That was the bill for my wife's hospital stay during and after the delivery of our second child, a daughter, at a major teaching hospital in Washington, DC. It seemed extreme even to us (two family doctors who are used to navigating the byzantine, overpriced health system on behalf of our patients) especially since my daughter was delivered by a nurse midwife, without anesthesia or other drugs, and my wife labored in the hospital for only 2 hours and was discharged after less than 30 hours. Curiously, when we requested an itemized bill, the hospital could only account for $6562.47 of the tab, of which our health insurance (a program for federal employees) ended up paying $4352.32 and we paid $100.
I might use this absolutely true story as an example of the complete lack of transparency and common sense in health care costs, or as a morality tale about greedy hospital executives or cheapskate health insurers. But instead, I'd like to make two other points: 1) You are not the customer. 2) You're subsidizing care for the uninsured already, but in the worst possible way.
What does it mean when I say that you, the patient, are not the customer? For insured people, it means that medical bills are a complex negotiation between insurers and providers of care (hospitals, physicians, outpatient facilities, etc.), where actual costs mean very little to patients. Sure, my wife and I felt our hospital bill (which included mysterious charges such as a separate $163.90 "daily supply charge" on top of the $1115.00 daily room fee and $1074.70 "recovery first 2 hours" when my wife shivered under a cheap blanket, her lunch never arrived, and she ended up lunching on a reheated hamburger I purchased in the hospital cafeteria) was excessive, but what did it matter to us since our insurance was footing all but $100 of the bill? When we, the real consumers of care, are completely disconnected from what that care actually costs, most of us are inevitably tempted to request too much care, which hospitals and physicians are usually happy to provide but which does nothing to improve our health.
The other reality illustrated by our bill is the hospitals, like all medical institutions, already use insurance payments (your money) to subsidize care for the uninsured. When a patient without insurance and no other means to pay comes to the hospital to deliver a baby or in the throes of a heart attack, who pays? You do - in the form of higher insurance premiums that pay for artificially inflated bills.
This is why it makes no sense to advocate for limiting health care to U.S. citizens, or legal immigrants. Illegal immigrants get sick too, and they end up going to U.S. emergency rooms when their health problems become too serious to ignore. The high-risk premature delivery that could have been prevented by routine prenatal care, and the heart attack that could have been prevented by controlling blood pressure and cholesterol levels (which primary care does very well and cheaply, given the opportunity), instead become expensive, catastrophic emergency visits, which are charged to your hospital, and therefore your health insurance, and therefore, you. Immigration policy is an important and divisive issue, but it should be separated from the issue of public health and the health reform debate.
Sunday, August 30, 2009
Thursday, August 27, 2009
Heroic medicine vs. public health, part II
In the previous post, I described some hypothetical trade-offs that might need to be made in a health system with strictly limited resources, such as the British or Canadian systems, for example. Critics of those systems point out that the beauty of the U.S. system is that we can choose to pour in more resources whenever we want - and indeed, over the past 25 years, we have done just that. Spending on health care now accounts for about 17% of the gross domestic product (GDP), and with new treatments and technologies being added every year, that percentage has only been climbing. Not only do we spend more of our wealth on health care than any other advanced country in the world, since our GDP is far larger than any other country's, we outspend them by almost twice as much ($6600 per U.S. citizen vs. $3800 per French citizen in 2006, for example). Who's paying for that difference? You are, in the form of lower raises in salary and increased cost-sharing.
I've already mentioned many good things that we don't get for these immense amounts of money: free immunizations and other preventive care, primary care physicians for all, etc. But what else would we do with the billions of dollars we currently spend on "heroic medicine," such as inserting cardiac stents into 90 year-olds, keeping comatose patients on dialysis, using feeding tubes and artificial respirators indefinitely in patients with no hope of recovery?
