Cell 2 Soul: The Humane Health Care Blog

Is Healthcare a Right?

by Atul Gawande
New Yorker, October 2, 2017
Link

This is a timely and informative essay.

Gawande meets with some old friends in Athens, Ohio, where he grew up, to discuss their take on the question. It is kind of a trip down memory lane for him.

The meat of the essay comes about halfway through when he discusses the work of the Oxford political philosopher Henry Shue who postulates that basic rights include physical security, water, shelter, and health care. Meeting these basics is among governments highest purposes and priorities.

I think the goal should be security. No matter how bad things get this shouldn't be what you worry about, namely healthcare.
When people in a society get very different deals on things like healthcare, the pact with the government breaks down. That's what is happened with American healthcare.
The reasons go back to a seemingly innocuous decision made during the Second World War. In that time, the administration permitted increases in health insurance benefits and made them tax-deductible for employers. It didn't seem like a big thing at the time, but ever since we've been trying to figure out how to cover the vast portion of the country that doesn't have employer-based health insurance. Therefore, we had to stitch together different rules and systems for each of these categories and the result is an unholy expensive mess that leaves millions of people un- or under-protected. As a country, where pretty much everyone gets options like K – 12 schooling we've been reluctant to address the Second World War mistake and establish a basic system of healthcare coverage that's open for all. The prospects and costs of healthcare in America very wildly and incomprehensibly according to your job, your state, your age, your income, your marital status, your gender, and your medical history, not to mention your ability to read fine print.
Do we want?

• Medicare for all
• Each state to have its own plan for care
• A nationwide market place where we all choose among a selection of health plans
• Or personal accounts that we can use to pay directly for healthcare?

Any of these could work. Each has been made to work universally somewhere in the world.

As a country, we don't have any of these at this time. Gawande's article is a lucid introduction to this area, and worth reading and studying for healthcare providers, the public, and all students.

The Rise of the Red Carpet M.D.

High-end boutique health services – doctors on retainers, 5-star hospitals – are transforming care (for the very wealthy).

[This article in the NY Times Sunday Business section describes what care for the wealthy is like. Those who can afford it can now jump the queue. The poor and even the average patient can wait in the wings while the privileged few are ushered into clinics and hospitals first.]

You have no idea how much money there is here,” said Dr. Harlan Matles, who specializes in internal medicine and joined MD Squared after working at Stanford.

Most of these groups do not advertise, virtually no presence on the web, and new patients come strictly by word of mouth. With annual fees that range from $40,000 to $80,000 per family (more than 10 times what conventional concierge practices charge), the suite of services goes far beyond 24-hour access or a Nespresso machine in the waiting room.

There are rewards for the physicians themselves, of course. A successful internist in New York or San Francisco might earn $200,000 to $300,000 per year; but these boutique practices pay $500,000 to $700,000 annually for the right practitioner.

Nowhere is the velvet rope in health care rising faster than in Northern California, where newfound tech wealth, abundant medical talent and a plethora of health-conscious patients have created a medical system that has more in common with a luxury hotel than with the local clinic.

The traditional model of having a good internist is dying,” said Mr. Traina, a scion of a prominent San Francisco family said. “Even the 25-year-olds at my company either have some form of concierge doc, or they’ll just go to an H.M.O. or a walk-in clinic. No one here has a regular doctor anymore.

 

As I read this article, I kept thinking, "Something is definitely wrong here.  This is immoral and flies in the face of what being a healer is about.

Who Are the Medically Uninsured in the U.S.?

In spite of the Affordable Care Act there are many people in our country without health insurance. "The remaining uninsured are primarily in the South and the Southwest. They tend to be poor. They tend to live in Republican-leaning states. The rates of people without insurance in the Northeast and the upper Midwest have fallen into the single digits since the ACA’s main provisions kicked in. But in many parts of the country, obtaining health insurance is still a problem for many Americans."

See: We Mapped the Uninsured.

The states with the lowest percentage of uninsured tend to be the ones that have expanded Medicaid coverage.  However, it can be difficult for Medicaid patients to obtain health care, especially from specialists.  See: Cherry Picking in the Aina.

It's hard to believe there are still so many health care unequalities.

 

 

Steven Brill's Bitter Pill

There is a tsunami media blitz about Steven Brill's new book, America's Bitter Pill.  Is it because the book is really great or is it about marketing?  We will know in a few weeks.

Steven Brill has also recently published an important article in Time magazine on the same subject.  Both are called America’s Bitter Pill. 

See:  Zephyr Teachout’s book review of America’s Bitter Pill in the NY Times (1.9.15)
Time Magazine article:  you need to have a subscription to read it online
NPR interview with Teri Gross (35 minutes)
The Bill by Malcolm Gladwell (review of the Brill book). New Yorker January 12, 2015 (Full Text Online)  Gladwell, ever the contrarian, is less enamoured with Brill and his book than the others.

Excerpt from Terry Gross’ Interview of Steven Brill

“It's hard to understand why you get 36 different first-class envelopes with 36 different pieces of paper from the same insurance company on the same day. That tells you something about the efficiency of the health care industry right there. But then, as you open each envelope, they're as completely unintelligible to me as they are to you, as they are to everyone listening. But better yet, they're also as unintelligible, apparently, to the people who write them.

I got to do what is probably a reporter's dream ... which is I took one of those explanations of benefits, which said, "Amount billed: zero. Amount insurance company paid: zero." And the third column said, "Amount you owe: $154." So it makes no sense.

