Monday, November 9, 2009
H1N1 Vaccine
Sunday, October 4, 2009
My letter to my colleagues
Self regulation is one of the major components of the learned professions. We’ve all been there: Daily rounds where we are mercilessly “pimped,” standardized tests so often it feels like we’re testing every month, and the dreaded “morbidity and mortality” conferences where every move is scrutinized to the smallest of minutia. Despite how it may sometimes feel, these are good things. Look instead at what is happening now. Five years ago, I walked up the Capitol steps to meet with my senator, Dianne Feinstein, regarding Tort reform. I argued it was a threat to our profession, it was bad for patient care, and would ultimately cause ruin in our health care system. Although I wasn’t the only one, the few of us who descended upon Washington, D.C. weren’t enough to reform the practice of suing without limits. Four hundred million dollars a year later into the pockets of trial lawyers, the health care system is in shambles, physicians are having trouble paying back student loans, the numbers in primary care have dwindled to a splattering, and we are under the assault from the nation and even the president himself. We are looked upon by our patients as sometimes uncaring and inconsiderate as we leave them waiting while we fill out endless forms. We have become relegated to “providers” as we now are checking boxes and performing algorithms. Even our own president accuses us on national television of banding together to cut out tonsils and cut off legs for more money. Clearly, we are no longer trusted to police ourselves.
Roughly 40 years ago in 1965, the program called Medicare started. About 35 years ago, the Health Maintenance Organization act passed in 1973. With the formation of these entities, the best resources the country has to offer became less at our disposal. Terms like “pay for performance,” “preauthorizations,” and “rationing of care” became household terms. Years before, I sat in my high school classroom reading 1984 and about medical ethics believing we would never get here, but here we are. “Death panels” may or may not be completely accurate, but is “allocation of scarce medical resources” really that far from the truth? Whether we believe the actual terms are correct, it is happening. The problem is, it is happening and we are sitting on the sidelines. Once regarded as a “holy sanctuary,” the exam room has been infiltrated by CEO’s and special interests. Our decisions are made by “defensive medicine” and reimbursement. We have lost our self direction and ability to use all America has to offer to help our patients.
In regards to making a fair living, I don’t believe I need to talk about diminishing reimbursements and increasing medical school loans. Rather, I will focus upon fairness. Legislation is in process which would penalize physicians who are in the top 10% of Medicare cost 5% of their reimbursement regardless of the reasons. What greater incentive would a person have refuse care to the sickest of patients in an effort to avoid being in that 10%? It is then upon our conscience to harm people so we can feed our families and pay our bills when we took an oath to the opposite. Furthermore, someone will be in that 10% no matter what. If they are doing what is right for their patients, do they deserve to lose 5% of their income? Also, pay for performance is making its way through the legislative process. If the government has its way, even if our patients refuse to make changes to improve their health, we will be penalized for it. We will see reductions in our reimbursements despite making the correct medical decisions. Additionally, if a patient doesn’t respond to our treatments and requires longer hospitalization than what has been “deemed acceptable,” their extended hospital stay will come directly from our pockets. Furthermore, the protections of the conscience clause are not being included in the health care reform bills. This means we are open to not being hired, being fired, being sued, or being forced to perform procedures we find morally, ethically, or religiously objectionable. To top it all off, a National Provider Database has been set up in which any adverse action taken against us becomes public knowledge whether or not it has any merit, or we actually become convicted of the charge. This means there remains incredible incentive to sue us, and then we have it affect our record whether or not it is true. Some states also have a “3 strikes” law in which three accusations against us results in disciplinary action regardless of the validity. Even child predators are granted due process under the constitution! Evidently, fairness is not a principle which legislators believe applies to physicians.