Well, we could build more sidewalks. Or playgrounds. Public parks. Biking paths. These are the sorts of improvements that are designed to improve the public health - to encourage people of all ages to live healthy, physically active lives. In communities with the highest rates of obesity and diabetes, you generally won't find these sorts of improvements. So when certain members of Congress ridicule public health spending as irrelevant to health care reform, I'd like to invite them to take a look at the less touristy parts of my home town of Washington, DC. Let's take a look at the meager options some people have to make healthy life choices. Let them see exactly what they're trading off for the heroic technological interventions that do little to improve the health of my community and yours.
I've already mentioned many good things that we don't get for these immense amounts of money: free immunizations and other preventive care, primary care physicians for all, etc. But what else would we do with the billions of dollars we currently spend on "heroic medicine," such as inserting cardiac stents into 90 year-olds, keeping comatose patients on dialysis, using feeding tubes and artificial respirators indefinitely in patients with no hope of recovery?
Well, we could build more sidewalks. Or playgrounds. Public parks. Biking paths. These are the sorts of improvements that are designed to improve the public health - to encourage people of all ages to live healthy, physically active lives. In communities with the highest rates of obesity and diabetes, you generally won't find these sorts of improvements. So when certain members of Congress ridicule public health spending as irrelevant to health care reform, I'd like to invite them to take a look at the less touristy parts of my home town of Washington, DC. Let's take a look at the meager options some people have to make healthy life choices. Let them see exactly what they're trading off for the heroic technological interventions that do little to improve the health of my community and yours.
Monday, August 24, 2009
Heroic medicine vs. public health, part I
Grandma Smith is 80 years old, has chronic kidney failure, and requires dialysis three times each week to stay alive - treatment that she doesn't have money to pay for herself. A government-sponsored "death panel" determines that her life isn't worth what it would cost to continue her dialysis. This is the imaginary nightmare scenario that just doesn't seem to go away, even though its basis in the current health reform legislation is flimsy at best. No wonder so many people are outraged! Seen in isolation, this sort of callous decision seems to be emblematic of an unfeeling, bureaucratic health-care system that no sane person could possibly want.
But what if the trade-off for continuing Grandma Smith's dialysis was that we couldn't pay for yearly influenza vaccinations for 10,000 other grandmothers and grandfathers, protecting them from an infection that leads to death from pneumonia in thousands of Americans each year? Or what if paying for her dialysis machine, the technicians to run it, and the doctors to supervise it meant that your children didn't receive antibiotics for tuberculosis, or your community had to make do with inadequate water filtration? Balanced against the health of the public - that is, the health of countless others who are no less deserving - Grandma Smith's treatment begins to seem selfish at best.
Of course, health care isn't a zero-sum game. In fact, when dialysis machines were first invented, there were so few of them to go around that some municipalities formed committees who, much like the mythical Obama "death panels," determined which of their citizens with kidney failure would be able to go on the machine and whom would be left to die. The result was that eligibility for Medicare, which is primarily a government-run insurance program for the elderly, was extended to cover all patient with kidney failure severe enough to require dialysis, regardless of age. As a result, no person in the U.S. today goes wanting for dialysis.
But this is a double-edged sword. During my family medicine residency, I cared for a 45 year-old otherwise completely healthy man who, through an unlucky roll of the genetic dice, suffered catastrophic kidney failure and whose life was certainly saved by immediate access to the Medicare benefit. On the other hand, I've also cared for many other patients with irreversible brain, heart, or lung damage whose kidney failure was clearly part of the process of dying, and whose lives were merely prolonged ("saved" would imply that there was some purpose to continuing treatment) by dialysis while their loved ones avoided meaningful end-of-life discussions.
In my next post, I'll talk about the negative effects that spending on this type of "heroic" medicine has on the public health.
