Wednesday, January 26, 2011

Rant: How is American healthcare broken, let me count the ways.

Watching the State of the Union address got me thinking about all the ways the healthcare system in the US is, lets face it, FUBAR. This is from the perspective of a new physician in the field. The perspective of a new physician provides a fresh look at what is wrong with the system, though it also means my list is going to be shorter than that of a physician who has practiced for years. If you want to hear about what Scott Weingart, emergency physician/intensivist and founder of the blog EMcrit, thinks is the most pressing problem to be fixed in medicine then listen here:

I'll start on the same theme as Dr. Weingart.

#1. Medical malpractice and tort reform.  What is risk, and whose risk are we talking about?

The current state of the malpractice system in the US is a sorry state of affairs that any self respecting attorney should be ashamed of. Going into all the ways the tort system negatively affects the healthcare system, and thus hinders the ability of the system to provide quality care to patients, will have to wait for another blog post. 

The system is about money, not about malpractice. Lawyers know they can make money and have no risk by filing frivolous suits. In fact, its gotten to the point where hospital defense lawyers know exactly how much money it takes to go to court; if a claimant asks for less than that the hospital (and/or physician) coughs up the money. No questions asked. Cases that do go to trial are the ones where the claimant demands more money. Hospitals will always try to settle unless they are certain they can prevail in court, so the trials we do see are the ones that are often the most ridiculous. It doesn't stop there though, studies of malpractice suits have shown that who prevails in a suit and how much money is awarded is not correlated with the merits of a case. Let me say that another way. It does matter one bit who is right or wrong in a trial to determine who receives judgement. So what matters? How sorry the jury feels for the claimant. And its not only the hospitals and physicians that pay, its all consumers of healthcare. Lets take an example of a recent tort case in Florida: a patient arrived at a hospital after being involved in a serious motor vehicle accident. The patient was in shock and dying on the table. The physician who took care of her was renowned in Florida for being one of the most progressive and aggressive trauma specialists in the state. He had saved the lives of thousands of trauma victims in his career. So what did he do that was so wrong in this case that resulted in him and the hospital getting sued for 20 million dollars, him getting a permanent black mark on his record, and subsequently leaving the state depriving the people of Florida of the services of this amazing physician? He did his job. He saved the woman's life. There is no debate that if he hadn't tried as hard as he did, or if he hadn't been as good of a physician, that he never would have ended up in court. In the end, the woman required massive transfusions and aggressive shock treatment to survive. Do to the amount of blood she lost she was unable to pump blood to her extremities and subsequently lost both of her feet and her arms below the elbows. But she lived. And since she, and her lawyer, could not sue God, they did the next best thing.

Okay, so its easy to see how this drives up costs for all of us and creates a harsh working environment for physicians. Its also easy to understand why physicians practice what is called "defensive medicine", the practice of ordering test after test to attempt to eliminate risk of missing a diagnosis, often without regard to costs or to the risks associated with the diagnostic procedure themselves (e.g. its better to CT scan a baby to make sure you don't miss that .001% chance of a head bleed that is clinically occult than to worry about the 2% chance of future cancer associated with scanning a young patient). What isn't easy to see is how the system hamstrings the advancement of clinical research in the United States. In fact, very little cutting edge clinical research is currently done in the US. Most of it is done in Europe where researchers can examine best practices without having to worry about getting sued for trying to do what is best for their patients. Very little outcome data is collect here, and as a result we have little understanding of which of our daily clinical practices are any better than the others. How are we to cut costs, how are we to decide which practices help our patients and which hurt, when we can't even do the trials because we are so afraid of medical-legal risk? And don't get me started on how phony malpractice claims effect malpractice insurance for OB/Gyn and emergency physicians. Suffice to say, the fact that you can not find an OB/Gyn to deliver a high risk infant in many southern states speaks for itself. If we create an environment so hostile that physicians go elsewhere, then who will remain to care for the sick? As many southern states are finding out, no one will. 

I really must agree with Dr. Weingart here. Mistakes and malpractice are not the same thing. One is preventable, the other is not. One should be punished, the other should be minimized. If patients, and malpractice lawyers, truly want to decrease malpractice and increase "best practice" of medicine then liability as we think of it today should not exist. 

#2. Privately funded medical education. Almost all civilized countries have publicly funded medical education systems, we're the exception. The result? Massive debt my medical students and young physicians creates an environment where most physicians don't go into the black until middle age. Lots of problems associated with that, from burn out to billing practices to salary expectations.  

#3. Our current method of residency training. Its long, its inefficient. It treats young physicians as slave labor, forcing them to work long hours (longer than is safe) for very little pay. Some of the most highly skilled and educated surgeons in the world could make more money working at McDonalds. Get rid of the abusive training system and you'll have a happier and safer workforce. 