As you can see, our profession is being systematically dismantled as we stand by and watch. With all the publicity of the recent reform bills, this is our chance as physicians to take a stand for ourselves and our patients. Irrespective of your political viewpoint, I argue there is more we want for healthcare reform than what HR3200 currently gives us. Our greatest leverage is before a bill is passed. Once a bill passes, we may find ourselves in the same position as tort reform: standing around complaining about what should be. Please take the time to tell your friends, family, and patients your views when appropriate. After all, it is their healthcare, our healthcare, and all of our lives at stake. Never before in our lifetime have we had such an opportunity to make a difference in the lives of our patients, family, friends, and neighbors. Health care reform will pass no matter what because it needs to pass. When and what type of health care reform that passes I hope will be up to you. If you don’t make it your goal to be a part of the change, you leave it up to lawyers and legislators to do it for you. We have all seen what happens if we allow that to come to fruition. Please call the Capitol switchboard at 202-224-3121 and speak with your representative about what you, as a physician, want done in health care. We have less than 3 weeks to be heard, as HR 3200 reaches the House floor for vote in 3 weeks. When done, please forward this letter to as many fellow physicians as possible. If you do not know your representative, please go to https://writerep.house.gov/writerep/welcome.shtml.
Respectfully,
Johnny Do
Tuesday, August 18, 2009
This isn't about health care anymore...
The selling points in support of the proposed health care reform bill are: not being able to deny coverage based upon preexisting conditions, giving all Amercan citizens healthcare, arming the patients with information about end of life care, and supporting a standardized minimum level of care to protect both adults and children. The argument against this has been increased spending, diluting health care, less individual control, rationing of care, and loss of conscience.
If the arguement is solely about health care, why can't we agree upon a plan if we all want health care? The real issue is actually much deeper than the selling points. The selling points are there to intentionally or unintentionally distract because if the root of the matter were really being argued, we could never even hope to agree on the bill. The conservatives argue the issue is about the intrusion of government onto personal rights. They argue they support universal health care, but not in the proposed bill Obama would like to pass. The liberals argue they want universal health care, and this is how we address it. They deny a "government takeover."
So let's take a look at what's really going on. If the republicans argue this is a government takeover, can there be any merit to their arguement? Health care accounts for one fifth of the nation's total economy. During this present administration's short time in office, they have proposed sweeping legislation to control the financial sector, automobile industry, education, and energy. Keep in mind, they already control the millitary, and continue to seek to disarm the public with gun control legislation. With the government controlling and seeking to control basically every aspect of the American life, it is very reasonable this is a move from liberals for a government takeover.
On the other hand, the liberals argue this legislation will adquately deliver much needed health care to all American citizens. I disagree with this statement for many reasons. First, having insurance does not equate with having good health care. The government will tell you otherwise and cite a Harvard University study done over 10 years ago. The study is a comparison in health outcomes between the insured and uninsured. The problem with the study is it can never account for all the reasons an unisured person can be more sick than an insured person. This doesn't mean that insuring the person will give them good health. Maybe the unisured person has bad habits which a person who went out and bought health insurance doesn't have. Also, the criteria for judging health was a subjective rating by both the patients and doctors. If I wanted to have someone give me health insurance and I were uninsured, would I write on a survey I believe my health is better than an insured person's health? Absolutely not. Futhermore, if I spent my hard earned money and purchased insurance, would I say I think my heath is worse off by having insurance? You can see how subjective ratings can be misleading. What is ultimately the most misleading is that the study compares the uninsured with people who bought private insurance. It threw out medicare and medicaid which are government programs. I have argued private insurance is much better than the "public option" or government insurance. If anything, this study would support my argument better than theirs. Of course private insurance health outcomes are better than uninsured. Why don't they compare the uninsured with the government plans since that is what they are arguing for? This question is left mysteriously unanswered. One thing is clear, private insurance exceeds non insurance.
How does private insurance compare to public insurance? The two most logical comparisons would be between the United States and Canada, and the United States and Western Europe.