But what if the trade-off for continuing Grandma Smith's dialysis was that we couldn't pay for yearly influenza vaccinations for 10,000 other grandmothers and grandfathers, protecting them from an infection that leads to death from pneumonia in thousands of Americans each year? Or what if paying for her dialysis machine, the technicians to run it, and the doctors to supervise it meant that your children didn't receive antibiotics for tuberculosis, or your community had to make do with inadequate water filtration? Balanced against the health of the public - that is, the health of countless others who are no less deserving - Grandma Smith's treatment begins to seem selfish at best.
Of course, health care isn't a zero-sum game. In fact, when dialysis machines were first invented, there were so few of them to go around that some municipalities formed committees who, much like the mythical Obama "death panels," determined which of their citizens with kidney failure would be able to go on the machine and whom would be left to die. The result was that eligibility for Medicare, which is primarily a government-run insurance program for the elderly, was extended to cover all patient with kidney failure severe enough to require dialysis, regardless of age. As a result, no person in the U.S. today goes wanting for dialysis.
But this is a double-edged sword. During my family medicine residency, I cared for a 45 year-old otherwise completely healthy man who, through an unlucky roll of the genetic dice, suffered catastrophic kidney failure and whose life was certainly saved by immediate access to the Medicare benefit. On the other hand, I've also cared for many other patients with irreversible brain, heart, or lung damage whose kidney failure was clearly part of the process of dying, and whose lives were merely prolonged ("saved" would imply that there was some purpose to continuing treatment) by dialysis while their loved ones avoided meaningful end-of-life discussions.
In my next post, I'll talk about the negative effects that spending on this type of "heroic" medicine has on the public health.
Saturday, August 22, 2009
A "radical solution" to the health care crisis
If you have been reading this blog for a while, you may wonder where on the political spectrum I fall regarding health care reform. While I'll decline to reveal my major party affiliation for now to avoid possibly alienating half of you, I can say quite honestly that I consider my views of health care reform to be very non-partisan. What do I mean by this? I think that Democrats are right to believe that any health care system that continues to provide no insurance coverage, even for catastrophic events, to 47 million Americans will never be able to improve quality and control costs. I also agree with Republicans who believe that trusting the government (even though I'm a government employee) to efficiently manage the majority of the nation's health resources is a recipe for failure, and that in some ways government over-regulation of health care has led to unnecessary inflation in costs. On the other hand, I don't think that dumping another $1 trillion into an essentially flawed system will automatically deliver the long-term cost savings that we need, and I disagree with many Republican leaders who seem to feel that their "less government" philosophy means sticking with the status quo (for example, you can't favor less government involvement in health care and at the same time keep Medicare exactly the way it is).
However, until recently I've struggled to articulate a viable third way out of the health care morass. Now I don't have to. In a riveting piece in the Atlantic, titled "How American Health Care Killed My Father," business executive David Goldhill makes a convincing argument for a model of health reform that harnesses the advantages of market incentives while protecting the less fortunate and less wealthy. Far from being "radical," as the teaser paragraph describes it, his proposed solution makes more sense than anything I've yet heard out of the health care debate. Rather than trying to read the thousand-page bills currently winding their way through both houses of Congress, I recommend that you read this article instead to understand what's at stake and why reformers are probably moving in the wrong direction. The sections include:
1. Health Care Isn't Health (Or Happiness)
2. Health Insurance Isn't Health Care
3. The Moral-Hazard Economy
4. There's No One Else to Pay the Bill
5. The Government Is Not Good at Cost Reduction
6. Uncompetitive
7. Our Favored Hospitals
8. You Are Not the Customer
9. The Strange Beast of Health-Care Technology
10. The Limits of "Comprehensive" Health Reform
11. A Way Forward
12. $636,687.75
Goldhill concludes: "But let's forget about money for a moment. Aren't we also likely to get worse care in any system where providers are more accountable to insurance companies and government agencies than to us? ... Let me ask you to consider one more question. Imagine my father's hospital had to present the bill for his "care" not to a government bureaucracy [Medicare], but to my grieving mother. Do you really believe that the hospital - forced to face the victim of its poor service, forced to collect the bill from the real customer - wouldn't have figured out how to make its doctors wash their hands?"
