Map of life expectancy at birth from Global Education Project.

Tuesday, November 25, 2008

Cleaning out the attic

I just came across a memo I wrote concerning the curriculum for a course for first year medical students about everything that isn't biomedicine. I thought I'd clean it up a bit and post it here, just to give a sense of the complexity of the field of medical sociology. This is just the What part -- then there's the who, how and why of it all.

§ Disease, disability, and suffering -- Medicine addresses these starting from a focus on individual biology; has historically been less concerned with social and environmental conditions. Debate over appropriate boundaries for medicine – is more interest by medicine in social and environmental conditions a progressive reform, or an oppressive "medicalization" of society?

§ Well-being and health. See above. Also, medicine has historically been less concerned with promoting and maintaining well being than with intervening to treat disease. Again, what is the appropriate boundary of medical interest in public policies and individual behavioral modifications to promote well being and health, vs. historical role in treating disease?

§ Patients, clients, consumers, people. Interest by the medical profession in non-biological properties of patients is, again, greater now than in the past. Former model was hierarchical (or patriarchal, if you like) – physician told patient what was wrong, and what to do – "doctor's orders." Patients' attempts to introduce non-biomedical ideas into discourse were rejected. Now, more patient participation in decision making, physician interest in social and psychological dimensions of patient well-being and their relationship to treatment decisions, is encouraged -- at least that's the normative discourse. Whether it really happens is another question.

§ Medical Education. Comment: Medical school focuses largely on biomedical science; clinical skills are normally taught starting in the third year, but teaching, and evaluation, concerning the physician-patient relationship, communication, and support for healing is highly underdeveloped. These subjects aren't very well understood either.

§ Professionalization. This is a process that nobody controls, which happens largely ad hoc. It's an apprenticeship model, in which medical students and interns learn how to be a doctor by observing their preceptors. What they end up learnind depends on who those people happen to be, and the settings in which they work. Nobody is in control of the process, and it just keeps reproducing the same evils, generation after generation.

§ Regulation. Medicine is a regulated profession, requiring that practitioners meet licensing standards, and that they perform within certain limitations and according to certain generally accepted, though vaguely defined, standards.

§ Health Expertise: Scientific knowledge Gets top priority at medical school. Is there enough room for everything else?

§ Care. What does this really mean? What is the appropriate stance of the physician toward the patient – boundaries, limits of emotional involvement, what the physician can best offer in terms of emotional support.

§ Healing. Still largely a mystery, in spite of all our scientific knowledge. The most powerful source of healing we dismiss as the "placebo effect" and work very hard to find ways of eliminating and/or ignoring it in our research. Does this really make sense?
§ Health promotion/disease prevention. Again, where are the proper boundaries of the physician's role in this? What other kinds of professionals and institutions are concerned here?

§ Health Care Delivery Institutions: Ambulatory care can be offered by any of the below institutions, except I guess for nursing homes. The list gets confusing because of the trend toward vertical integration as well, i.e. academic health centers now include hospitals, ambulatory care centers directly associated with the hospital, affiliated physician practices, affiliated community health centers, and various other services including, in some cases, nursing homes and home care services (which by the way you left out.) It's hard to know exactly how to organize this but I would suggest that one way to do it is from the standpoint of the physician as a member of the labor force. What are the kinds of relationships physicians have with these institutions? They can own a practice or be partners in a group practice; work for a staff model HMO; work for a community health center or hospital based outpatient clinic; work for a hospital inpatient service; be full-time faculty doing research and teaching; and, not untypically, combinations of the above. If they are practice owners/partners, they will probably have various kinds of contracts and relationships with some of these other institutions as well.

§ Ambulatory Care
§ Offices,
§ Hospitals
§ Public Health Clinics
§ Nursing Homes
§ Academic Health Centers

§ Pharmaceuticals and Durable Health Care Products. Private, for profit corporations, motivated solely by greed.

§ Federal and State Policy Process and Regulatory Agencies Again, not in the curriculum previously – we're talking CDC, FDA, AHRQ, HCFA, state DPH, etc. – this is a lot, most of it thoroughly captured by the regulated interests.

§ Financing: I think we need to divide financing into the source of the money – govt., employers, individuals – and then the structures through which it is spent – indemnity insurance, HMOs of various kinds and variations such as PPOs – and finally the relationship of the provider to the payer, noting that the payer is not necessarily the entity that pays in the first place, but rather the entity that directly purchases the services – or provides them itself, as in a staff model HMO in which payer and provider are in fact the same entity. Any kind of insurer can be for-profit or non-profit, as can employers for that matter, and any kind of provider. I.e., both Aetna and Blue Cross/Blue Shield offer both HMOs and indemnity insurance. Does their organization as for-profit or non-profit companies matter? Why?

§ Not-for-profit
§ Medicare
§ Medicaid
§ Managed care organizations
§ For-Profit

And that's just the gross outline of the structural issues in U.S. medicine. I'll keep on unpacking them as we move -- we hope -- toward fundamental change next year.


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Dan said...