I've already written before about how cancer survival rates are much better in the United States than Europe or Canada. Likewise, the time to see your physician is much less. I'll instead take this moment to address the counter argument from the liberals. Michael Moore produced a statistic which shows infant mortality is less in Europe and Canada than the United States. What he fails to report, is that the definition of when we consider a baby alive is different. For example, viability in America is defined at 22 weeks, whereas 28 weeks in France, Denmark, and Sweden, 24 weeks in Italy and the United Kingdom. This means, they don't calculate the death of an infant earlier than these dates. Naturally, the United States would then register a higher infant mortality rate. If you look a the numbers, the infant mortality rate in America per 1000 live births is 6.3, 5 in Italy, 4.8 in Canada and the UK, 4.2 in France, 4.4 in Denmark, and 3.2 in Sweden. So the thousands of additional births in America at weeks earlier gestational ages results in 1.5-3 additional deaths per 1000 births. For any of you who have been around pregnant women, the difference between a 22 weeker and a 28 weeker is night and day. So much development takes place, it's actually extremely remarkable the United States does so well. With the recent adjustments made to make the statistics more comparable, other countries numbers on infant mortality now surpass the United States. It is very reasonable to say, therefore, the care in the United States surpasses that of countries which utilize a government/universal health care system.
So the government plan does not necessarily deliver better health care by insuring Americans in general, and also does not necessarily deliver better health care than what we already have. Is the government plan more sustainable than our existing system? The other prominent government plan in the United States is Medicare. Currently, medicare is on schedule to go bankrupt in 10-15 years. Under the new health care reform bills, no significant changes are being made to medicare. This means it will still go bankrupt in 10-15 years. What will happen to all those people when medicare goes bankrupt? If you look at the reform bills, the financial projection is for 10 years. We've heard the price tag for this plan to be between 1-2 trillion dollars. What we don't hear so much about, is that for the health care reform bill to even have a "chance" at breaking even, it needs to pull money from other bills such as "cap and trade." President Obama says he needs these other bills passed in order to be able to provide health care. Does that mean he's trying to use healthcare to get other bills passed, or does that mean he hasn't came up with enough money to balance the healthcare budget? Either one is inexcusable. If he can't even balance the budget in his 10 year plan without taking into account a faltering medicare plan, what makes us think he can do it after 10 years? I have already argued Obama would likely take the money from elsewhere (rationing of care, higher taxes, etc.). Clearly, his plan is not selfsustaining, and would likely go bankrupt at the same time medicare does, unless the United States goes bankrupt first.
Saturday, August 15, 2009
So what's my recommendation? Part 2
Ironically, Democrats assert that private programs exist outside the government and in fact thrive. In a rather poor argument for his health care plan, Obama himself stated that UPS and Fedex do "just fine" and it's the "postal service that has all the problems." Why then would we need a larger postal service with all the government inefficiency and beauracracy? Why not improve the existing postal service (or allow UPS and Fedex to thrive and pick up the slack)? Likewise, Medicare is failing, and I will soon give some good reasons why it is. Why not eliminate those problems rather than making a larger goliath that is more of a fumbling baffoon than the first?
Capping malpractice lawsuits/Tort Reform has long been the most needed change in health reform. Currently, only certain states have placed restrictions on how much money a person can sue for. This is problematic because there are no laws against suing in general, and when there are no limits, there's really no harm in filing a lawsuit. Additionally, many lawyers will take the case based upon a potential settlement without any cost up front. This creates a major problem because there is substantial financial incentive without deterrent or regulation. In fact, many cases are settled outside of court, despite no wrong doing from the physician, just because a trial costs much more money. Malpractice insurance then increases substantially, and physicians begin practicing "defensive medicine" where they order more tests just to protect themselves from a potential lawsuit. This also drives physicians away from areas needing physicians because it costs too much to practice in that area due to malpractice insurance, or the risk is too high because one lawsuit can devastate an entire career. Tort reform would therefore:
1)reduce paperwork
2)reduce unnecessary tests
3)lower malpractice insurance
4)increases access by encouraging providers to serve all geographic locations
Another way to decrease the cost of healthcare is by restricting pharmaceutical advertisements. We have all seen those drug commercials on the televsion set, but we never know what they're for. All we know is, a middle aged man is throwing a football through a tire and then going away with some woman we presume is his wife. Sounds sort of benign, but what does that commercial do? From the very beginning, people have been skeptical of doctors receiving incentives from the pharmaceutical industry, and for good reason! All the studies demonstrate drug representative dinners hosted by pharmaceutical companies does influence prescribing practices. So the lawyers caught on and introduced legislation to prohibit pharmaceutical companies from "buying off doctors." No problem there; I made it my own decision not to be influenced by drug companies long before that law came into effect. Many of my colleagues did the same. The reasoning is this: having a really nice dinner for free, or whatever else they give you, really isn't. Nothing is free. Universal health care is NOT free. A dinner by the drug companies is NOT free. The truth is, less than a quarter of the total budget of pharmaceutical companies actually goes to research, development, and production. More than two-thirds goes to marketing and advertising. The drug companies spend millions of dollars on these 2 minute commercials because physicians have chosen not to allow them to influence our prescribing habits. They now have the patients ask us if the drug "is right for you." Which amounts to the same thing. I was opposed to drug rep dinners because the dinner wasn't on the drug company, it was on my patients. The cost of advertising and marketing (or soliciting doctors) gets passed directly on to the consumer. The pharmaceutical company is in it for the money. You can ask a few of my friends who have worked at drug company parties how much they're bringing in. The millions of dollars in a commercial is passed directly onto the patient. That's why brand name drugs cost an arm and a leg! Think about it, when was the last time you saw a commercial for penicillin?
