Q. and A. about Health Care Reform

By Shawn Vuong


This week Dr. Holm writes a short Q & A about the current health care reform and debate.  It's a nice concise summary of the basic problems of the reform, and I have nothing to add.  Hopefully, we find a workable and solid solution to our healthcare system problems.  So without further ado, the Health Care Reform Q & A.  
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By Richard P. Holm MD


Q. Do we really need health care reform?


A. The answer is a clear yes, because of ACCESS and COST issues:
1. Without reform, insurance companies will remain free to increase profits by cherry-picking only the well people, leaving too many Americans without access to health insurance. What’s more, many people will continue to be unable to change jobs for fear of losing insurance. These are problems of ACCESS;
2. Without reform, health costs will continue to rise, and health insurance will become more unaffordable for many businesses, let alone many individuals. Unchecked, by 2017 Medicare will bankrupt social security. This is a problem of COST.




Q. Why is US health care twice as expensive as any country in the world?


A. There are many reasons, which is why this is so hard to fix. Here are the most significant.


1. Payment for health care rewards hospitals for making available and encouraging the most expensive technology which does not necessarily improve care;
2. Physicians, especially in the emergency rooms have every reason to order the most complete and often most expensive tests or treatment because the patient wants it; the hospital wants it; and there is a risk of law suit if every test or treatment is not done and something bad happens. This again, does not necessarily improve care;
3. Patients expect the most expensive care for their family and for themselves, someone else is paying for it. Studies show the most expensive does not necessarily mean the best care;
4. Too often we do not have our personal doctor directing care, but have turned to that which is specialist driven. This kind of care can become very disjointed and very expensive.




Q. Will the solutions working their way through Congress right now solve the access and cost problems?


A. Both problems are being addressed. Ethically, I believe the access problem must be solved first. Although the more complex challenge of reducing health care costs will require a great deal of political will, it is a problem that also must be solved.


Both parties, of course, are playing their political hands with this issue, but I believe that without health care reform the consequences will be too dire for the any of us to tolerate. Our Washington leaders will have to find a way to make it happen.

Impossible To Fix

By Shawn Vuong

Medicine demands perfection. Nobody wants their loved one to die of something that could have been caught earlier on a blood test or CT scan.

So, a lady with a headache comes into the ER. The ER doctor knows that this headache is probably a tension headache or a migraine headache. The ER doctor also knows that the odds of this lady having a brain tumor are low, very low. Although every other ER doctor in the state would order a CT scan for every headache case that comes to the ER (due to the fact that they are scared of litigation brought against them, not because they think every headache warrants a CT), this ER doctor decides it is close to the end of his shift and he doesn't want to waste time ordering the CT scan this lady probably doesn't even need. So, he sends her home with some migraine medication.

Well, thanks to Murphy's Law this lady ends up permanently injured due to a malignant brain tumor. So because of this devastating turn of events, the family files a malpractice claim against the ER doctor.

Thanks to the teachings of a very wise law professor with significant expertise in tort law, I know what's coming next.

The doctor will be asked if it is the 'Standard of Care' to order a CT scan for a headache patient. Although medical literature may say that it is not the best practice to order a CT for every headache patient, and although every other ER doctor in the nation is ordering CT scans for fear of medical malpractice litigation, it IS considered the 'Standard of Care' just because every other ER physician is doing it. Right or wrong. Thus, this ER doctor will likely lose this malpractice case.

How do we as a profession change this? Obviously, a group of ER doctors cannot just follow the medical literature and stop ordering CT scans for every headache. This will just increase the chance that they will be successfully sued in a malpractice case. So, in reality, no ER doctor will stop ordering unnecessary scans. The more the 'Standard of Care' deviates from what the medical literature considers the best medical practices, the more of a disservice physicians are providing to patients. Yet, the legal climate prevents the doctors from changing the way they practice from the 'Standard of Care' due to fear of litigation.

This sounds impossible to fix.

-- Please note that this article is not trying to say ER doctors should not order CT scans for headaches. I have no idea if you should or not, I am not a licensed physician. This hypothetical scenario was merely thought up to help illustrate the problem with defensive medicine.

