Tackling the numbers problem

So let's say this nationalized health care comes to fruition, what would that look like? For starters, many more people have to be insured. We have a limited number of practitioners, so more must be recruited. There is no way to churn out that many physicians in a short amount of time, so the health care will then mostly be managed by nurse practitioners, physician assistants, nurse anesthetists, etc. Although this may be very cost effective and address the immediate need, everyone must admit there is some benefit to having someone who has gone through the rigors of medical school, residency, and possible fellowship to examine a medical illness. Coughs and colds are one thing, but what happens when the cough is because of a rare toxic exposure? It's fine to say that's rare and doesn't happen very often. The problem is when it's your mother and she's dying because her asbestos exposure turned into cancer which didn't get detected early enough. That doesn't mean we shouldn't insure people because we don't have enough doctors, what I'm saying is this plan is not addressing all the needs at this time.

While we're discussing resources, health care costs have "skyrocketed." Fifty years ago, current and cutting-edge technology did not exist, but we now have the capability to do amazing things - which can be expensive. The question is, how do we give cutting-edge care to everyone? When we instantly increase the number of people with access to care, we now have to decide how much care to give. If we gave everyone total care with access to everything at our disposal, there is no way we can fund it. It's simple budgetting. We're feeding a family of 4 on a certain income. Now we're feeding a family of 40 on the same income. You can see, that would be impossible.

So Obama is proposing ways to increase the income or decrease the expenditure. Obama is brokering deals with hospitals and services to try to reduce the cost of care. This is no different than what is occuring right now. The other way to increase income is to increase taxes. He has said he would not tax the middle class; he also said he wouldn't tax anyone making less than 250K annual income. However, his own treasure secretary Tim Ghentner has said they would not rule out increasing taxes on the middle class. With the sheer volume of people in this country (40 million uninsured) it would be difficult not to increase taxes across the board.

The other plan is to decrease expenditures. He has stated numerous times that he believes cost is due in large part to wasteful spending. He then blames physicians for taking out tonsils for allergies in order to make personal gain, or for ordering unneccessary tests for the same reason. A quick day in the life of a physician and you can see why tests are ordered.

A Doctor's Dilemma

For instance, a person comes into the emergency room for a fall where he hit his head 3 days ago. He states he had a brief headache which went away within the first day. He's been otherwise normal and without any medical illnesses. His neurologic exam is normal. Evidence based medicine would state that for post-concussive syndrome, a person can have a brief loss of consciousness and headache with vomitting in the first 24 hours of head trauma. After that point, if symptoms improve, the risk of a head bleed is very small and does not require further examinations. That would mean no further testing is required. We can observe the patient safely, and have him return if things get worse. What do we do instead? We order a head CT scan without contrast to rule out a head bleed because we are afraid of being sued. Why you ask? Because too many doctors have been sued for outrageous amounts of money and were either forced to settle or lost the suit because of an adverse outcome which was not affected by the doctor's decisions. Often, the jury will have pity on the patient and/or does not understand medicine enough to see that the physician followed accepted standards of care. Unexpected bad outcomes happen just as often as unexpected good outcomes. The percentage of head bleeds in this case are extremely rare, however, they are still possible. The less than 1% chance of a head bleed can put a hospital out of business and/or destroy the doctor's career and send his family rocketting to the poor house. For that reason, the doctor orders the CT scan to CYA (cover your a$$ets). This results in thousands of dollars in wasted resources for "defensive medicine."

The AMA has sought for years to place restrictions on the amount of money a person can sue for (tort reform). In addition, frivolous lawsuits are settled all the time to reduce the cost of a lengthy trial. Suing for millions, or settling out of court, even when the doctor is not at fault is commonplace, and drives up the cost of malpractice insurance, which is then passed on to the patients. Attempts for reform have been rejected many times by politicians. I myself have gone to Washington D.C. to speak with Diane Feinstein about this matter. Her response was "why, do you want another BMW?" Honest. (By the way, most physicians I know live modest lives. We don't go into this profession for the money.) So, who benefits from these trials? The person who gets the settlement, and the lawyers. What profession are most politicians? Lawyers. I do not discount that there may be legitimate wrongs that require compensation, but having a cap on the amount someone can sue for (as well as what they can sue for), and limits on lawyer fees, would greatly reduce the cost of health care.

