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    "When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov

    ''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.''
    -Robert Ehrlich, drug advertising executive.

    "Opinions are like sphincters, everyone has one." - Chris Rangel

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    Sunday, April 18, 2004

    Big Business: Big business is disillusioned with employer-provided healthcare:

    In the early 1990s, big business largely opposed Hillary Clinton's ill-conceived effort to establish a government-run universal health insurance plan. But over the past several years—and especially in the past year—large corporations, and the trade groups that speak for them, have been subtly changing their tune.

    One sector that's especially suffering is big healthcare corporations, such as HCA:

    This week, HCA, the nation's largest hospital company, unexpectedly lowered earnings estimates for the year by about 10 percent. The main reason: It had to set aside extra cash to deal with swelling numbers of uninsured patients who can't pay their bills. In the first quarter, HCA had to set aside 11.7 percent of its revenues of $5.9 billion for bad debts, up from 8.1 percent the year before.

    .....HCA CEO Jack Bovender came close to calling for a single-payer system, though he still couldn't utter the phrase "socialized medicine." "Hospitals have become the ultimate safety net for health care services for the vast majority of America's more than 44 million uninsured," he said. "It is time for all sectors of society, both public and private, health care and non-health care, to participate in solving this societal issue, by providing affordable health insurance for all Americans and more equitably sharing this growing cost to society."

    This is a meme that's spreading throughout the hospital management sector. The CEO's of the three major hospitals in our city have all gone on record with similar statements. And here's another from Massachussetts:

     Polanowicz sees the root of the problem in the explosive increase in the number of our citizens with no health insurance, or with high-deductible insurance not adequate to their needs. There are now about 600,000 men, women and children in Massachusetts without health insurance, up more than 30 percent in just the last couple of years.

    ...As for a possible solution, the Marlborough Hospital CEO can only argue at this time for a somewhat nebulous conference or coalition between insurance carriers, multi-national pharmaceutical companies, healthcare providers, hospitals, patients and community leaders -- perhaps under the direction of Gov. Romney or his designee.

    These guys better be careful what they wish for. They just might get it.

    Speaking of Hillary: I can no longer remember all the details of the original Hillary Clinton Healthcare plan. But, some of the ideas in her Sunday Magazine article are a little, um, half-baked:

    The likes of SARS can travel quickly from Hong Kong to Toronto, and news of a strange flu in Asia worries us in New York. Welcome to the world without borders.

    The Pulitzer Prize-winning science writer Laurie Garrett has described it as ''payback for decades of shunning the desperate health needs of the poor world.'' No matter the blame, the need to act now to address issues of global health is no longer just a moral imperative; it is self-interest.

    Except that SARS wasn't a disease of poor people. It disproportionately affected healthcare workers. It was spread globally by affluent travellers. And it did its worse damage in countries with the sort of healthcare systems that Senator Clinton prefers to ours -like Canada and China and Singapore.

    If we as individuals are responsible for keeping our own passports, 401(k) and tax files, educational histories and virtually every other document of our lives, then surely we can be responsible for keeping, or at least sharing custody of, our medical records. Studies have shown that when patients have a greater stake in their own care, they make better choices.

    Many of my patients can't be relied on to keep track of something as simple as their immunization records. (Oh, we lost them when we moved.) I certainly am not going to trust them to keep their entire medical record. I'm willing to share it with them by giving them copies of it if they want, but since I have to rely on that record to both do my job and to protect myself against lawsuits, I'm certainly not going to give it over to someone else to keep.

    We should adopt the model of a ''personal health record'' controlled by the patient, who could use it not only to access the latest reliable health information on the Internet but also to record weight and blood sugar and to receive daily reminders to take asthma or cholesterol medication.

    What's stopping people from doing that now?

    Moreover, our current system revolves around ''cases'' rather than patients. Reimbursements are based on ''episodes of treatment'' rather than on a broader consideration of a patient's well-being. Thus it rewards the treatment of discrete diseases and injuries rather than keeping the patient alive and healthy.

    News flash. "Episodes of treatment" keep patients alive and healthy. It's "episodes of treatment" that prevent pneumonia from becoming fatal, that rescue the heart attack victim, that keep blood pressure under control with medication, that keep diabetes under coutrol...Well, you get the idea.

    The structure of the health care system should shift toward rewarding doctors and health plans that treat patients with their long-term health needs in mind and rewarding patients who make sensible decisions about maintaining their own health.

    That was the idea behind HMO's. Doctors were paid a set fee per patient, the idea being that they would keep the patients healthy and thus out of the office. It didn't work. People get old, they get sick. We've made great advances in treating and preventing infectious diseases, and in treating some chronic diseases such as hypertension and emphysema and diabetes. But, in the end, the diseases still win, eventually, because we can't halt their progression. We can only slow it.

    A government study recently documented that it takes 17 years from the time of a new medical discovery to the time clinicians actually incorporate that discovery into their practice at the bedside. Why not 17 seconds?

    Because it takes more than 17 seconds to determine the clinical worth of a new medical discovery. If we adopted every new finding that was hailed in the media within even a day of it appearing in the newspapers, we'd all be dead and/or broke within weeks.

    Computers could crunch the variables on a particular patient's medical history, constantly update the algorithms with the latest scientific evidence and put that information at the clinician's fingertips at the point of care.

    Ah, now. There's the solution to the high cost of healthcare. Replace doctors and nurses with robots.

    It comes down to individual responsibility reinforced by national policy.

    Translation: From where you live to what you eat, we'll tell you what you can and can't do - for your own good and the good of all of our nation.

    We should also be looking at sprawl -- talking about the way we design our neighborhoods and schools and about our shrinking supply of safe, usable outdoor space -- and how that contributes to asthma, stress and obesity. We should follow the example of the European Union and start testing the chemicals we use every day and not wait until we have a rash of birth defects or cancers on our hands before taking action. And we should look at factors in our society that lead to youth violence, substance abuse, depression and suicide and ultimately require insurance and treatment for mental health.

    That's a very expansive and far-reaching definition of what constitutes healthcare. It would be a very expensive proposition, with very little to gain in concrete health for money spent. But, that was the problem with Hillarycare from the beginning. Its reach exceeded its grasp.

    A Better Article: The Times piece on the individual insurance market is spot on, though. Speaking from personal experience, it's every bit as difficult as the article portrays it to get individual coverage - regardless of the insurance company. Forget about all the social engineering that Clinton would incorporate into healthcare. We could make significant strides if we just opened up the risk pools to include everyone:

    Ultimately, what is disturbing is not the idea of community rating but the idea that millions of people are denied the community rating now enjoyed by the vast majority of Americans -- a denial due only to the accident of where they are employed or to health woes that are largely accidents of birth.

    Allowing everyone access to the same risk pools would require mandatory health insurance coverage, but we live with mandatory car insurance and no one seems to mind. This makes the most sense. It would allow people to choose types of insurance coverage that suits their healthcare and financial needs the best, and it would allow more personal freedom in job choices. Our current system of corporate-driven heatlhcare is a system whose time has come and gone.

    posted by Sydney on 4/18/2004 10:42:00 PM 0 comments


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