Powerful stuff.
However, until recently I've struggled to articulate a viable third way out of the health care morass. Now I don't have to. In a riveting piece in the Atlantic, titled "How American Health Care Killed My Father," business executive David Goldhill makes a convincing argument for a model of health reform that harnesses the advantages of market incentives while protecting the less fortunate and less wealthy. Far from being "radical," as the teaser paragraph describes it, his proposed solution makes more sense than anything I've yet heard out of the health care debate. Rather than trying to read the thousand-page bills currently winding their way through both houses of Congress, I recommend that you read this article instead to understand what's at stake and why reformers are probably moving in the wrong direction. The sections include:
1. Health Care Isn't Health (Or Happiness)
2. Health Insurance Isn't Health Care
3. The Moral-Hazard Economy
4. There's No One Else to Pay the Bill
5. The Government Is Not Good at Cost Reduction
6. Uncompetitive
7. Our Favored Hospitals
8. You Are Not the Customer
9. The Strange Beast of Health-Care Technology
10. The Limits of "Comprehensive" Health Reform
11. A Way Forward
12. $636,687.75
Goldhill concludes: "But let's forget about money for a moment. Aren't we also likely to get worse care in any system where providers are more accountable to insurance companies and government agencies than to us? ... Let me ask you to consider one more question. Imagine my father's hospital had to present the bill for his "care" not to a government bureaucracy [Medicare], but to my grieving mother. Do you really believe that the hospital - forced to face the victim of its poor service, forced to collect the bill from the real customer - wouldn't have figured out how to make its doctors wash their hands?"
Powerful stuff.
Wednesday, August 19, 2009
Does one drink a day help keep dementia away?
Although it’s clear that heavy drinking is bad for your health, some studies have suggested that drinking “moderately,” defined as up to two alcoholic beverages per day, may actually improve cognition (thought processing in the brain). In a 2005 study in the New England Journal of Medicine, Dr. Meir Stampfer and colleagues from Harvard Medical School examined the relationship between moderate drinking and measures of brain function in women age 70 years and older.
Women in the study completed six dietary questionnaires between 1980 and 1998, including questions about frequency and type of alcohol use. They were classified into three groups based on average daily alcohol consumption: non-drinkers (55 percent of participants), those who drank up to one drink daily (44 percent), and those who drank one to two drinks per day (5 percent).
Specially trained nurses, who were not given information about the womens’ drinking habits, tested their memory and cognition in telephone interviews between 1995 and 1997. While nondrinkers and women who consumed one to two drinks daily had similar cognitive scores, women who consumed less than one drink daily had higher average scores, and their risk of being classified as cognitively “impaired” was 20 percent less than that of nondrinkers. The type of alcoholic beverage consumed did not affect the results.
Given the impracticality of using alcoholic beverages in a randomized clinical trial, it is unlikely that we will ever know conclusively if any amount of alcohol is good for the mind, and if so, how much. The observational design of this study leaves open the possibility that women with better cognitive scores were more likely to consume moderate amounts of alcohol, rather than the other way around. It would be premature to recommend that women who are nondrinkers start consuming alcohol to prevent dementia. On the other hand, this study suggests that women who drink up to two alcoholic beverages per day will be no worse off, and may possibly fare better, than their nondrinking peers.
**
Note: the above posting is adapted from an article I wrote in the November 1, 2005 issue of American Family Physician.
Women in the study completed six dietary questionnaires between 1980 and 1998, including questions about frequency and type of alcohol use. They were classified into three groups based on average daily alcohol consumption: non-drinkers (55 percent of participants), those who drank up to one drink daily (44 percent), and those who drank one to two drinks per day (5 percent).
