Friday, May 22, 2009

American Healthcare: Follow the Money

Readers' experience of the U.S. healthcare system suggests that care follows money, not the other way around. Is anyone looking at the incentives and disincentives in our model of "healthcare"?

Readers wrote in response to Social Welfare, Socialism and Healthcare (May 19, 2009).

Galen W.

Please allow me to relate two medical-related events that took place with family members this year.

In late January, my older brother Robert died of leukemia. He was 53. Rob had been originally diagnosed some ten years earlier and had been in remission and on a maintenance chemotherapy up until the spring of 08, when all of a sudden, his symptoms returned with a vengeance. The lymph nodes in his neck and stomach swelled horribly. Between the spring of 08 to just before his death, he tried four different chemo regimes including a clinical trial. Nothing worked.

Of course during all this, he became weaker and weaker, going from 6'5" tall and 230 lbs (Rob played small college basketball when he was young and continued to play up until the disease returned) to about 170 lbs. He also developed a lung infection and was on oxygen for a while. As a last ditch, my sister and I were tested for bone marrow stem cell transplant and I was found to be compatible.

On the day of the transplant, Rob had to undergo more chemo as well as radiation to destroy his immune system. He returned to his room ashen and barely able to sit up. My stem cells were transplanted through a drip feed to my brother. That night he deteriorated. His breathing became labored and they had to draw fluid out of his lungs. It got worse and he had to be sedated and placed on a ventilator. Rob did not want to be kept alive artificially so his partner and the family decide to take him of the ventilator and he died within minutes. A test of the lung fluid later found more cancer.

The lead oncologist had said Rob had a 50/50 chance to survive the procedure. I think he knew full well it was much, much worse than that. They could have said 'Rob, we are sorry but it's the end of the line' and let him die without putting him (and by extension, his loved ones) through the horror of more chemo, radiation and pain. The outcome was the same but the hospital got paid through my brother's health insurance.

My 82 year old father was diagnosed with a heart valve irregularity. He is otherwise in good health for his age. A scope of his arteries showed no clogs. Last month after consulting with two doctors, he decided to have the heart valve replaced. This is supposed to be a routine surgery. After a few days of recovery, he went home.

After a couple of days at home he said his stomach was not right. On a Sunday evening, he got up to go to the bathroom, became light-headed and fell. He was not injured by the fall but my mom called 911 and he was taken to the emergency room. His blood pressure was dropping and he vomited several pints of blood and was also bleeding from his rectum. They were giving him blood but it was coming out as fast as it was coming in. That evening they scoped him and found two ulcers in his stomach. He was on blood thinners, so he almost bleed to death through these ulcers (he had never had stomach problems before). During the scoping procedure they clamped the ulcers which stopped the bleeding and so far (two weeks later) he has been OK. He comes home - again - tomorrow.

What would have happened if he decided NOT to get the new heart valve? How long would he live? Would he be debilitated? He was fine before he went in for the surgery - able to walk, work out at the gym and work in his garden. How tough is it for an 82 year-old man to recover from open-heart surgery? I guess if Medicare is paying, these questions aren't asked.

I always thought a good idea for government-funded health care would be for the Feds (or the states paid by the Feds) to open up health clinics in cities. Care in these clinics would be totally free to anybody who walked it BUT the patient would have to sign a waiver stating that they could not sue the clinic or the doctors and if there was a medical accident it would be arbitrated for settlement without appeal. The doctors would work for a reasonable wage (not get rich) for a fixed length of time and have their medical education paid by the government in exchange for thier service. Doctors would be allowed to practice medicine without the threat of suit hanging over them. I am sure it would be just as cost-effective as the VA.

Jim S.

Another very interesting post, as usual! This one hits close to home, as my parents, aged 87 and 89, are active consumers of both Medicare and VA services. They've been on the Medicare gravy train for more than 20 years, but only recently did my father discover the "free" services of the VA. As their designated driver for long-distance medical appointments, I've made a few observations that may explain some of the cost differential between the two services.

With regard to Medicare, there is a growing movement among physicians to simply stop accepting Medicare patients. I learned this when trying to find a specialist for my mother. The patient does not have the option to just pay the bill herself. If she has Medicare, it's a violation of federal law for the doctor to accept payment outside of the system. As you might expect, this limits the pool of providers to choose from. On the doctor's side, the problem is the amount the Medicare will pay, which is non-negotiable. After factoring in the paperwork and record-keeping costs, many doctors have decided that it's unprofitable to accept Medicare, period.

Although both of my parents were hard-working, conservative and definitely against a welfare state, they simply do not see that they are now active welfare recipients. The attitude is "We worked hard, we're entitled." I expect they used up the full amount they paid into the system within 3 years of going on Medicare. Now they are willing to schedule doctors appointments for the least little symptom, since Medicare will cover it. Any gap is covered by the insurance provided by their pensions.