#4. Failure to standardize education. 100 years ago we saw the problem with having a lack of standardized scopes of practice. Now we have a plethora of grey areas where non physicians providers practice. The results of this haphazard system are just as bad for our patients as it was 100 years ago. Whats the kicker? Originally begun to save money, studies show that non physician providers actually cost the system more. Go figure. 

#5. Middlemen. They are everywhere. Insurance company overheads, government inefficiency. Its all waste that does nothing to better healthcare yet sucks dollars out of the system and contributes to the massive healthcare debt in this country. 

#6. Medicare. Ask anyone in medicine and they'll tell you its broken. Its not even a debate. Yet we're all so afraid to do anything about it. Medicare (and even worse, Medicaid) pays less than costs for most procedures, so the loss has to be made up by overcharging paying patients (e.g. non Medicare patients). Private insurance companies wonder why they should pay for procedures when the government doesn't; good question. Now, lots of them aren't paying either. The result, some physicians close their practice, some charge their insured patients higher and higher rates, and others simply opt out of the Medicare system all together and take only privately insured and cash patients. 

A recent publication in a prominent medical journal illustrates how some physicians are finding the only way to practice medicine the way they want is to refuse Medicare/Medicaid all together. A California physician found that when he opted out of Medicare/Medicaid he no longer needed to employ 3 medical coders and his overhead costs were reduced by 200%. By taking only privately insured and cash patients he was able to double his revenue stream. He posts the costs of every test and procedure in his office waiting lounge so patients know exactly how much everything costs. This helps them decide which elective tests are really needed. Patient satisfaction also soared, he was able to spend an hour with each patient instead of the 10 minutes he was forced to see patients with under Medicare. Word got out about his clinic and he started to draw patients who would pay cash rather than be forced to endure another 10 minute Medicare funded evaluation. He opened up his Friday's to patient's as a free clinic so he could see patients who couldn't afford him or didn't have insurance. The end result was better job satisfaction, better physician income, lower patient costs, and much higher levels of patient satisfaction. All without Medicare. 

#7. Direct to consumer advertising by pharmaceutical companies. Not only does 20% of the costs of your medications go allowing pharma to place advertisements for you to watch during Oprah commercials, but the truth about a lot of on patent medications is that most patients don't need them. Yes, thats right, the inexpensive generic medications work just as well for most patients. Try to tell that to the patient who comes into the office demanding the newest drug they just saw on TV and an argument is sure to ensue. Most physicians just give up and write the prescriptions their patients ask for, even if they'd be served just as well by a generic. Not only is it not good for patients, but they pay extra for the privilege. Only in America...

#8. "Empowered" patients and an emphasis on autonomy over physician judgement and beneficence. More on this later, but suffice to say many patients make bad choices and their physicians fail to dissuade them otherwise because our society is afraid of physicians making choices for them. Medicine, like the other profession (law), requires years and years of study to fully understand, the very reason we seek out medical advice from physicians is because they have special knowledge and we want their opinions.

In a similar vein, I can't even recall the number of times family members have requested physicians take extraordinary measures for their parents (child, spouse, whatever). No one wants to think that they didn't do everything possible, but spending large amounts of money, prolonging pain and suffering, and in some cases causing harm with inappropriate testing (*cough* please, please just scan my child*cough*please give my kid an antibiotic for this viral infections*cough*please my 91 year old mother with 13 medical comorbidities will get better after this 15th hospitalization*cough*) will only increase how much of our GDP we spend on healthcare and won't get us any better results. Physicians know the down side of inappropriate tests, medications, and procedures; they need to grow some backbone and stand up to demanding patients who ask for inappropriate care. 

#9. Lack of individual responsibility. A large proportion of medical expenses are spent on treating illnesses associated with lifestyle choices of Americans. Obesity, sloth, and the usual "vices" take a toll on the human body; the medical system expends vast amounts of resources trying to fix years of bad lifestyle choices when they could easily be prevented from occurring in the first place. In spite of this our healthcare system manages to keep us alive longer and longer, at greater and greater cost.

#10. Fragmented care of uneven quality. American healthcare was once aptly described as pockets of absolute excellence surrounded by vast areas of suboptimal care. We need to implement best practices in a standardized system everywhere in the US, not just at big academic institutions or cutting edge private clinics. We need to get rid of the barriers (financial, medical-legal, etc.) that keep physicians from practicing in less desirable parts of the nation and get rid of incentives that encourage doing more for patients over doing what is best for our patients. 

I'm ending this artificially short list here, it could go on and on. But lets be honest, its already depressing enough at #10, and who wants to keep reading?  

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