Doctor Shortage Makes Headlines

Dr. Chen with the New York Times makes the public more aware of the extreme situation known as the doctor shortage.  She wants people to know, "its three strikes and game over" and we are already at strike 2.  So soon-to-be president Obama please remember to address the physician shortage before mandating/allowing people to have insurance and putting us at strike 3.

Tom Daschle for Health and Human Services Advisor

By Shawn Vuong

Well its pretty much official, our own Tom Daschle will be the secretary of HHS.  What does this mean for doctors and patients in South Dakota?  What does this mean for doctors and patients nationwide?  

Some don't believe Daschle is the right man for the job.  They may be worried about his past voting history, his history of partisan politics, or even his wife's job as a lobbyist that may play in conflicts of interests.  Others think he's perfect.  Either way you look at it, he's going to be a key component of the healthcare reform that America is about to see.  

To get a good idea of what's in store for us, I plan on reading "Critical: What We Can Do About The Health-Care Crisis" by Daschle.  The book came out Feb 2008, and I think its going to be the outline of what's to come.

Doctors Feeling Gloomy?

By Shawn Vuong

Yesterday I was talking about my worries of becoming a bitter doctor.  But why do doctors loose morale?  Today, Sarah Rubenstein of the WSJ gave me some insight on this matter.

Here are some of the bracing findings from 11,950 primary care docs and specialists who responded to the survey:

94% said the time they’ve devote to non-clinical paperwork in the past three years has increased. 63% said the paperwork has meant they spend less time per patient.

82% said their practices would be “unsustainable” if proposed Medicare pay cuts were made.

78% believe there is a shortage of primary care docs in the U.S.

49% said that over the next three years they plan to reduce the number of patients they see or stop practicing entirely.

60% would not recommend medicine as a career to young people.

42% said professional morale is either “poor” or “very low.”

17% rated the financial position of their practices as “healthy and profitable.”

6% described morale of their colleagues as “positive.”

Wow, if that isn't depressing I don't know what is.  Paper work, a shortage of doctors, and low morale possibly through low reimbursements, insurance controlling care, and less doctor-patient time.  I may be wet behind the ears in the world of medicine, but I can tell you one thing, I am going into medicine to take care of people.  If a primary care physician told me that all the paper work they do keeps them from seeing the patient, I'd dodge primary care like the plague.  Many other medical students already are dodging away from primary care.

A couple questions come to mind after reading this.  First and most obvious question, how do we fix this?  Also, since Dr. Holm is a family doctor himself, I would like to know what his general opinion is on this article.  Is morale really low here in South Dakota?  Are family physicians here feeling the pinch of administrative work, low reimbursements, and insurance control?

Healthcare Costs Part 1

By Richard P. Holm MD

Maybe it was ten years ago I heard a political reformer pose the question: What if we paid for groceries like we pay for health care in the U.S.& how different would it be? He described buying groceries where there would be no reason to look for a bargain, but rather motivation to buy the most expensive items, and everybodys basket would be filled to the brim.

I think there is still some truth to the comparison, because in this world of third party payers for health care, the consumer is still not driven to look for value. Rather it seems the employer who buys the insurance has to do that. But in 2008 there are some changes we would have to make to the grocery-store/health-care comparison.

Now you find that there are only three grocery stores in the state, and you have to go to the store your employer chose. Upon arrival to the store you find a very elaborately decorated and expensive building, the carts are robotic, the aisles are wide and beautiful, and there are way more managers than checkout people, due to government beaurocracy.

Looking around you realize that every customer in the store seems to have a different way of paying for the food. One person has a plan where all the food is free, once he reaches his deductible, but it pays only for certain food, and he cant figure out what that is, except to know that generic beans are always paid for. And then there are customers who have managed care advisers walking around the store with them pointing out which food is not available to them. What's more, there are many people outside the store that can't get in.

It is not a perfect metaphor but it makes one point very clear the system is a mess. In this age of healthcare reform, please be pro-active and contact your Washington legislators.