Sunday, July 4, 2010

Differences of Opinion (Part 1?)

As a member of the American Academy of Family Physicians, there are a number of listserves I can track.  I'm transcribing an exchange between me and other physicians because I think it's interesting to see how far apart docs are regarding the best way to provide health care to all those who need it and whether or not health care should be a accessible to all.  Dr. L's comments started the discussion which ensued between me and Dr. S.  I don't think either of these physicians are bad people; in fact, I know that one of the two is a dedicated supporter of family medicine and primary care.  It is striking to me, though, how differently we see the world.


Dr. L:

For me the real issue is that everyone counts on someone else paying for health care.
Healthcare is not a right. We all have the right to be as healthy as when we were born.
I know I will get tons of replies grilling me for that stance, but so be it.
As an immigrant, I am concerned that in the greatest nation in the world we have so many rights and entitlements, and NOT A SINGLE DUTY.  And now we want to add healthcare as a right!
Healthcare is a privilege like driving is a privilege. Could you imagine if driving was a right?  I could be as drunk as I wanted and get in a car and crash into anyone regardless of consequences, because it is a right?
Most of the cost of healthcare is for chronic  and preventable diseases and the morbidities that it brings. Most of these issues could be prevented by better choices and better public policy. But I am a doctor, not a policy maker.
I embrace freedom of choice. But why should I pay for the consequences of your freedom to be irresponsible?
I was raised with simple values, one of which is “be responsible for your actions”
The central issue is that there is no Personal Responsibility, and then the masses want someone else to fix the problem.

Dr. S:

OORAH!  Well said, Dr. L!  We must all admit the truth here!! Health care is a privelege, NOT a right! 
Again, I will come out of 'hiding' and say what I think a lot of us here realize probably has to happen. GET THE GOVERNMENT OUT OF HEALTH CARE. It is the only real way for any reform to occur. This whole thing is going to be bad no matter what we do, but it will only get worse if we go toward more government regulation(e.g., single payor system, Obamacare, etc...). At least if people are given back the responsibility for their own health care, then they can realize that they have more choices to make (hopefully healthy choices).  Again, thank you for saying this.


Dr. S:

Just asking: if you end govt roles in health insurance

--how do you propose the poorest in our nation access care?

--how would you prevent private insurers from continuing their regressive policies?

Dr. S:

Dear Dr. R,
It depends on how much of the 'government' you get out of health care. Here would be some starting thoughts (and these are rudimentary, by the way):
If we still require public institutions to not turn away anyone for care, then the poor will continue to access these facilities as they do now. This, in my opinion, is the 'myth' of access to care that everyone seems to believe. EVERYONE in this country, including those who are not even citizens, cannot, by law, be denied access to care and at least a screening physical exam in a public facility. 
If we eliminate Medicare and Medicaid, then I would hope that we eliminate their pay system as well. In which case, we would then have the potential for a true 'free market,' and I would think that if hospitals, health care providers, etc...  didn't have to have as much administrative costs, then we would already be able to offer care at a lower rate (or even at what Medicare and Medicaid reimburse now). Their would be competition for patients that would take the form of price reductions - this already happens with 'elective' procedures, such as LASIK, for example.  It would take a little time, but one would logically think that health insurance companies would have to lower their rates or be priced out of the market by individuals being able to get their care for less money than what they pay for their health insurance premiums. 
What about health care consortiums? I know of some groups of people agree to pool their money to pay for everyone in the group - I think one is called the Christian Health Care Alliance(?) 
If you take a look at history, you will note that the Church set up many hospitals all over the country to take care of the poor. Why not allow them to do this again?? 
Could we incentivize people to practice good health habits?? For example, could we pay people to lose weight (sort of like the "Biggest Loser" competition?).  Could we somehow incentivize people to stop smoking or drinking, or doing drugs?  This could be positive incentivization or negative incentivization -- I would even be so bold as to say that if we are going to deny care to anyone, the first group to be denied care would be known alcoholics, known drug addicts, and even smokers. That would certainly make them at least consider changing their behavior. 
I once asked one of my attendings during residency who practiced before 1964 (before Medicare and Medicaid)  in a major metropolitan area (>300,000 people) how the poor and disadvantaged got care at that time. He said that in the city hospital, there was a "City Ward" where these people were cared for, and the doctors on staff in that community rotated through the service to care for these people. Why can't we do something like this for the poor and disadvantaged?  
It's true, we will always have the poor -- but isn't there a way to incentivize people to NOT be poor?? If America is truly the land of opportunity, then this would certainly be possible. 
Much of this depends upon the individual person's sense of responsibility, civic duty to his/her country, and living up to our motto of  "In God We Trust."  Maybe it's time the citizens of this country took these matters into their own hands, instead of giving this responsibility to the government. 
It has taken us 46 years to get to this point -- how can we expect to reform it in 46 months, or even 46 days?? 
This situation is going to be bad either way (whether we have more governmental intervention or less) - I submit to you and to all of my collegues on this list serve that if we get the government out of medicine, it will be bad for a shorter period of time as the market rights itself, than if we allow more government intervention into health care -- my belief is that this new system will probably be really good for about the first 10 years or so, and then it will become corrupted (just like Medicare and Medicaid already have), and then we will be paying higher and higher taxes, and getting essentially NOTHING for it. AND giving up more and more of our freedoms as the price - something one cannot even place a price tag on is freedom.  
Stuff that I believe we ALL need to be seriously thinking about right now as this whole mess of "Obamacare" that has been forced upon us by a minority of elitists presumably goes into effect.
Respectfully and in the spirit of compassionate care for our patients as a fellow Family Physician,