Specially trained nurses, who were not given information about the womens’ drinking habits, tested their memory and cognition in telephone interviews between 1995 and 1997. While nondrinkers and women who consumed one to two drinks daily had similar cognitive scores, women who consumed less than one drink daily had higher average scores, and their risk of being classified as cognitively “impaired” was 20 percent less than that of nondrinkers. The type of alcoholic beverage consumed did not affect the results.
Given the impracticality of using alcoholic beverages in a randomized clinical trial, it is unlikely that we will ever know conclusively if any amount of alcohol is good for the mind, and if so, how much. The observational design of this study leaves open the possibility that women with better cognitive scores were more likely to consume moderate amounts of alcohol, rather than the other way around. It would be premature to recommend that women who are nondrinkers start consuming alcohol to prevent dementia. On the other hand, this study suggests that women who drink up to two alcoholic beverages per day will be no worse off, and may possibly fare better, than their nondrinking peers.
**
Note: the above posting is adapted from an article I wrote in the November 1, 2005 issue of American Family Physician.
Sunday, August 16, 2009
My first experiences with end-of-life "care"
There's news today that the White House seems ready to strike reimbursement for end-of-life counseling sessions from the health reform bills in order to save it from critics who manipulated the concept into fictitious "death panels" staffed by cold-hearted bureaucrats who would decide "when to pull the plug on Grandma." That's a real shame. I hope that primary care clinicians and others will continue having these discussions with their patients nonetheless, because they are sorely needed - not to save money for the government and private insurers, but because without them, our grandparents (and our parents, and ourselves, for that matter) have little chance to die with dignity. (Strongly recommended reading: How We Die by Sherwin Nuland, a Yale surgeon's sober reflections that will poignantly dispel any myths you may have about how death occurs in the U.S.)
As a medical student, my first experiences with end-of-life care occurred in Bellevue Hospital in New York City, a 150 year-old institution famous for caring for the city's poor and being a rite-of-passage learning experience for generations of medical students. I inserted my first "chest tube" into a man from Thailand who spoke no English and was dying painfully from incurable rectal cancer. After we ran out of sites to place intravenous lines for his medication and intravenous fluids, a 1st year surgical resident inserted a "central line" for access directly into his neck veins, but managed to nick the top of his right lung in the process (a common complication of this procedure). In order to re-inflate his collapsed lung, I used what was essentially a large pair of sterilized pliers to punch through his chest wall (yes, it's almost as painful as it sounds to read) and force in a large plastic tube connected to suction. None of these procedures, incidentally, would have been necessary had this man chosen hospice care instead, but no one had ever bothered to find a translator to talk to him about it. So he lived the last few days of his life, as it turns out, alone and with a tube in his chest.
My second encounter with death was no better. For several weeks during my 4th year, I cared for an elderly woman who was dying slowly from metastatic colon cancer. Surgeons had removed most of her large intestine, but were unable to completely remove the cancer that had spread to her liver and bones. (This type of cancer, by the way, is almost completely preventable with colorectal cancer screening, the topic of a previous blog - but only 53% of eligible adults receive such screening.) After the surgery, her kidneys failed, and her wound healing was so poor that they were unable to close the surgical incision. Day after day I took a scalpel to the outer edges of the incision, carving away blackened, dead tissue; day after day I searched in vain for more sites to draw blood from her battered, bruised veins; and finally resorted to painful arterial punctures to get the laboratory tests that I was told we needed. Unlike my earlier patient, she and her family spoke perfect English; but she was essentially comatose and the family (who filled the sterile hospital room with flowers, balloons, and photos) seemed to never be around when the doctors were at the bedside.
On my last night on call at Bellevue, the inevitable happened - my patient stopped breathing, her heart stopped beating, and having received no orders to the contrary, we attempted to revive her. As I performed CPR for the first time on a real patient, I remember thinking how brittle her bones had become from the cancer, and how easily her ribs shattered under the weight of my chest compressions. The "Code Blue" team, knowing nothing at all about the patient, swarmed into the room, donning gowns and gloves inserting lines into every orifice. As we worked futilely to revive this dying woman, her bowels reflexively emptied one last time, soiling the sterile towels. We worked on her for twenty minutes, and when it was over, the room reeked of blood and urine and feces.