We have already heard of the government's plan to impose a tax on "junk food." Rather than having the government regulate everyone, why don't we regulate those who are already depending on the government? Advanced disease conditions are already associated with lower socioeconomic status. Why don't we prevent part of this by regulating use of food stamps for "junk food?" A person could argue we tax cigarettes because they are unhealthy, why should junk food be any different? Cigarette smoke is correlated with disease, but it affects everyone and is therefore a greater public health issue. The risks of second hand smoke are well documented, and if it causes an increase in our health care costs, by all means it should be taxed. Eating a hamburger does not harm the person who is in the room with you while you eat it. If the lower socioeconomic class creates a greater burden on the system by depending on the system for food stamps, and then also by having poor health, why not reduce the strain on the system by promoting healthy food consumption? The government already regulates food stamps so that a person cannot by drugs or alcohol, it would be fairly simple to extend it to junk food.
Another option would be to allowing insurance companies to cross state lines. This would encourage competitive rates throughout the nation rather than in states alone because the insurance companies could negotiate deals with hospitals and physician groups are a broader scale. It would also allow greater access to care and reduce costs in other ways as patients would not have to worry about being "out of network." Obama has stated he believes the bad guys are, in addition to doctors, insurance companies. Similarly to pharmaceutical companies, I don't believe insurance companies themselves are the problem. I believe the problem is allowing various sectors of the health care industry to go relatively unchecked. By placing regulations on the insurance companies, we can avoid the problems, and still reap the benefits. Just like banks are not the problem, unchecked banks who give bad loans to everyone are the problem.
One important issue that hasn't gotten any media attention, but deserves just as much attention as Obama's healthcare reform plans, is illegal immigration. Please note the emphasis is on "illegal immigration." Obama's plans for next year have been stated to include legal immigration, but the discussion on illegal immigration has been surprisingly absent for the last decade.
The most illustrative perspective of this problem is from the perspective of what is happening in California. Please note that I did two years of family medicine residency in Santa Ana, Southern California. Emergency rooms around the entire southland have shut down permanently due to the strain on the hospital - much coming from undocumented immigrants who cannot or will not pay for care. Typically, emergency rooms aren't a very lucrative investment for hospitals unless they are able to admit patients to the inpatient service. Unfortunately, hundreds of thousands of emergency room visits are for uninsured patients, and additionally uninsured undocumented patients. ER's are not permitted by law to turn anyone away, consequently they absorb the brunt of uninsured undocumented patients.
With all of the manpower involved in the ER, this can be a very costly endeavour if the patients cannot pay, will not pay, and there is absolutely no recourse to make anyone else pay. They get all the best resources the ER has to offer, and they are discharged. That's the best case scenario. What happens when the patient is really sick and needs additional care? The hospital cannot turn the patient away from the ER in the first place, and therefore also cannot turn them away if they're really sick and need to be admitted. The hospital then admits them, and they are treated on the inpatient service even though they still can't pay.