Dear Dr. S;

I agree with some of your points.  Providing incentives for people to follow healthy lifestyles can be beneficial, but must be carefully structured to make sure that the opportunities are open to all.  People living in poor or underprivileged neighborhoods may not have valid access to safe places to exercise, healthy foods, etc.  This is a society-level issue, and one that must be accounted for if we intend to incentivize healthy choices.

Incentivizing people not to be poor sounds nice.  Haven't yet met someone who hoped to remain poor.  If/when you have an idea how to do that, please let me know.  I work in communities where structural poverty is a fact of life and no simple answers will work.  Again, making changes to this are a major society-level challenge that will be very difficult to enact. 

If we thought health care reform was a tough fight, imagine what will happen if we try to enact reform to encourage the healthy living programs and the economic empowerment programs that would be necessary to effect the changes you propose.

In terms of your contention that all Americans are entitled to access to some sort of medical evaluation (I presume you mean the ER); you have to admit that that is irrelevant.  Just because an ER can't turn me away doesn't mean I will get the care I truly need (and we know I won't get the chronic care I need), that I'll be able to afford the care, that medical costs will be managed in some responsible way, or that having this "access" provides any benefit to anyone (unless I am truly facing a life-threatening emergency).

Unlike you, I have great qualms about entrusting the health of our most vulnerable citizens to faith-based organizations.  I do not argue that faith-based or church-based hospitals have provided a great deal of valuable care, but they do so only within the confines of their religious missions.  If an uninsured woman presents to a Catholic hospital requesting help with contraception, she will have no access and she will have to find other options.  In Virginia she could go to the public health department, but (under your structure) this sort of government program would be de-emphasized.  Do you not have concerns about what would happened if a patient of one faith was forced to access care in another faith's hospital?  Although in many cases belief might not affect care, there will be cases where this would be an issue.  What if a Christian Science health care center opened focusing on healthy living but not using medications or medical technology? Would we, as physicians, feel this is the best option?  What about treating illnesses that have social elements (HIV, STDs, etc)?  Would faith-based systems be able to exclude those conditions?  If not, how would we prevent it?  Govt regulations?

Health care consortia are also very concerning to me.  Would these consortia be allowed to set rules as to who they will pay for, and for what procedures?  If so, how would this be controlled/regulated?  Should we simply trust to their better natures?

