Wednesday, May 31, 2006

Culture and Health Care Reform

The issue of medical safety provides a clear illustration of the important bearing that cultural forces have on health care reform.

Not so long ago, it was generally believed that doctors did the best they could but there were no guarantees and sometimes things came out badly. Only in the most extreme circumstances would it be thought that an unfortunate outcome was somebody’s fault.

That is changing. Ever so slowly, perhaps, but then cultures seldom change rapidly.

One recent bit of evidence was the recent report that CMS, the federal Medicare agency, is considering the possibility of not paying in the case of what are called “never events” (Modern Healthcare, May 22, 2006).

A “never event” is something that should never happen. One example is wrong-site surgery; for example, doing rotator cuff surgery on the wrong shoulder. It doesn’t happen so often, but it isn’t rare, either. According to the Modern Healthcare report, the Joint Commission on Accreditation of Healthcare Organizations last year received reports of 84 wrong-site surgeries.

Anyone not familiar with American medical culture might well wonder why anybody should pay for surgery done at the wrong site. But that is exactly what Medicare (like most insurance plans) is doing. Furthermore, when wrong-site surgery causes further damage that needs repair, Medicare pays for that, too.

Robert Wachter, chief of the medical service at the University of California at San Francisco Medical Center, was quoted as saying that not paying for never events would be “a very large and bold step.”

In a way, he is right about that. Any step that changes the culture qualifies as “large and bold.”

Tuesday, May 23, 2006

The Hazards of Comparisons

Friend Donna Anton, now living in the far southwest of England (Cornwall) and an avid reader of the New York Times via Internet, calls to my attention the article in last Sunday’s edition of the paper titled “Here, if You’ve Got a Pulse, You’re Sick.”

The article reported a study indicating that Brits are healthier than Americans. However, looking into the matter a little further suggests that things are not always as they seem. For one thing, Americans are a lot more compulsive than Brits are about doing screenings for colon cancer, skin cancer, and the like. As a result, we get diagnosed for things that ultimately we die with but don’t die of. In the meantime we add to the statistics of those with the disease, making it appear that we incur the condition more frequently than the Brits, who don’t bother to get the test in the first place.

In the U.K., according to the article, the tradition is one of “independent and perhaps more skeptical primary-care practitioners who are probably slower to label and diagnose people.” Americans, on the other hand, are more likely to say “Do something, Doc. Don’t just stand there.”

The article ended with the story of a medical resident in the U.S. who defined a well person as a patient who hadn’t as yet been completely worked up.

It is a good reminder of the important influence culture has on health care and that what is acceptable in one culture is unacceptable in another.

Those who would duplicate the British health system in the U.S. would be well advised to take note.

Monday, May 15, 2006

Logic and the Massachusetts Plan

Those who pay attention to such things will know that Massachusetts recently passed a law designed to reduce the number of people in the state without health insurance. Among other things, the law

- requires companies with more than ten employees to offer and contribute to a health insurance benefit,
- requires all residents of the state to have health insurance,
- assesses a “fee” against those who do not comply, and
- subsidizes health insurance for people with low incomes.

The most controversial part was the requirement applied to employers. The Republican governor vetoed that provision, but the Democratic legislature quickly voted to override.

Whatever else one might say about it, the law enjoys a foundation in logic.

If we are to have a pluralistic, public/private system of financing health care, and if we believe that everybody should have health insurance, then we need to know who is responsible for making it happen.

We have already decided that the federal government will be responsible for seniors (Medicare) and that the states – with federal help – will be responsible for the poor (Medicaid). That leaves the employed population and its dependents.

For a number of reasons, the most practical way to offer coverage to the employed group is through employers. Almost all employers of any size already do.

Smaller companies have resisted being required to offer a health insurance benefit. In doing so, they are by implication taking a stand either against the pluralistic system of financing or against minimizing the number of uninsured. One doubts that they would be willing to defend either position openly.

Furthermore (as was repeatedly pointed out during the Massachusetts debate), since those who pay for care also pay for those who don’t, the companies that provide health insurance are, in effect, subsidizing the companies that don’t.

Whether the Massachusetts plan will prove successful remains to be seen. There are a number of hurdles yet to be overcome.

But logic is on its side.

Saturday, May 13, 2006

If Doctors Can’t Fix Them, Who Can?

Long-time friend Bob Odean was good enough to call to my attention the May 1 issue of Time magazine and its lead article titled Q: What Scares Doctors. The theme of the article is that when doctors need health care, they are as vulnerable to medical errors as anyone else.

The key sentence, in my mind, said “While doctors are often in a better position than most of us to spot the hazards in the hospital and the holes in their care, they can’t necessarily fix them.”

Which raises the question; if the doctors can’t fix them, who can?

To me, the answer is pretty clear. Hospitals have to do it. There isn’t anybody else. We don’t see that yet, because we remain immobilized by the notion that the practice of medicine and the doctor-patient relationship are sacrosanct and not to be interfered with.

When we get over that, health care reform can begin in earnest. Maybe admitting that doctors can’t fix the hazards or plug the holes is the necessary first step.

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