Wednesday, August 20, 2008

"The Best Healthcare System in the World"...

I'm always struck by how many of my fellow US citizens fail to see the great failings in our healthcare "system". I say "system" because we certainly do not have a cohesive, organized, orchastrated approach to providing our citizens with health care, but rather a series of niche providers, many with an entrepreneurial underpinning - we're all in it to make money! (If you've read my blog, you know that I'm a physician working as an employee of a community-owned nonprofit medical practice serving the poor, and I recognize that most physicians didn't go to med school thinking it was [only] a great way to make a living, but that we wanted to be in a helping profession. But, I would argue that the institutions of care are very much dependant upon profit, even with the best of intentions...)

I sat with a patient Monday who came in to seek care for rectal bleeding. He had met me several months ago with this problem, but couldn't find a physician willing to do a colonoscopy for less than $1400 cash. He is one of the working poor, uninsured. He has had increasing concern that something is wrong, and comes back seeking this testing again. (We are a primary care clinic, and have depended upon specialists for these sorts of tests in the past. As time has gone by, we have seen less access to specialty care for indigent patients.)

So, he tells a story that is much too common - the uninsured often delay care until disease is advanced. If, indeed, his bleeding is caused by colorectal cancer, his chances of a cure have markedly diminished by this delay.

So, do we have a great "system?" This patient clearly tells me that he doesn't think so, and wonders how his life would be different if he had access to care that other countries provide.

This report from the Commonwealth Fund shows that our "grade" as a system in the US has fallen from 67 in 2006 to 65 today, largely due to the 16% increase in the number of working-age adults who are uninsured or underinsured. That's this patient.

And, what could I say to him on Monday? Well, we'll ask our colleagues in the community and region again if they can provide this diagnostic test for you at a reduced cost to you. All we can do is ask...

Tuesday, August 5, 2008

Stating the obvious...

I'm always amazed at medical studies which seem to state the obvious. And, I'm always wondering, "Who didn't know that"?

The most likely to elicit a response of "Duh" are the articles like "Childhood obesity linked to eating too much and not exercising enough." Gosh, that's all it would have taken for me to get published?

But, when it comes to healthcare policy, it becomes apparent that many of my friends and neighbors don't have the same experience of the needs in our community, and frankly don't believe that things are as difficult as they really are. That might be reflected in blaming the uninsured for being "lazy", or thinking that all Medicaid recipients are just "welfare moms", who will keep having kids so that the State will pay them more money. Or simply that the elderly Medicare patient can't be underserved; after all, they have insurance.

My favorite example of an unbelievable situation is that of the GAU system in our state. (If "favorite" is the right word ...) In our state, we have a public program to provide support for those who are disabled, referred to as "General Assistance for the Unemployable ". Well, that makes sense - if we have citizens who are unable to provide an income for themselves, I would argue that our rich society has an obligation to help them in meeting their daily needs.

But, listen to these words that one of my patients read on the letter which announces her enrollment:
We have decided that you are unable to work at this time based on Mental Health Disorder. ... You do not qualify for medical that covers mental health treatment and so, you must find a primary care doctor to help you explore possible medications for your mental health disability.

So, did you catch that? You are disabled. So, you deserve medical insurance coverage. But, we're providing you with insurance coverage which does not have the benefit of coverage for care for the condition which causes your disability. (And, then, goes on to suggest that your PCP just give it a whirl and see if he/she can help you, without benefit of specialty consultation, if indicated.) Incredible. But, true.