Map of life expectancy at birth from Global Education Project.

Monday, September 21, 2009

Utopia Now!

Thank you for the comments on my previous post, as usual the best part of doing this blogging thing for me.

So, here's more of what really matters about transforming health care in the U.S. As I have said many times, the debate we are having right now defines universal coverage as the issue, but in fact it is only the beginning. How we achieve universal coverage matters not only because of how the financial burden will be distributed and whether or not insurance company CEOs will continue to jet to Paris for Sunday brunch, as Jesus said God wants them to do. It also matters because of the prospects it offers for changing the way health care is delivered and the way we all relate to the health care institution.

The patient-centered medical home is the hot new ideal. The linked document is a bit dry, so let me tell you how I envision this from the patient's point of view.

Right now, people with more than minimally complicated medical problems negotiate a fragmented non-system that reflects the historic biological reductionism of medicine. If you have -- as too many people do -- say, diabetes, kidney disease, arthritis, and heart disease, you probably see at least four different doctors at least three of whom are specialists. They are likely to be in different places, have little or no contact with each other, and each of them is worried about a particular organ or metabolic system. Each of them is handing you two or three or four different prescriptions and telling you to do various, possibly contradictory things about diet, activity, and so forth.

You, however, are not a bag of kidney, pancreas, knee joints and heart, you are a person. You have a life, which is not well served by taking 12 different pills on eight different schedules, finding a way to haul your ass to five different places 8 times a month, telling the same story over and over again to six different people who don't listen anyway, and by the way, how did you end up with all those problems in the first place?

What you need is a doctor, your own doctor, the person who knows you and what-all is going on with you. And by the way, you don't necessarily need to see a doctor regularly, that "doctor" could actually be a nurse practitioner or a physician's assistant, although a primary care physician who really understands how to do patient care and care management might also be the best for you. Certainly a physician will supervise and work with the non-physician provider, and you will know that physician and have access to him or her when you want.

The specialty doctors get called in for the technical stuff but your personal doctor knows all about it, keeps track of it, and keeps the whole story in one place. Oh yeah -- as much as possible, all of these people are also in the same place, along with the pharmacy, counselors such as nutritionists, health educators, a nurse who you can call with routine questions, etc. Your doctor has an electronic medical record where all the information about you from all the different providers, including prescriptions, test results, physical exam results, notes about what you told them, is right there. Your doctor will talk with you, and listen to you, and help you make your own choices. And the entire team will work with you from cradle to grave to try to keep you healthy and prevent medical problems.

This requires a radical restructuring of how we pay for medical care, how doctors are trained, and how much different categories of doctors get paid, among other changes. The shortest path to such a new world goes through universal, comprehensive, single payer national health care, but it isn't absolutely essential. However, nothing remotely resembling this will ever be produced by the fictitious, impossible, "free market." Believe me.


roger said...

hey, that sounds like a great system. how can we get that camel's nose under the tent?

"The shortest path to such a new world goes through universal, comprehensive, single payer national health care, but it isn't absolutely essential."

is that a teaser? what would you say IS essential?

kathy a. said...

i'll take universal and comprehensive. my son works full-time at a low-paying job, and he has no health insurance.

he was beaten up a week ago; and he has had what he thinks is a sinus infection for almost a week. his pain is screamingly bad. he didn't call us until yesterday; would not let me take him to the ER for fear of huge bills. we'll see the family doc in an hour or so; they have a discounted rate for people who "self-pay."

i have a feeling we'll end up in the ER anyway, to sort out injuries and infections; the worst pain and obvious swelling is along his upper jawline, which doesn't sound much like a sinus infection to me. he just mentioned a possible abcess on the roof of his mouth, too. i'm beside myself with worry. obviously, he is much worse off than if he had seen a doctor last week.

Cervantes said...

Wow Kathy, that's a horror story. Let us know what happens. Sounds to me like a hematoma, he could have a fracture -- probably nothing extremely serious but obviously needs treatment.

