Thursday, July 9, 2009

Telling Grandma "No."

“...creating a national health insurance to cover everyone will probably increase costs, not decrease them, just as feeding the world's hungry three full meals a day would not reduce our grocery bill. Personally, I think instituting universal health care is the humane thing to do, but let's be honest: Somebody will have to pay for it.”
Dr. Tom Shragg, The Sacramento Bee, Sunday, July 5, 2009

Dr. Shragg describes himself as “a specialist in pulmonary and critical-care medicine with 30 years of experience.” In his opinion piece for the Sacramento Bee entitled “The Conversation: Is health care cost debate focused on wrong issues?” Dr. Shragg looks at some of the leading suggestions for healthcare reform in the US--EMRs, shifting of compensation from specialists to primary-care providers and a “single-payer” system---from his own view as an experienced special-care physician in private practice the US. His primary point is these solutions to rising healthcare costs are either inappropriate or plain wrong.
The doctor describes these foci of cost reduction as “the wrong birds.”
Dr. Shragg’s writing is reflective of his practical history. EMRs, he feels, are only a distraction from the healthcare process. Using and EMR, he writes, “slows me down and diverts my attention from the patient to the computer…These computer records may improve accounting, but not health care.” After 30 years in practice, Dr. Shragg (like most physicians) probably does little of his own charting, as nurses, PAs and other staff would be both taking and charting vitals, lab results, etc. He finds increased compensation for primary care over specialized care to be “naïve,” and “somewhat insulting.” As a specialist, he is understandably sensitive to the legitimate need for specialists. But as such, he has limited experience with the current US system’s “only pay for crises” incentive structure (it should be noted that the Doctor’s group practice does accept payment by most major insurance companies). And lastly, national health insurance might be “humane,” but it would not reduce the cost of health insurance (see above). All three are the “wrong birds.”
So, what does Dr. Shragg consider the “right bird?”
Dr. Shragg describes a 92-year old patient suffering a variety of late-stage ailments; renal failure, stroke and mild dementia among others. Her treatment included oxygen, consultation with a nephrology specialist, in-patient intensive care and dialysis. This is Dr. Shragg’s identified “bird.”
“If you wanted to eliminate the costs associated with that patient's treatment, you would have to empower somebody to deny the care she and her family desired. To borrow a popular expression, the elephant in the room that nobody addresses is the ‘R word:’ rationing.”
The US healthcare conversation is still ongoing, and no consensus has been reached, so it cannot be said if Dr. Shragg expresses the mainstream. But the Doctor’s does demonstrate something particular to US healthcare; commodification. Doctor Shragg’s access points to the issue are remuneration and funding--who is getting paid and who is paying them. In this dialectic, healthcare is a consumable--something to be bought and sold.
Every western nation currently has a national approach to healthcare, ranging from the single-payer/single provider (UK) to nationally regulated private-sector insurance with multiple providers (DE).
US focus on healthcare has only recently expanded beyond academia and industry, while many other nations are already at a “Phase 2” stage of revising a chosen healthcare architecture. In none of these nations is finance any longer a barrier to service. Citizens of the UK do not think about “health insurance.” They have “The National Health Service,” and like the Postal Service, it is expected and committed to deliver to everyone.
In none of these other nations is healthcare thought of as a commodity available only to those possessing adequate resources. They have already decided the question “who gets care?” with “Everyone.” Now they are working on the questions of access, of economies of scale and of quality of patient experience.
Canadian healthcare is one of the more mixed-bags of solutions. While healthcare is nationally defined as a basic right of all residents, its management is the responsibility of the Provinces; thus, there is Alberta Health Services, the Ontario Ministry of Health and the Ministry of Health of British Columbia, among others. Each Province has pursued its own solutions to healthcare. In Alberta, there is a single central authority (at present) that directly oversees each discrete facility. Ontario operates with a mix of state and private insurance, with regulated drug prices far below those in the states. The models in Canada, and the changes in these models are many and varied. As Canada successfully delivers on a national commitment to healthcare for all, the ways of managing delivery, access, quality of care, breadth of care and, yes, cost are always evolving.
This example of one nation successfully implementing a variety of solutions could serve as a valuable resource to the US in developing its own solutions. The US has a free-market hodgepodge of healthcare methods; state and local facilities and services; not-for-profit clinics; private practice and public-service doctors, and; insurances of all sorts. The successful mix of many Canadian models could quickly shorten the US learning curve. But to benefit from the Canadian example---or the French or the Swiss or the German--would still require a shift in US thinking. Other nations manage to deliver medicine and care to all of their people because they hold healthcare as a “must,” not a “maybe.”
Dr. Shragg writes of healthcare as something to be bought or “maybe” given as charity. His is not the only voice to lament the cost of late-stage care; but the US is the only nation to consider first and foremost the cost of care. If the US is to make a national effort (and to date the only national efforts have been the regulation of healthcare products--drug and device approval and patents and licensing), a true commitment by the nation must be made---to the nation.

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