As the only person around who remotely knew the patient, I dutifully made the middle-of-the-night call to give the news to her sons and daughters. They sounded surprised, which shook me, since I understood metastatic cancer as a death sentence (which it is, but no one had explained this to them, they said). Sad to say, these events repeat themselves on a daily basis at hospitals all over America, where end-of-life discussions are pushed aside by misrepresentations, false hopes, and a technologically-driven, unrealistic, never-give-up mindset that pervades our broken health care system. How many medical students and doctors in training are, right now, learning about death this way? Will these be the medical professionals who attend to your loved ones when they reach the ends of their lives? Is this the kind of care you would wish for them?
As a medical student, my first experiences with end-of-life care occurred in Bellevue Hospital in New York City, a 150 year-old institution famous for caring for the city's poor and being a rite-of-passage learning experience for generations of medical students. I inserted my first "chest tube" into a man from Thailand who spoke no English and was dying painfully from incurable rectal cancer. After we ran out of sites to place intravenous lines for his medication and intravenous fluids, a 1st year surgical resident inserted a "central line" for access directly into his neck veins, but managed to nick the top of his right lung in the process (a common complication of this procedure). In order to re-inflate his collapsed lung, I used what was essentially a large pair of sterilized pliers to punch through his chest wall (yes, it's almost as painful as it sounds to read) and force in a large plastic tube connected to suction. None of these procedures, incidentally, would have been necessary had this man chosen hospice care instead, but no one had ever bothered to find a translator to talk to him about it. So he lived the last few days of his life, as it turns out, alone and with a tube in his chest.
My second encounter with death was no better. For several weeks during my 4th year, I cared for an elderly woman who was dying slowly from metastatic colon cancer. Surgeons had removed most of her large intestine, but were unable to completely remove the cancer that had spread to her liver and bones. (This type of cancer, by the way, is almost completely preventable with colorectal cancer screening, the topic of a previous blog - but only 53% of eligible adults receive such screening.) After the surgery, her kidneys failed, and her wound healing was so poor that they were unable to close the surgical incision. Day after day I took a scalpel to the outer edges of the incision, carving away blackened, dead tissue; day after day I searched in vain for more sites to draw blood from her battered, bruised veins; and finally resorted to painful arterial punctures to get the laboratory tests that I was told we needed. Unlike my earlier patient, she and her family spoke perfect English; but she was essentially comatose and the family (who filled the sterile hospital room with flowers, balloons, and photos) seemed to never be around when the doctors were at the bedside.
On my last night on call at Bellevue, the inevitable happened - my patient stopped breathing, her heart stopped beating, and having received no orders to the contrary, we attempted to revive her. As I performed CPR for the first time on a real patient, I remember thinking how brittle her bones had become from the cancer, and how easily her ribs shattered under the weight of my chest compressions. The "Code Blue" team, knowing nothing at all about the patient, swarmed into the room, donning gowns and gloves inserting lines into every orifice. As we worked futilely to revive this dying woman, her bowels reflexively emptied one last time, soiling the sterile towels. We worked on her for twenty minutes, and when it was over, the room reeked of blood and urine and feces.
As the only person around who remotely knew the patient, I dutifully made the middle-of-the-night call to give the news to her sons and daughters. They sounded surprised, which shook me, since I understood metastatic cancer as a death sentence (which it is, but no one had explained this to them, they said). Sad to say, these events repeat themselves on a daily basis at hospitals all over America, where end-of-life discussions are pushed aside by misrepresentations, false hopes, and a technologically-driven, unrealistic, never-give-up mindset that pervades our broken health care system. How many medical students and doctors in training are, right now, learning about death this way? Will these be the medical professionals who attend to your loved ones when they reach the ends of their lives? Is this the kind of care you would wish for them?
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