The consequence is we all pay. All of us tax paying Americans. A couple cases here and there aren't a big deal, but when hundreds of thousands of people use the ER to see any doctor because it's free health care for them, it becomes an enormous problem. I see people for colds every day, just because they can't or won't pay for a clinic visit. It becomes the most expensive clinic visit ever, but at the American tax payers' expense.
Additionally, why not go to the hospital for an expert opinion for everything if it's free? I have seen a child run into the emergency department and jump on my lap so I can examine his scraped knee. If a child runs through your office and jumps into your lap, chances are there's nothing wrong. It was even worse because mom didn't even clean it or look at it. She didn't have any reason to do anything - we would do it for her for free.
Additionally, illegal immigrants also do not have the same vaccination policies and health care from their native countries. They may expose our current population to communicable diseases which otherwise may be eliminated from our society. This can be seen in the rise of pertussis, tuberculosis, measles, etc.
There is also the phenomenon of "anchor babies." The law is interpreted as anyone who is born in America is now an American citizen. Illegal immigrants count on the sympathy of Americans to keep them in the country because if their baby is born in America, we wouldn't separate them to send their parents back to their country of origin. This places tremendous incentive for them to utilize the health care system. If they wait until they're going to deliver, run into the hospital for free health care, their baby and themselves are taken care of, the baby is documented as a citizen, and they have just punched their ticket to stay in America- all on the tab of the American tax payer. What makes it worse, is these babies have little or no prenatal care. The physicians have no idea what they're walking into, and these babies can potentially be very sick.
Even more difficult than seeing an illegal immigrant receive care for free, is seeing a tax paying American citizen get the same exact care and having their savings wiped out, their credit destroyed, and their wages garnished because they have a social security number. Why should people who haven't contributed any taxes to our system be bailed out for free, when someone who has contributed their entire life gets everything taken away from them? It should not be a punishment to be a tax paying American. What is important to note is that equality does not mean equivalence. I believe people have the same inherent worth, but that doesn't mean they should get the same treatment. We love our children the equally, but we wouldn't allow our 5 year old to drive our 16 year old's car. Likewise illegal immigrants are equally as valuable as citizens, but that doesn't mean illegal immigrants should recieve benefits at the expense of tax paying citizens.
I do believe emergency rooms should always be available for everyone, no matter what their citizenship, in the event of an emergency. However, I believe if they are not an American citizen, after their condition is stabilized, they should be deported to their country of origen. This alone would decrease the burden on our health care system by hundreds of millions of dollars.
Passing legislation to close our borders and elimate "anchor babies" would therefore:
1)ease burden on emergency rooms
2)eliminate wasteful spending
3)focus health care attention on tax paying Americans
4)decrease potential risk of some diseases
My final point I believe everyone would agree with. It is important to legislate against denying care based upon preexisting conditions. Obama stressed this as an important point, and I agree completely. I don't, however, believe we must implement universal health care reform to do so. Simply making a bill to stop health care insurances from discriminating against people with preexisting conditions would do the trick just fine. By doing so, it would allow equal access whether or not a person is already sick, it would increase preventative care because their condition can be treated before it gets worse, and it would encourage patients to obtain health insurance for other medical needs. A simple solution to cover the cost, rather than overhauling the current health care system, may be to increase copays.
Friday, August 14, 2009
Why all this now?
Second, doctors are taught to be as sure as we can about things, but we've seen nothing is ever "black and white" or clear cut. Unexpected things happen all the time, and we can't tell the future any better than anyone else. It may be a product of our culture, but that makes us not as vocal when asked about our opinion. We try to be sensitive to others, and as I've said before, if this were a completely one-sided issue, everyone would probably be on the same side. These issues, however, are multifaceted and we often have to concede one point in order to obtain another. Just like voting for a president often feels as though you're voting for the "lesser of two evils," health care legislation is usually loaded down with "pork," special interests, and other uneccessary provisions. We also try to be sensitive to others' viewpoints. It just wouldn't be very "kosher" for a physician to get in a debate with a patient during an appointment, and would actually be counterproductive. A patient has probably waited a long time to see their doctor for a medical issue, and it takes time to get the correct diagnosis and treatment. It would be wrong to spend that time on politics, or to take that time away from someone else who needs treatment.
