Friday, May 19, 2006

My Diatribe

This is a continuation of where my story ends off as mentioned in my website (under "History" and "Practice Stories")

What I had seen, experienced, and read about during my years in college and medical school (in the 1990's) was the decline of the United States health care system over the past several decades. Although there were good intentions by all (physicians, government, health care administrators, insurance companies) to try to "fix" the system, we are now left with a fragmented health care system that does not effectively address the spiraling cost of health care. Symptoms of this ailing system are increasing health care costs and decreased access to care. What I believe are the major problems with this current system stem from four major factors. These are (in no particular order):

1. Over-specialization
2. Lack of focus for preventative care
3. Medical malpractice
4. Over-reliance of pharmaceuticals.
(I suspect at this point in the diatribe, there is going to be a lot of flaming going around).

Overspecialization limits access as patients usually have multiple health issues and no one specialist can address all of them in an effective manner. This is where a primary care physician can provide efficient care. Unfortunately, physician reimbursement schemes in the United States do not provide incentive to support primary care providers. In fact, it is driving down the number of providers, limiting access to care even further. Some of the evidence for this includes a decrease in matched residency positions for the primary care specialties reflected by a decrease in interest by medical students. There is also a decrease in active primary care providers due to burnout. A recent article from the American College of Physicians reported that unless there is a significant change in health care policy, we will see the collapse of primary care as we know it. I believe there there is too much emphasis on specialist care and not enough on holistic care. Don't get me wrong...specialists do play an important role and they must be compensated fairly but there must be some equality and fairness to the reimbursement scheme. If there is any serious effort to fix the decline of primary care, the reimbursement schemes must be adjusted to reflect that. Otherwise, it's all lip service. These schemes are developed and based on rules set up by Medicare (relative value units and such). Only through governmental change can this be trend be reversed. Unfortunately, I also believe that the US government has become inextricably linked to those with the money (special interest groups and lobbyists) that make it difficult for any such change to happen. But that's for another topic...

Lack of focus on prevenative medicine and services continues to be a sore spot. It's all talked about on the news, the medical journals, on TV, but there is nothing that indicates any significant policy change that suggests that we have turned the corner. For instance, it was only just in January, 2005 that Medicare had recently started covering for preventative care services, but even then, it is very limited in scope. However, preventiative services start at the beginning and that means children. The disheartening thing about our current health system is the increasing number of uninsured children. Where I work in the urgent care, I see so many children that could have had preventative services and adequate management of chronic illnesses such as asthma so that they could avoid a major hospital bill. I see frightened families who are unable to afford basic medical care and only until they are near death's door do they go to the hospital in desperation. The cost of desperate care is always more than the cost of prevention. To remedy this, there must be incentives to place a higher value on prevention (or even have coverage) by the payer, whoever it may be.

Medical malpractice is also affecting access to care as physicians are under economic pressure and practice defensive medicine which both increase health care costs. When did this become a crisis? There are some that believe that doctors have become less trustworthy. There are some that believe that the medical malpractice insurance companies are inflating premiums that don't reflect the number of malpractice payments. I think its probably both. There is a perception by patients, and rightly so, that doctors are not as trustworthy and this goes back to the lack of a doctor-patient relationship. We try our best, but given the economic model of our current health care system, doctors are driven to see as many patients as possible in the limited time that we have. How can one possibly establish a meaningful relationship in 5 to 10 minutes? Unfortunately, that appears to be a norm rather than the exception in these times. When there are less primary care doctors available (see above), how can such a system survive? The only result is decreased access to care. Patients aren't able to be seen in a timely manner and when they do, they only spend a scant amount of time with their physician. No wonder patients are skeptical. If that were the case for car mechanics or any other service industry, I'd be fuming! It's no wonder that patients just resort to going to the emergency department because they can't see a doctor. This affects everyone because the costs of the ED visits just gets passed down to the ones who can pay. What that means is that for every uninsured person who receives essentially subsidized care, that subsidy is paid for by the insurance companies who then passes down that responsibility to those who can afford health insurance (businesses or individuals). Which leads us to the concept of increased cost.

The significant influence of the pharmaceutical industry cannot be denied. The amount of money that is poured into advertising as well as direct-to-patient marketing translates into spiraling costs of medications. The temptation by physicians the use the newest drugs further fuels the fire. Besides patient marketing, there is heavy physician marketing which further influences prescribing and treatment practices. There are few things about pharmaceuticals I have observed which I have no particular answers to. There are proponents from the pharmaceutical industry that say that the high cost of new medications come from the research costs. However, there is pretty good evidence that suggests that research only contributes to a smaller percentage of the product's cost and the majority goes into marketing. Big Pharma also states that most of the research, development, and production of the medications come from the United States; but from my own scanning of pharmaceuticals; the majority come from other countries when you read their "Made in" labels (i.e. UK, Canada, Japan, France, amongst the ones I've seen). Seems kinda fishy to me. What's even more of a travesty is that when I cross the border to Canada, there are equivalent medications (i.e. Zyrtec in the US) that are now over the counter and cost nearly 10 times less than the US equivalent ($4 as opposed to $40 for the same quantity!!). So when there are people who say that drugs coming from other countries besides the US do not stand up to the same rigorous testing and quality standards (i.e. the FDA), and therefore are inferior; or it takes more money in the US to develop and create these medications; all of these arguments are so hypocritical...especially when the drugs that are sold in the US (approved by the FDA) are made from these "different" countries. Furthermore, it makes no sense to me that the nonsedating antihistamines need to be so expensive and still need a prescription when the ones that are over the counter (like Benadryl) have serious side effects (sedation) that put patients in danger if they are not careful (driving). Can't help but feel puzzled by that either...

The take home message from all of this is that I think that there should be no "business in medicine". Health care should not be "for profit". That includes medicines, research, health care. To be "non-profit" doesn't mean that those in the health care field should not get paid. It means there there should not be any CEOs making billions of dollars in take-home pay or any participant in the health care delivery system (physicians, insurers, consultants, pharmaceutical companies, medical technologies, electronic medical record vendors or programmers) that think that there is a "killer" profit that will increase their stock options when they do anything health care related. I think that capitalism has run amok in the health care industry because it is so easy to take advantage of people willing to find that magic pill or treatment. The fact is, there should be no temptation in health care delivery because I believe it is unethical to tempt people with a treatment that they cannot necessarily get because they don't have enough money; unfortunately, health care in the US is all about the have and the have-nots. It's a cruel reality. We have a very ill medical delivery system and it's on life support. In subsequent posts, I'll be discussing more about what I've done as a solo family physician to "survive" on this broken system and what got me there in the first place.

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