The VA is another story. Again because of the "free" nature of it, my father decided to start using it in lieu of a local doctor. There is a clinic about 30 minutes away, staffed by nurse practitioners and one or two doctors. When a routine visit produced a questionable test result, he was scheduled to visit a specialist at the VA hospital in Dallas. You don't call to make an appointment. They tell you when your appointment is, some 4-6 weeks in the future. The hospital is well over an hour's drive from his home, at freeway speeds. It's in the part of Dallas where one is advised to keep the doors locked and the windows up. I spent 30 minutes finding a place to park in the acres of lots surrounding the hospital.

We waited about an hour past the appointed time for a 5 minute visit, after which he was sent home with no further follow-up needed. While waiting I observed a lot of patients coming and going, and it seems apparent that most of them use the VA because they have no other recourse. The process is so burdensome that nobody would put themselves through it if they had an alternative. This may be why the VA has a lower budget. A veteran who also has Medicare would probably choose a local doctor, since his cost is almost the same.

While I'm on a rant, there's another troubling aspect of the coming econopolypse that troubles me. I'm 61. My meager retirement funds have been clobbered, and likely will be sufficient for no more than a few years at best. I expect to continue working as long as I'm able to get out of bed in the morning, and I'm OK with that. In the unlikely event that Social Security is still available when I hit 65, I don't plan to file for it. My children and grandchildren are already facing crushing debt, and adding to it would be unthinkable.

However I've observed a number of fellow "boomers" who are retiring at the earliest possible time in order to maximize their "take" from Social Security. One such guy claimed that he "paid in for 40 years, and now it's my turn!" Of course what he paid in for those 40 years went to his and my parents, and anything he takes out will come from his own kids. Unfortunately this seems to be the mindset of most people now turning 65, and I expect it will hasten the crash of the entire Medicare and Social Security system.

The news this morning brings a proposal for national health care to be funded by taxing health insurance benefits as income. The additional taxes will fund the system, problem solved. But wait - if I can get national health care, why shouldn't I just use that and forget the insurance? After all, it's free!

David C.

On the Medicalization of Our Culture (Harvard Magazine)

This is an interesting article about the legal drug culture in America. Big pharma is promoting a pill for every ill. I get tired when every time I watch TV I am bombarded with drug commercials. I've come to the conclusion that it's abnormal to be healthy in this society, that it's normal to be sick. I was watching a Kevin Trudeau infomercial on his book Natural Cures 'They' Don't Want You to Know About and yes I know he's a convicted felon and a con artist but I think he said at least one thing that was correct when he said the drug companies don't want to cure disease, they want to manage it, because if they cure a disease they stop making money off of it.

I think the drug companies want everybody in America to be either physically or psychologically addicted to drugs for life so they can make money. Witness the heavy advertisement on TV, Magazines, Newspapers, and the internet.

I am not opposed to taking drugs if it's necessary, however adults need to look at the side effects of the drugs to determine if it's worth taking, they need to determine if the advantages of taking the drug outweigh the disadvantages. If I had a serious infection I would take Penicillin despite the side effects because the benefits would outweigh the disadvantages. However, I would rather change my diet, change my physical activity and exercise then take drugs for Obesity, High cholesterol or High blood pressure.

For example the Obesity drug Fen-Phen caused pulmonary hypertension and heart valve problems ( I would think that if you are Obese that the wise choice when looking at the pluses and minuses of taking an anti-obesity drug is not taking it and instead change your diet and exercise.

Unfortunately a lot of people would rather take a drug for the rest of their lives then to change their lifestyle because it's easier. When you are healthy or are trying to get healthy by using a scientific non-drug approach then you don't have to worry about doses, overdosing, side effects, drug interactions and finding a drug store when you are traveling.

I really liked your quote from your "Food For Thought" May 9, 2009 article "either we restrict the foods we eat when we have a choice, or our diet will eventually be restricted by chronic diseases." I think you should consider posting this at the bottom of your web page under Aphorisms.

Thank you, Galen, Jim and David for illuminating the darker corners of U.S. healthcare. Can anyone deny that those with "coverage" from gold-plated health insurance or Medicare will get over-medicated, over-tested and unfortunately over-"cared for" (as in sliced open) because these services are "bill for service" items?

As noted here many times, there are few incentives for prevention and non-drug, non-intervention treatments and lavish incentives to pathologize every aspect of life as way of reaping vast profits off the "management" of the multitude of diseases thus identified.

What few citizens are willing to accept is that the system is careening toward the cliff of insolvency. As the U.S. economy unravels and those paying the bulk of taxes become insolvent or opt out then there simply won't be any money to fund this stupenous pathology-producing, "follow the money" bill-for-service system.

So the sort of non-drug treatments David mentions above will become the only option for most people because Medicare as we now know it will be gone by 2014-2015 and Social Security as we now know it gone by 2021. As we print and borrow our way to "prosperity" our currency and debt payments will move in opposite directions; we as a nation will be insolvent. We will be unable to pay the staggering interest payments or con anyone into believing the dollar has any value worth trading oil or gold for.

Believing we can endlessly print and borrow trillions of dollars every year with zero consequences is to believe in a dangerous, utterly unsustainable illusion.

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