Third, law isn't our area of expertise (just like medicine isn't the area of expertise for lawyers and politicians), and we really don't like how it has intruded on our ability to practice medicine. All doctors are familiar with malpractice, and it's like driving a car: you're likely to get into an accident someday. It is the norm for a physician to be sued at least once in their lifetime. For that reason, we quietly despise getting involved in law. Furthermore, part of the push for physicians to become specialists is that we are "type A." We want to be good. We want to know something really well. If we're not trained in it, we likely don't want to comment on it as much because we don't want to be incorrect or wrong. If you spend any time watching TV, you can see the "beat down" residents get during their training (on a side note, the TV show Scrubs pretty much hits the nail on the head).
On a personal note, I am absolutely opposed to "lining the pockets of politicians." I believe a person does that "right thing" because it is the "right thing to do." It makes me furious to have to pay someone for my rights, or the rights of my patients. Lawyers knew of the conflict of interest created when money gets involved in patient care. For that reason, multiple laws have been passed to prevent money from being the determining factor of someone's health. In every other field, a person can receive monetary or tangible incentives for their business. It is not uncommon to go golfing, to a show, or on a vacation in other businesses. It is unethical in our business. Laws were passed to keep pharmaceutical companies from "buying off" their doctors prescribing practices. I myself was opposed to getting freebies from pharmaceutical companies before rules were passed by residencies prohibiting such a practice. Furthermore, physicians hire office staff for their accounting, because we don't like getting bogged down in the billing aspect. We are much more interested in proper diagnosis and treatment. Call it a weakness, if you will, but wouldn't you rather your doctor spend time treating your illness correctly instead of cashing his checks? For goodness sakes, we go on missions trips ALL THE TIME to give free health care to people- on our vacation time!
Activism organizations have been set up to represent physicians on these important issues. Each of our professional affiliations have an advocacy wing. Unfortunately, those organizations don't always represent the views of their constituents. Sound familiar? Congress seems to have the same problem. There is nothing more infuriating than your representatives not representing you, and instead representing their own interests, agendas, or political goals.
I chose to finally blog about this now because this is a pivotal time in health care for our country. There are definitely important issues to address and, if we are not heard, the United States may go down a path that would take years if ever to repair. I hope my opinion gives all you readers a greater perspective from a physician's viewpoint on the situation we face in the American health care system.
Wednesday, August 12, 2009
So what's my recommendation? Part 1
Healthcare can therefore be divided into these categories:
Quality
Accessibility
Cost
Autonomy
As far as quality goes, America ranks amongst the highest quality health care systems in the world. Technology is unmatched, and outcomes are comparable if not exceeding other nations. According to the Lancet Oncology journal 91.9 per cent of American men with prostate cancer were still alive after five years, compared with only 51.1per cent in Britain.
The same publication suggests that 90.1 per cent of women in the U.S. diagnosed with breast cancer between 2000 and 2002 survived for at least five years, as against 77.8 per cent in Britain. Overall life expectancy in general is very similar between the United States, the United Kingdom, and Canada; varying only 2 years according to the World Health Organization (WHO). Wait times are comparable if not shorter in the United States. According to the nonprofit Commonwealth Fund, which studies health-care policy, U.S. patients had the second-shortest wait times if they wished to see a specialist or have nonemergency surgery. Germany was the fastest, which does have nationalized health care, but interestingly has gone through massive reform recently with the conservative party taking control. So the question then is not whether or not the health care in the United States is any good, but is instead if the health care in the United States will be the same or better with Obama's proposed reforms. Technology shouldn't be affected very much, but if you bombard the health care system with 40 million more people without changing the number of practitioners, it is doubtful the wait time will decrease, or that the outcomes will improve.
After comparison has been made to universal health care models in other countries, the argument could be posed that our society is somehow different. We do things differently in America for sure. What would it look like if the government had a larger role in the health care system. To do that, we can look at what the government already does in health care. The best example of currently government run hospitals are the Veterans Hospitals (VA). Without even attempting to find written evidence VA hospitals are poorly run, I can tell you first hand of my experiences there. I also challenge you to discuss with ANYONE who has worked at the VA hospital in ANY CITY about how terrible the health care can be. I have worked at the VA in Lebanon (PA), Phoenix (AZ), Long Beach (CA), Hampton (VA), and Portland (OR), so I would argue I have a fairly representative sample.
