
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