I do not consider myself a greedy person. I drive a Corolla and live in an affordable apartment. Residents make 40-45K/ year and work 80-120 hours per week. We graduate with an average of 200k in student loans. However, Obama has proposed that a doctor pay money out of his or her own pocket if a patient ends up staying in the hospital too long or requiring additional treatment above and beyond a set "evidence based" care structure. (Now, who would establish the "evidence based care structure" I don't know, but I have a hunch it would be a government establishment.) I really don't have too much else to give out of my own pockets, and every single day a person is in the hospital is actually more work for the doctors and nurses, and exposes the patient to possible risk of infection. Needless to say, the goal is to get a patient out of the hospital as quickly as possible while still providing excellent care. I would personally prefer to not have to write a note on a person I didn't have to see in the hospital another day.

How else can we reduce costs? We have already seen that not everyone can see a specialist whenever they want. As it is, the wait time for an appointment with a specialist can be as long as 6 months. What happens when we add 40 million new insured patients? The answer is that the people have to wait, or they cannot see a specialist. It is simple supply and demand. A dermatologist can only see so many patients in one day. They are human also. What happens if the specialist is an oncologist for your mom's cancer? She has to wait, or not see the specialist. Cancer doesn't wait. She may not make it to the appointment. Obama has used the same argument for current health care. How is he suddenly going to have enough oncologists to see a potential 40 million new patients? There is no easy answer to this situation, but rushing a bill through congress will definately not help.

Finally, Obama has brought up this idea of "evidence based medicine." That means we don't do anything that is outside the realm of scientifically tested double blinded control trials that have a number needed to treat small enough to warrant the intervention. Sound complicated? What that means, is we need to have 2 groups. One group gets a pill, one group gets a placebo. They both don't know what group they're in, and the tester doesn't either. If it turns out the pill is better than placebo, and not too many people have to recieve the pill to benefit, then we do it. What does that mean for experimental drugs? It's not covered. What does that mean for drugs that can't be tested that way? For example, we can't test to see if a drug is teratogenic (harmful to an unborn baby) by giving the drug to one group and placebo to another. What if it is harmful? Then you just harmed a whole bunch of babies. Ouch, not so good. So you can see, not everything can be evidence based. Have you ever done everything right, and things still didn't turn out? Why did that happen? Because nothing is perfect, and nothing is a machine. Then again, how many times have you wanted to throw your laptop against the wall? Even machines aren't perfect. Why do we think people fit into nice little cookie cutter shapes and boxes? Following evidence based guidelines does not mean the outcome will be positive every time.

The other can of worms is that medicare (government run) is the largest insurer of people in the country and dictates reinbursement costs and standard of care currently. If medicare states that a certain procedure is worth a certain amount of money, the other insurance agencies then base their reimbursements on medicare. When the largest insurer of Americans gets even larger, it will completely dictate care and reimbursement. Obama has already stated his plans for algorythms and standards of care. At that point it will be politicians, the government, or lobbyists who determine the care of your loved ones ... not the doctors. I don't know of any politicians who went to medical school, and I certainly don't want the doctors who are on the politicians payroll to be making medical decisions - you know, the whole "conflict of interest" thing.

Clearly, there's a problem with the numbers. We can't reduce the cost with his plan, we can't increase our revenue to support it with his plan, how can we throw more demand into the picture and expect to afford it? I am not opposed to making affordable health care more easily available, but it has to be done right, cannot eliminate physician and patient choice, and it should not be run by the government.