Employees in the VA system run on a different time scale than the rest of the world. If you thought government employees at the DMV were slow (no offense, but we all know it's true), just imagine if your grandfather were dying and we needed a CT scan. He may get one tomorrow, or monday if it's the weekend. It better not be a holiday on monday, because he'll definitely have to wait until tuesday. What about blood? If your same grandfather came into the VA complaining about chest pain and needed to be evaluated for a heart attack, we draw blood every 6-8 hours to make sure his heart is ok. There better be someone else who knows how to draw blood because the ONE phlebotomist in the ENTIRE hospital may decide to take a break, not come to work, or quit without telling anyone. Yes, all three have happened to me, and I drew the blood MYSELF because I didn't want my patient to die. Now I don't think I'm above drawing blood, but if every doctor had to perform each test he ordered himself, no patients would be taken care of. That is why we do hire phlebotomists, nurses, and technicians. A person may argue it doesn't take that long to draw blood. Try doing that on all your assigned patients in the hospital, and then there's definitely a problem. For the sake of argument, I'll give you an example of something that takes longer than drawing blood. A man comes into the hospital with liver failure and about 8 liters of fluid in his belly. He's having a lot of abdominal pain, so I perform a pericentesis where I stick a needle in his belly to drain the fluid for comfort and to make sure he doensn't have an infection which can kill him. I drain the fluid and take the sample down to the laboratory and order a stat gram stain and fluid studies to make sure he's not infected. The lab tech responds by asking me if I know how to do a gram stain because he doesn't "feel like doing it." Once again, I'm not above doing gram stains, and I did them in medical school, high school, and college biology. The problem is, you have to put the sample on a slide, dry it, stain it twice, and look under the microscope. This is something a physician would rather not do when he's on call, and all the new sick patients need his attention, but yes I did the gram stain. I have also wheeled my own patients to the CT scanner, MRI, and Xray because nobody else wanted to do it. To make things worse, I've had at least a couple patients who the nurses decided to let stay at an oxygen level of 60% without calling a doctor because they didn't feel the need. Just so you know, a person needs much more oxygen than that, and all of them died that morning. I filed incident reports on all of those, and the people still work at those same hospitals. The problem is, my experience is not unusual, and I doubt anyone would want that kind of care for their loved one.
In regard to accessibility, I would argue EVERYONE in America has the potential to access the health care system. This doesn't mean everyone has good care, but everyone can obtain health care in one way or another if their life depended on it. There are private hospitals if the patient can afford it, there are county hospitals if they can't afford it, and there are countless low cost commuity clinics to render care to people. There are also many charity programs available. Please don't take me as saying I am satisfied with the current state of healthcare, but rather there are minimum standards currently being addressed in America. Why then would the entire health care system require an overhaul to a completely different system if a little improvement could go a long way? I'll discuss my ideas for improvement shortly.
One last comment before I discuss some suggestions we initiate prior to revamping the entire healthcare system. I believe everyone should have health care, but I don't believe everyone should demand it from others or be entitled to it. What ever happened to personal responsibility? I would like everyone to live in a big house and have lots of money, but that's not how the world works. In fact, I work very hard for my salary, and would like to choose to who and what cause it goes to benefit. The private sector donates millions if not billions to charity and health care in various forms, why should everyone then be mandated by the government to give a percentage of their hard earned money to specific causes they don't believe in? I volunteer at free clinics, go on medical missions trips, and contribute my share in addition to taxes to the poor. I don't believe everyone should be FORCED to do what others do voluntarily. Why did some of my patients at an underserved clinic in Santa Ana, CA come to my clinic driving a better car than I do? That's not me saying I want a really nice car, that's me saying they can probably afford to pay for their care. Monthly insurance costs roughly $300 a month. As you add people/dependents, the relative cost per person decreases. It comes down to priorities. If they value a nice car more than they value health care, why should someone else pay for their health insurance? If they truly are unable to pay for it, as I've stated before, there are programs to assist them.