The free market rules do not really apply to health care.  Free markets, to my understanding, really only work when both sides of a transaction are free to walk away from the deal or to argue or negotiate for better options.  This is not the case in medicine.  True, for some purely elective care this might work.  But what about acute care?  Urgent interventions?  Trauma?  Should we expect to negotiate the prices of a CABG, maybe 3 vessels for the price of 2?  The current free-market portion of our health care system has brought us pre-existing conditions and rescission.  How would you propose this be stopped?  Also, what about communities where there is no health care competition (such as 1 hospital, 1 pulmonologist, 1 endoscopist, etc)?

Unless we think we'd be able to drop the costs of health care interventions to levels easily affordable by even the poorest in our nation, then patients will require health insurance.  Without significant oversight and regulation (such as that incorporated into the Accountable Care Act), private insurers will fall back in their recessive ways.  Remember, Blue Cross/Blue Shield started as non-profit insurers, and then morphed into Anthem and then WellPoint courtesy of the free market.  Do you feel this has really benefited patients?

You speak about the corruption of Medicare and Medicaid.  Do you really believe that private payers do not have their own motives and their own "corruption"?  Private companies are only answerable to shareholders and board members.  Is this really better than having (at least on paper) a public accountability?

Virgina, to my knowledge, has no public hospitals.  Your idea of forming a "city ward" in a city hospital would require establishing an entirely new govt hospital.  Is this really what you propose?  If so, how is this really better than current govt programs?  Will we provide a govt outpatient clinic, too, in order to provide the follow-up car?  Or are these hospitalized patients (with some bill of some sort due as a result of their inpatient stay) supposed to negotiate with private providers and shop around for the best price for their post-hospital visit?  Or will the same city hospital provide the outpatient care in the same rotating system?  And how would you get the providers for the city hospital?  If the city hospital is added to the private hospitals in a given community, why would providers choose to provide care (unless they did so out of humanistic ideals)?  Would the humanistic volunteers be sufficient?  If providers were required to provide care at a public hospital as a condition of practice or licensure, would we prefer this to choosing whether or not to accept Medicare/Medicaid?

I am not a huge fan of the current Accountable Care Act, largely b/c it underwrites a dysfunctional private insurance system without enough recourse to universal access to true, meaningful, evidence-based, chronic disease care and preventive care.  But, this was what the political climate allowed.  Under this law's conditions, insurance company abuses are directly addressed and all citizens will have access to insurance coverage that will allow access to needed services.  Indeed this insurance is required by the law's individual mandate, and the costs of the coverage is subsidized for those who cannot afford it.  (And individual mandates are necessary to ensure that costs are truly shared across everyone, and not shifted towards the public programs or shifted onto those who have private health insurance).  Small business tax credits will help extend the employer-based system we currently have.  I'm not saying this is the best system, but these reforms seek to improve the system we have.

Asking people to live up to their civic duty and their personal responsibility is fair, but as a nation we must make sure that the potential benefits of doing so are really available to all.  I challenge those who support this position to explain how to make sure this is really the case.

I know that all of us will continue to provide the best care to our patients, and to do right by the person we are working with.  It is when we try to determine the national policy that best allows this that we tend to separate in our opinions.  Still, I am glad that we are able to have a free and open discussion about this.


Dr. S:

Dear Dr. R,
Thanks very much for your thoughtful reply. It is these sorts of conversations that I hope to have on this subject - I truly believe they are meaningful if any sort of reform is to occur. I just have a few minutes here, so I want to reply to a couple of your concerns:
I want to say that anybody that comes into the ER gets a basic medical evaluation because I worked ER for four years, and I WAS the one who did the evaluation - this was in rural ER's where I was the contract doc on call, and there was no mid-level coverage.  I also worked in a major city hospital ER as the 'pit boss' overseeing at least one PA - again, everybody got a basic evaluation and at least the emergent care they needed.
I agree that chronic care is very much needed by patients, but in my opinion, there are some of what I would call 'major categories' of patients that come into an ER (and arguably, that come into my office even at the present time): 1 - those who want care, but really don't need it, 2- those who need care, but really don't want it -- or really don't want the care that we deem they need, and 3 - those who need care and want what we can provide. Yes, these are arbitrary distinctions, but my point is that the term 'access to care' is really more complex than I feel we make it out to be.
My question to you (and anybody else that may be reading on this list-serve) regarding allowing so-called 'faith - based' organizations to provide care is:  we are already having problems with entrusting the care of our most vulnerable citizens (BTW, how do you define who our most 'vulnerable' citizens are?) to the government  -- would we do much worse to let these organizations have a try at it??? If nothing else, these organizations could ease the burden on the public facilities, such that people would then have more of a 'choice' as to where they feel comfortable getting their indigent care.  I mean, what about the Shriner hospitals??? With respect to these organizations, it would be implicit that physicians, nurses, support staff, etc... would be donating their time or at least agreeing to take a lower pay scale to care for these patients. 
By stating that I would want to incentivize the poor 'not to be poor,' I'm not implying that there are people who hope to be poor (however, the nuns and Mennonites I have met have in effect chosen this lifestyle). These people are often poor because of the choices they have made, or choices that their significant others have made (or not made) -- or quite commonly, because of mental illness.
Just some starting thoughts... more to come.


Dr. S;

To continue our previous conversation--

I agree that "access to care" is a fairly general term, but this is the way all of us look at our health insurance.  Can I see the doctor I want to see?  Can I get in to a physician if I don't feel well?  Can I get the tests my doctor recommends, and the medications he prescribes?  As you know, your 3 categories of patients exist in all communities--insured, well-off, poor, Medicaid, etc.  It would be more cost effective (and maybe easier to support) if we agreed to provide health care for those who *really* need it (those having an MI, appendicitis, pneumonia, etc).  But as we know, we really can't discriminate well as to who is SICK and who isn't when people first present.  Why shouldn't it be possible for all of us (poor, wealthy, in-between) to be able to get care when needed?  I suspect that the ER screening exam isn't free, so even this "guaranteed" care is not really (affordably, sustainably) available for many in the US.

I also realize that "vulnerable populations" is a vague phrase.  Insert your choice: poor, disabled, chronically ill, economically marginalized, etc.  In some conceptions of reforming health care that emphasize the free market, none of these population categories are accounted for.  We are all supposed to sink or swim in the market of free competition.  I foresee a lot of sinking.

Regarding enrolling faith-based organizations in providing health care, my main issue is how you would ensure that these organizations provide PATIENT-centered care, regardless of the organization's agenda.  As I noted earlier, Catholic health systems (at least in the Richmond, VA area) do not support or provide any contraceptive procedures, medications, etc.  Other denominations and faiths would likely have other restrictions.  How would this be avoided if these organizations are to be the new safety net once gov't services are gone?  The Shriner's programs are wonderful, but are not really in the same category.  Shriner's Hospitals provide orthopedic, burn, SCI and cleft lip and palate care for children; areas where any denomination or faith would be on the same page as being a good thing.  Also, the Shriners are a fraternal organization, not a religious organization.  Maybe a Rotary Club hospital or a Lions Club vision hospital would be more comparable to the Shriners.  Finally--we have already seen private faith-based charitable organizations try to opt-out of federal laws requiring equal and fair hiring.  A few years ago, the Salvation Army asked to be exempted from federal laws requiring fair hiring (they didn't want to hire gay or lesbian employees) but wanted to keep receiving federal funds under the Bush administration's faith-based initiatives.  Faith-based hospitals or clinical systems might seek similar exemptions to avoid providing services inconsistent with their beliefs. 


Dr. S:

Dear Dr.R,
Thanks for the reply. I'm on call, so only have a few minutes, but I want to hone in on a couple of concepts you presented, and hopefully not get on an unproductive tangent...
1. What is the difference between 'triage' and 'discrimination' in the context of healthcare?? I mean, one draws an intellectual (if not philosophical) line when we are determining who is sick, and needs emergent medical care, and those who are not 'ill' and really don't need the care that they think they need... i.e., the alcoholic who is not physically ill enough to need inpatient treatment for DT's, but who desperately needs treatment for his/her anxiety disorder, and frankly doesn't want it??
2. The term "patient-centered" care needs to be 'fleshed out' here -- some of this will depend upon one's (both the patient's and the physician's)  'world view,' but I would maintain that if so-called 'faith - based' orgainizations held as their rule to treat or not treat a certain kind of condition in a certain way that is consistent with their 'mission statement, or bylaws' then they would certainly be free to do so. There are already biases in our current health care system anyway - you could argue this to the moon. It's still a free country (thank God).  You are also touching on a huge issue with contraceptive services - I agree that it should be patient - centered, but I am also implying here that this would include adequate education of the patient with respect to ALL available choices, including non-hormonal therapies, and non-abortifacient methods, etc... Again, a potential HUGE tangent, but there are many more than these.
3. I appreciate your further analysis of the 'vulnerable populations' -- my next question would be "vulnerable to what??" Alternative medicine? Alternative beliefs? What about appropriate treatment, and a caring atmosphere that maybe some of them (particularly the children) have not as yet experienced? Just being in our American society and pop culture, these people are already vulnerable to very damaging behaviors being represented in the media - is exposing them to a Catholic (or Protestant, or Jewish) hospital that much more damaging than what probably many of them have already seen?? I'm not sure what the answer in all cases is here, but I trained in a Catholic Hospital, and I certainly felt that the care was of the highest quality and the atmosphere was most certainly a caring one - and certainly at par with the University Hospital, VA Hospital, IHS hospital, and community hospitals in which I had worked as a medical student and in practice. 
Anyway, some more thoughts....


Dear Dr. S;

Happy 4th of July!  I hope you have a quiet, enjoyable day.

To address your most recent comments:

--To me the issue between "discrimination" and "triage" in health care is an apple/oranges proposition.  I think we would all agree that "triage" is a process by which we decide who is ill and needs care, and who will benefit from our care.  In the ER, this would come down to determining who needs care urgently and who can be put lower on the list of priorities.  Of course, as you point out, the ER has to provide care regardless of what the triage process determines.  I would argue "discrimination" is a different issue altogether.  In the context of accessing health care, discrimination would involve keeping those who desire access from gaining access to the system for purpose of evaluation, diagnosis and treatment.  I agree that many people who seek care do not (in our estimation) really need it. But how often are somatic complaints part of a psychiatric issue?  How often are chronic problems found when addressing acute issues?  Do not acute visits allow us opportunities to address chronic problems (such as addressing smoking in the context of a URI visit)?  Why should 85% of us have such opportunities and 15% of us (the uninsured) be denied?  Ideally, our health care system should allow all of us to access at least screening services, but also have affordable and *real* access to care if needed.

--I agree that faith-based health care systems can be very valuable to many, and particularly to patients who share a similar world view.  However, in your suggestion, these faith-based systems would largely take the place of of government-provided care.  This will lock patients in to faith-based systems--with which they may not agree.  Would you agree, for example, if an Islamic health care system set up a health care center providing care to the indigent/uninsured but required that men and women be kept fully separate and only be cared for by providers of the same gender?  I realize this is an extreme example (implying, as it does, that Islamic-oriented health care centers would be organized on conservative principles).  Should non-Catholic patients be required to access care in Catholic systems and accept the restrictions the Catholic Church places on providers?  I feel it is better to ensure that patients could access providers of their choice, something that Medicare and Medicaid already allow to a large extent (though I realize many providers do not participate in these programs), and that the Accountable Care Act will promote through allowing affordable health care coverage.  If patients have health insurance, they can find providers that share their "world view" to the extent that such providers are present.

--By "vulnerable populations", I would further clarify with the phrase "economically vulnerable"--patients who do not have the income or resources to freely pay for care on their own and who currently need to access it by means of government programs (or avoid accessing care at all).  I would also include communities that typically have been on the short end of health disparities.  These 2 descriptors will often overlap and, to me, any reform we implement needs to look at hair we can create a more just and fair system for these groups.


This discussion has been going on for about a week now, and I'm going to take the author's prerogative to post it as an "in-progress" conversation.  If/when Dr. S re-posts, I will post the further discussion that might ensue. 

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