A Need To Reformulate

The following are facts that are believed to exist regarding the present U.S. Health Care System. This may be why about 80 percent of U.S. citizens understandably want our health care system overhauled:
The U.S. is ranked number 42 related to life expectancy and infant mortality, which is rather low.
However, the U.S. is ranked number one in the world for spending the most for health care- as well as being number one for those with chronic diseases. About 125 million people have such diseases. This is about 70 percent of the Medicare budget that is spent treating these terrible illnesses. Health Care costs are now well over 2 trillion dollars of our gross domestic product. This is three times the amount nearly 20 years ago- and 8 times the amount it was about 30 years ago. Most is spent with medical institutions, as far as health expenditures are concerned. One third of that amount is nothing more than administrative toxic waste that does not involve the restoration of the health of others. This illustrates how absurd the U.S. Health Care System is presently. Nearly 7000 dollars is spent on every citizen for health care every year, and that, too, is more than anyone else in the world.
We have around 50 million citizens without any health insurance, which may cause about 20 thousand deaths per year. This includes millions of children without health care, which is added to the planned or implemented cuts in the government SCHIP program for children, which alone covers about 7 million kids.
Our children.
Nearly half of the states in the U.S. are planning on or have made cuts to Medicaid, which covers about 60 million people, and those on Medicaid are in need of this coverage is largely due to unemployment. With these Medicaid cuts, over a million people will lose their health care coverage and benefits to a damaging degree.
About 70 percent of citizens have some form of health insurance, and the premiums for their insurance have increased nearly 90 percent in the past 8 years. About 45 percent of health care is provided by our government- which is predicted to experience a severe financial crisis in the near future with some government health care programs, it has been reported. Most doctors want a single payer health care system, which would save about 400 billion dollars a year- about 20 percent less than what we are paying now. The American College of Physicians, second in size only to the American Medical Association, supports a single payer health care system. The AMA, historically opposed to a single payer health care system, has close to half of its members in favor of this system. Less than a third of all physicians are members of the AMA, according to others.
Our health care we offer citizens is the present system is sort of a hybrid of a national and private health care system that has obviously mutated to a degree that is incapable of being fully functional due to perhaps copious amounts and levels of individual and legal entities.
Health Care must be the priority immediately by the new administration and congress. Challenges include the 700 billion dollars that have been pledged with the financial bailout that will occur, since the proposed health care plan of the next administration is projected to cost over a trillion dollars within the first year or so of the proposed plan to recalibrate health care for all of us in the U.S. Yet considering the hundreds of billions of dollars that are speculated to be saved with a reform of the country’s health care system, health policy analysts should not be greatly concerned on the steakholders who may be affected by this reform of our health care system that is desperately needed. Tom Daschle leads this Transition’s Health Policy Team. And we also have Ed Kennedy, the committee chair and a prolific legislator. So if the right people have been selected for this reforming team, the urgency and priority regarding our nation’s health care needs should be rather overt to the country’s citizens.
Half of all patients do not receive proper treatment to restore their health, it has been stated. Medical errors desperately need to be reduced as well, it has been reported, which should be addressed as well.
It is estimated that the U.S. needs presently tens of thousands more primary care physicians to fully satisfy the necessities of those members of the public health. This specialty makes nearly 100 thousand less in income compared with other physician specialties, yet they are and have been the backbone of the U.S. health care system. PCPs manage the chronically ill patients, who would benefit the most from the much needed coordination and continuity of care that PCPs historically have strived to provide for them. Nearly have of the population has at least one chronic illness- with many of those having more than one of these types of illnesses. A good portion of these very ill patients have numerous illnesses that are chronic, and this is responsible for well over 50 percent of the entire Medicare budget.
The shortage of primary care physicians is due to numerous variables, such as administrative hassles that are quite vexing for these doctors, along with ever increasing patient loads complicated by the progressively increasing cost to provide care for their patients. Many PCPs are retiring early, and most medical school graduates do not strive to become this specialty for obvious reasons. In fact, the number entering family practice residencies has decreased by half over the past decade or so. PCPs also have extensive student loans from their training to complicate their rather excessive workloads as caregivers.
Yet if primary care physicians were increased in number with the populations they serve and are dedicated to their welfare. Studies have shown that mortality rates would decrease due to increased patient outcomes if this increase were to occur. This specialty would also optimize preventative care more for their patients. Studies have also shown that, if enough PCPs are practicing in a given geographical area, hospital admissions are decreased, as well as visits to emergency rooms. This is due to the ideal continuity in health care these PCPs provide if they are numbered correctly to treat and restore others. Also, the quality improves, as well as the outcomes for their patients. Most importantly, the quality of life for their patients is much improved if there are enough PCPs to handle the overwhelming load of responsibility they presently have due to this shortage of their specialty that is suppose to increase in the years to come. The American College of Physicians believes that a patient centered national health care workforce policy is needed to address these issues that would ideally restructure the payment policies that exist presently with primary care physicians.
Further vexing is that it is quite apparent that we have some greedy health care corporations that take advantage of our health care system. Over a billion dollars was recovered for Medicare and Medicaid fraud last year through settlements paid to the department of Justice because some organizations who deliberately ripped off taxpayers. These are the taxpayers in the U.S. who have a fragmented health care system with substantial components and different levels of government- composed of several legal entities and individuals, which has resulted in medical anarchy, so it seems.
Health 2.0, a new healthcare social networking innovation, is informing patients about their symptoms and potential if not possessing various disease states- largely based on the testimonies of other people on various websites. This may be an example of how so many others rely now on health concerns from those who likely are not medical specialists, instead of becoming a participant, if not victim, of the U.S. Health Care System.
Thanks to various corporations infecting our Health Care System in the United States, the following variables sum up this system as it exists today, which is why the United States National Health Insurance Act (H.R. 676) is the best solution to meet our health care needs as citizens, it appears. We would finally have, as with most other countries, a Universal Health Care system that will allow free choice of doctors and hospitals, potentially. It should be and likely will be funded by a combination of payroll taxes and general tax revenue:
Access- citizens do not have the right or ability to make use of this system as we should.
Efficiency- this system strives on creating much waste and expense as it possibly can.
Quality- the standard of excellence we deserve as citizens with our health care is missing in action.
Sustainability- We as citizens cannot continue to keep our health care system in as it is designed at this time- as it exists today.
Dan Abshear

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