Rog, you could do a radical regulatory reform of health care reimbursement policy, which would essentially require providers to set up such systems and then pay on a modified capitation basis. There would still be waste, and the insurance company profit would be even more pointless since they would have essentially nothing to do but skim, but it could be done.

kathy a. said...

the swelling has gotten far worse in the last day. there is no visible bruising. i'm suspicious about infection besides the sinus infection. also, a mom never wants to hear the words "brown pus."

the irony is that he is trying hard to be a responsible adult, to live within his means, to not be a burden.

i was talking to a friend in israel yesterday -- we normally avoid any political discussion, because she is so conservative that it makes my teeth hurt. but she expressed shock that "the richest country on earth" cannot provide medical care for its people.

kathy a. said...

hi-test antibiotics; vicodin alternating with advil; warm moist compresses; return wednesday to see how it's going.

$72 payment for the visit, representing a 40% discount for same-day self-payment. [via the bank of mom, since this is an astronomical amount for someone who works in a warehouse and lives in a garage.] since the practice is now owned by one of those patient-centered sprawling medical foundations, i assume the discount represents their savings in not having to pursue insurance or billing, rather than the kindness of our doctors' hearts.

Cervantes said...

I'll bet if he had insurance they would have taken an X-ray. Just sayin'. Not necessarily indicated, but they would have done it anyway.

Don't forget that Vicodin contains acetaminophen. He must not drink alcohol while he's taking it.

kathy a. said...

no alcohol. this is a real nightmare, though -- he has some grossly more obvious problems this afternoon as well as a lot more pain. he did not mention an injury to a tooth that just began spouting pus, because he was in such pain during the exam. i'm waiting for the doctor to call back and confirm he needs the ER; then we'll have a big fight about whether i can get him in the car.

he'd be just ordinary ornery but for the cost.

Anonymous said...

kathy a.

I feel, I truly do, My son of 18.7 was abducted and made to take money from an ATM, thankfully he was able to talk his way out of something worse, It was bad enough that he was 2000klms away at the time, I would not know how to handle it if I also had the worry about the how, where, or cost of medical treatment if he needed it! I am in Canada, it's just something we don't even think about.

kathy a. said...

thanks, anonymous.

i was not successful in getting him to the ER yesterday. one of his friends must have had an ER visit that cost $2000, because he keeps mentioning that figure.

aside from the abcess in his mouth and horrible pain, the other alarming development after he saw the doctor was that half his face swelled up, from the jawline to his eye. we'll see how today goes.

Cervantes said...

Get him to the ER. By any means necessary.

kathy a. said...

the swelling has gone down greatly, and he is in less pain today. no fever, today or yesterday -- if his temp had gone up or he had any difficulty breathing or mental confusion, i would have called 911.

this live, developing anecdote started as a rant about the need for universal basic coverage. whether or not to call 911 implicates a couple of other issues, though -- personal autonomy in medical decisionmaking, and the psycho-social context in which people make decisions.

"life-threatening emergency" and/or "mental incompetence" are good reasons to override an adult's wishes about medical care. the situation wasn't quite there, even though my strong preference was and is to err on the side of safety.

in the psycho-social area, things are fairly complicated. my son had a very rough patch in high school; we tried less intrusive things and ended up taking some more aggressive measures. it is kind of a miracle that he turned things around, that he is serious about taking responsibility for himself, and that we mostly get along now.

in the worst times, i had my son hauled off in an ambulance twice. we have more baggage about that kind of thing than most parents and adult children.

kathy a. said...

at the followup visit today, they prescribed an additional antibiotic; cultured an abcess in his mouth to be sure it isn't antibiotic-resistant; and ordered a skull x-ray at the imaging center. no fracture.

we also got a discount on the x-rays for self-payment, only $230 including the radiologist. unlike the doctor's office, there was no option for later payment -- the ER would be the only choice for someone who couldn't pay up front, and that would clearly be much more expensive.

this part is up your alley, cervantes, given your interest in doctor-patient communications. the doctor asked my son to bring me in so she could explain her findings and orders, and my son was very offended because he felt she was treating him like a little kid and not an adult; he felt that she only really wanted to talk to me. son may have over-reacted a little, but overall it's a valid complaint -- he is the patient, and the one who needed convincing by his provider.