No doubt, we are in a major health care crisis in this country. Pathology continues to spiral out of control, putting greater and greater economic demands on an already-stressed system. Doctor-patient relations as well as hospital-patient relations have become adversarial. Malpractice litigation continues to impact health care costs and the way patients are treated. Hospitals are understaffed. Physician offices are overcrowded and overbooked. Time constraints have fueled increases in pharmaceutical medicine in many practices. This has fueled side effects, drug-related deaths and poor quality assessments. Patients are being under-diagnosed and under-treated for more severe conditions and over-diagnosed and over-treated for lesser issues. Patients freely and openly criticize their physicians for a myriad of perplexing issues that are neither the fault of the doctors nor the patients. More and more patients are turning to the Internet for answers that they cannot seem to get at the doctor's office. And even if they get them from their physicians, they don't trust them. Doctors have been forced to deal with ever-increasing skepticism for their recommendations, and compliance is becoming a major threat to many practices as patients are not willing to fill yet another prescription.
The focus up until now, in my opinion, has been monocular, i.e., "How are we going to fix this system?" Government is focused on this, hospitals are focused on this, the public is focused on this, economists are focused on this and every health care provider is as well. But is this where we should be putting all of our attention and energy? It seems to me that the more apparent focus needs to be less on how to fix it and more on how it happened. A mechanistic diagnosis is in order here. Trying to fix a broken system is like trying to treat symptoms without a working diagnosis and no understanding of causative factors. It is nothing more than throwing water on the smoke. It seems that the government is loathe to undertake analysis as to how and why this has happened in the most technologically advanced medical culture in the world. In my opinion, you cannot and will not repair the mess we are in by trying to create an economic solution. The medical crisis we find ourselves in is not one of how we finance the ever-increasing burden on our health care system. The financial strain is just a symptom. The crisis that we are in is multifaceted and needs to be addressed piece by piece so that once we understand the causative factors we can then implement a "protocol" that can truly heal the condition.
Health Insurance Companies
Should these companies be calling themselves "health insurance" companies? It does not appear to me that they are here to ensure that anyone has good health. They are here to maximize profitability by minimizing payments to doctors and hospitals. A better name for these companies would be Premium Preservation Companies, as they work to protect their bottom line by trying to keep as much of their premium collections as they possibly can. And they have done this VERY successfully. They have been so successful that they have been able to set the standard of care for physicians. Thirty years ago, the standard of care was set by physicians. That is no longer the case. The current standard of care does not consider what is best for each patient. It considers what is best for the insurance company's bottom line. If you don't believe this, you are living with your head in the sand. How is it possible that these companies dictate to physicians how they should treat their patients? How is it that decision making for what is appropriate for patients is based on an invented standard that protects insurance company liability? They have worked a magical formula -- in my opinion, probably the best piece of capitalism I have ever seen. Not only did they convince doctors to sign contracts to participate in their provider panels, but they convinced them that if they were left out, they would not be able to survive in practice. At the same time, they convinced the public that they could get all the medical care they needed for the price of a co-pay. This did two amazing things for their profit model: 1) They conditioned the public to believe that medical care should have no costs other than a co-pay, successfully convincing the public to purchase health insurance; and 2) They were able to convince most physicians that what they are offering their patients has no value other than the co-pay, thereby making physicians clamber for acceptance into the provider panels.
There are other issues with insurance coverage. In-network fees are so low now that in order for a medical practice to survive and flourish, an extraordinary volume of patients needs to be seen. This means that the time spent per patient is extremely limited, the amount of information used to make a diagnosis must be cursory and not detailed, and the treatment must be simple and quick to make room for the next patient in the queue. The system lends itself to poor quality and, by its very nature, nurtures it. In addition, the need for more administration of the medical practice, as well as adjunct health care needs, forces them to employ more personnel, which cuts into profitability. As such, we have developed a system of rapid symptom care with no understanding as to cause and effect. Hmm. Sounds familiar.
Medicare
At the same time, the government was working tirelessly to deconstruct the Medicare program by placing more and more limitations on care and requiring more and more guidelines for what is considered acceptable care. NONE of this was with the patients' best interest in mind. It is strictly economic. The government is also guilty of throwing water on the smoke, making it more and more difficult for physicians to practice according to their training. In essence, insurance companies and Medicare eliminated patient-specific medicine. If you don't fit the guidelines, you don't get the care. But remember, we have patients who believe they are "entitled" to receive whatever care they need. We have physicians who believe that what they offer has no value. Therefore, we have many doctors who will do their best to get patients cared for, even if they have to "invent" the charting to fit the scenario. This is great for the government and insurance companies who can "investigate and audit" doctors records and then find them guilty of fraud, over-utilization or using "experimental/investigational" therapies and demand money back. Wow! How amazing is this? First, take away a doctor's ability to practice prudent medicine by setting standards of care that are handcuffing patient-specific medicine. Then, audit records, find violations and make demands for refunds. Now, the government or insurance company gets their money back, the doctor is no longer a liability to them and no one is the wiser to the charade.
Lifestyle Diseases
Another equally important issue here is that the explosion in lifestyle diseases is creating demands for ever-expanding technologies, which place a huge financial burden on the industry. Who is supposed to pay for the much needed advances in medicine and surgery? Certainly, physicians and hospitals cannot be expected to foot the bill and provide quality care. So who should own this? In my opinion, it is the public themselves. The diet and lifestyle of the average American is fueling an array of diseases. Essentially, they are eating themselves sick. They are not exercising. They are not doing anything to curb the stresses of modern living. Who is responsible? In a world dominated by "adults," the adult mind needs to be responsible for its own existence. If you walk into a supermarket and only one aisle is marked "Health Foods," then what are they selling in all the other aisles? Obesity and, more specifically, "diabesity," is an epidemic that is not only going to wreak havoc on the health of this country, but the economic ramifications of treatment (management) will continue to spiral out of control. I implore every adult reading this to take stock of their own diet and lifestyle. Do not expect to live unconsciously and enjoy good health. Do not expect physicians to come and "save" you from yourself. There is only so much medicine can do for you. You have to be the advocate for your health. No one else can be.