The AMA, AAP, ACP, AAFP
Since the days of Andrew Jackson (who was notorious for this practice), politicians reward those who support them. Obama is no different in this course of action, as you can see the millions of dollars in earmarks added at the last second to his bills once he became president. The AMA, AAP, ACP, AAFP, and other groups all met with Obama in the infancy of his health care reform bills. Previously, they had supported other measures (Tort reform for example), and following the meeting they publicly endorsed Obama's plans, even though the plan is not necessarily in the best interest of physicians or patients (see prior posts). Of course, going into the meetings, they had some pretty significant concerns. Do we honestly believe when we watch months of debate, that the questions were all answered in those brief meetings? I would hope not. It would be more reasonable to believe there was some incentive for changing their position.
We can see an example of incentive and reward in the pharmaceutical industry. According to Bloomberg, "two firms that received $343.3 million to handle advertising for Barack Obama’s White House run last year have profited from his top priority as president by taking on his push for health-care overhaul. This year, AKPD and GMMB received $12 million in advertising business from Healthy Economy Now, a coalition that includes the Washington-based Pharmaceutical Research & Manufacturers of America, known as PhRMA, that is seeking to build support for a health-care overhaul." Besides having already received massive compensation for their efforts in getting Obama elected, they have the potential for substantial gains if his health care plan goes into effect.
How, you ask? Allow me to explain. In medicine, there is something called a formulary. This is a list of medications the hospital has chosen as the first line agents it keeps available for use. For example, there are many competing "statins" on the market to treat cholesterol. The hospital chooses a particular drug because the hospital has worked out a deal with the distributor to get the drug at a lower cost. This helps the pharmaceutical company because its drug is chosen over other cholesterol lowering agents, and the company is banking on the number of people who will be using the medication. It helps the hospital because the drug company offers the medication at a lower cost. By "scratching Obama's back" (multiple times), the drug companies have a lot to gain. There is a good chance that the government will decide which drugs (manufactured by certain companies) a hospital can use to "control costs". Does this sound like special interest to anyone else? Oddly enough, Obama and other politicians refuse to pass legislation against pharmaceutical agencies. Instead, insurance companies are "villains" and doctors take tonsils out "for money."
What kind of incentives can Obama offer the various specialty groups? The AMA, for example, has been arguing for tort reform for nearly a decade without success. On the other hand, the current administration has been steam rolling bills through the house and senate without pause. If the specialty groups would like a different type of legislation passed, it would be plausible to assume cooperating with Obama on his most aggressive reform to date would be a good starting point. Additionally, one of the techniques to get a bill passed is to make it appear as though it is inevitable for that bill to be passed. Politicians don't like to vote on the "wrong side" because the people who maintain power passed the bill. It would make for difficult working conditions later.
It is far easier, then, to go along with the health care reform bill if:
1) it's presented as though it's going to happen anyway
2) what you're already seeking seems unable to come to fruition (tort reform)
3) current concessions or future promises are made by those in power to look "favorably" on your cause
4) you have a way to "spin" it so you still achieve success.
Keep in mind everyone has different priorities, and how we prioritize is only that. Just because we put something in a bill at the top of the list does not mean we want everything else that is included in the bill, nor does it mean we completely devalue everything else. Obama stood at a press conference recently amongst liberal Christian leaders who support his plan. They cited the need for universal health care. This is the same citation the AMA uses. Both groups believe that the uninsured are a priority, but it might not mean that they agree with the remainder of the bill. I discuss access to care in another post. First, I don't believe access to care is the primary problem. Second, I don't believe this bill adequately addresses this problem (also discussed in another post). Third, in some cases this may be a "smoke screen" or "spin" so both parties can claim "victory."
In any case, regardless if you believe Obama used the "carrot technique," these professional organizations are their own entity and do not necessarily exemplify the beliefs of their members. Personally, for every 25+ physicians I discuss the issue with, only 1 agrees with Obama's health care reform plans. Although this isn't a scientific argument, it just is to make the point that people have varying opinions - even physicians. The choice, ultimately, is in each one of us when we discuss these issues prior to congressmen voting on them in the future.