Chronic Drug Management
Living unconsciously and treating all of our symptoms with medications may "keep us alive and comfortable," but chronic drug management does not optimize our health. In fact, drugs are also toxins that put a burden on our immune systems. Reaching for a pill for every symptom will only allow us to continue our unhealthy lifestyle, fooled by the mechanism of symptom relief. We have already seen what the over-utilization of antibiotics has done. We have super-bugs that are resistant to our antibiotic therapies. These bacteria are placing new burdens on us financially as we clamber to find the next generation of antibiotics that can prevent more unnecessary deaths.
I am not at all saying that drugs are not needed. Quite the contrary. They are miracles when used in situations where there is no other option. What I am saying is that a complete reliance on drugs to manage the growing population of patients with chronic illness will not stem the tide.
Taking Responsibility
If every adult in this country realized the importance of healthy, unrefined, organic foods and demanded it, then it will be supplied at much lower costs than it is now. This is straight forward capitalism -- supply and demand. Our refined, chemicalized, hormone-treated foods, pesticides, herbicides, genetically-modified foods and the tormented lives of the animals being raised for consumption (which sharply elevates stress hormones in the meat we consume) are all killing us. If everyone "got off the couch" and began exercise programs (under medical supervision if need be) and improved their diet as much as is reasonably possible, we would see a huge decrease in pathology. Basically, what I am saying is that prevention is much cheaper and a whole lot less painful than treating pathology. It is like chasing the speeding train. You cannot catch up unless you slow the train down (i.e., establish a healthy diet and lifestyle).
The Environment
What else is stressing the health care system in this country? Our environment is. Every day, we breathe in toxic airborne pollutants. Imagine, with every breath we take, we are creating stress in our systems that needs to be dealt with. This constant onslaught of poisons misdirects our immune system and takes away much of our ability to detoxify, repair and replace our cells. We need to clean up the environment, but we really need to do this NOW! It is not okay to say it and then buy products from, and invest in, companies that continue to support the destruction of our environment. It is critical that we GO GREEN. If we want the planet to be a healthy and safe one for our children, we need to take our heads out of the sand. This has never been a more critically urgent matter than it is now.
Medical Malpractice
Lastly, we have the issue of medical malpractice. This has simply gone "hog wild." While there are true and absolute cases of negligence, I believe they are far more infrequent than statistics on malpractice reveal. However, attorneys have developed a definition of negligence that feeds their agenda. Doctors are being held to an exaggerated "standard of care" that drives up the cost of delivering health care. For doctors, malpractice defense costs can run into tens of thousands of dollars, even if there is a defense verdict and no payout to the plaintiff. In addition, yearly premiums for some specialties cost six figures. In her article in Health Day, Mary Brophy Marcus enlightens us to a report appearing in the April 5 edition of The New England Journal of Medicine, which reveals that the patient ends up paying in the end. "Higher defense costs and higher malpractice premiums are ultimately passed down to patients through higher physician fees. Expert witnesses, research costs, lawyers' fees and funding overhead costs, such as filing fees, are among the expenses that rack up bills", said Dr. Anupam Jena, a physician at Massachusetts General Hospital, Harvard Medical School, and a senior fellow at the Schaeffer Health Policy Center at the University of Southern California.
Ms. Marcus goes on to say that Dr. Jeffrey Segal, a neurosurgeon and founder and CEO of Medical Justice, heads a for-profit company that helps physicians deter and manage frivolous medical malpractice lawsuits. He said the letter in NEJM points out not just costs of claims, but the significant number of cases that come through the legal system that aren't won by the patient.
"We see here many claims are coming through that don't have merit. In a perfect legal system, you'd have the dollars going to a patient who is injured by medical negligence," he said. "This reaffirms that it's a system that takes a lot of time and is very expensive."
Doctors are trained to provide health care, but we are human. Society has become intolerant not only of errors in judgment, but also intolerant of less than perfect outcomes.
Suffice it to say that ALL physicians have been forced to practice defensive medicine. That means they have one eye on the potential of a lawsuit and how best to position themselves for a good defense. This clearly leads to lots of diagnostic tests and additional consults that may, in fact, not be necessary, thus driving up the cost of care.
In Conclusion
As you can see, this is no simple process. It requires that each and every citizen understand the complexities of our current medical crisis and look at the problems from outside of their own personal agenda. The real fix will come only from commitment, responsibility and sacrifice on everyone's part in creating healthier diets and lifestyles. And, we need to take MUCH better care of our environment.
Additionally and most importantly, it is time for insurance reform if we want our health care system to be maximally functional and patient oriented. That includes both health insurance reform and malpractice reform. The bottom line is that we all need to be part of the solution. If so, then everyone benefits from improved health, and health care services can be provided in a prudent, efficient and effective way. As a doctor who has been in practice over 30 years, it has been my personal experience that the health of our population is declining, our ability to provide services to our patients is declining and health insurance companies and malpractice cases have become HUGE thorns in the side of every physician in this country.
I, for one, am mad as hell, and I'm not going to take it anymore!
For more by Dr. Robert A. Kornfeld, click here.
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