But here's what I got to do: I had scheduled, as part of the reporting for my book, an interview with the CEO of United Healthcare, the largest health insurance company in the United States — and my health insurance company, as it turns out. I went out to Minnesota to interview him and asked him all kinds of questions about what he thought the impact of the Obama health reform was likely to be. And at the end, I took that explanation of benefits out of my suit pocket and said, "I'm wondering if you could do me a favor, could you explain this to me?" ... "How can I owe $154 if nothing was billed?" He looks at it ... and looks up at me and says, "I could sit here all day and I couldn't explain that to you. I have no idea why they sent this to you."

Summation of NPR Interview:

GROSS: So we started our conversation by talking about your experiences as a patient and the bills that you got when you had open-heart surgery. So now being an expert on the history of Obamacare, on billing practices and on being a patient, if you could make one change what would it be?

BRILL: Well, it would be three.  You take the people who provide the kind of care that I saw firsthand in my own situation, and you put them in charge. You let them expand. You let major hospital systems expand, and you let them provide their own insurance. I'd rather buy my insurance from New York Presbyterian Hospital in New York or Yale New Haven because that's a brand I trust. And then you regulate them like crazy to make sure that they live up to their promises, and you control their profits. And at the same time, you regulate the cost of drugs, and you provide significant malpractice reform.

The NPR piece is a great interview and compliments the Time article.  The latter is not available online at this point.

There is a lot of important information in these resources.  If you are busy with many other things, start with Zephyr Teachout’s book review (online) and the Time magazine article that your local library will have.  I wonder, though, is this "a tale told by an idiot, full of sound and fury and signifying nothing?  Or is this "divinest sense?"

 

 

 

The Shame of American Health Care

Even as Americans struggle with the changes required by health care reform, an international survey released last week by the Commonwealth Fund, a research organization, shows why change is so necessary.

The report found that by virtually all measures of cost, access to care and ease of dealing with insurance problems, Americans fared poorly compared with people in other advanced countries.

See full editorial.  Read and weep!

The Appointment: Then and Now

Dr. E. Ceriani ~ 1948

Sue Mayfield Geiger submitted a fine essay to us on how the doctor's visit has changed over the years.

Basho has a haiku:

Chrysanthemum growers --
you are the slaves
of chrysanthemums

one might say

Doctors --
you've become the slaves
of corporate medicine

Please read Ms. Geiger's fine essay:  The Appointment:  Download The Appointment Geiger

Author Bio:Sue Mayfield Geiger writes and edits for regional and national publications, and lives on the Texas Gulf Coast. Her first book of prose and verse (with photos) is now available. www.gibbonsstreet.com.  You can email comments to her at:  SMG

 

Concierge Medicine

There is an old Yiddish saying:  "If the rich could pay the poor to die for them, the poor would make a very good living."  Well, it is coming to pass.

Concierge medicine is a relationship between a patient and a physician in which the patient pays an annual fee or retainer. In exchange for the retainer, doctors provide enhanced care. Other terms in use include boutique medicine, retainer-based medicine, and innovative medical practice design.

The NY Times had an eye-opening article on this topic on April 30, 2011:  Putting Your Doctor, or a Whole Team of Them, on Retainer.  It is worth reading to see where this trend is going.  The rich are, in this case, co-opting physicians' time that might better be spent with poor suffering humanity. 

Osler wrote:  "The practice of medicine is a calling not a business."  Clearly, some arrogant, greedy physicians do not adhere to his sentiment.

 

If Air Travel Was Run Like Health Care...

Jonathon Rauch, a staff writer at the National Journal has written a compelling article on Health Care delivery.  The seven minute video based on this is brilliant, funny, poignantly true and more direct..  It summarizes the frustrations patients and care givers deal with daily in the attempt to navigate the medical-industrial complex.  For a memorable video see: You Tube.

"Hello! Thank you for calling Air Health Care, the airline that works like the health care system. My name is Cynthia. I will provide you with outstanding service. How can I give you travel care today?"

Rauch's essay can be read at the National Journal.

Strangely, this video recalled a fine skit the late Hawaiian comedian, Rap Repleinger, produced in the 1980s.  This, too is available on You Tube.  See:  Room Service.

  .

Marginal Notes: A Socratic dialog on health care reform (VI)

Toward the evening of a long day, the philosopher Socrates finally makes his way to the home of Hippocrates, the father of medicine.  >>more

The final in a series of Socratic dialogs on health care reform.  Apropos of these discussions, interested readers may wish to peruse previous conversations with Aeschylus, Plato, Aesculapius, Apothos, and Litigius.

 

Brian T. Maurer has practiced pediatrics as a Physician Assistant for thirty years.  His "Marginal Notes" column appears periodically in the Cell2Soul Blog. The title "Marginal Notes" is taken from a quote by Henry David Thoreau: "I love a broad margin to my life."

Marginal Notes: A Socratic dialog on health care reform (IV)

The philosopher Socrates seeks advice from Apothos the sorcerer for a potion or pill to dampen the discomfort in the wound on his foot and learns a bit about standards of practice in the pharmaceutical industry.  >>more

 

The fourth in a series of Socratic dialogs on health care reform.  Apropos of these discussions, interested readers may wish to peruse previous conversations with Aeschylus, Plato and Aesculapius.

 

 

Brian T. Maurer has practiced pediatrics as a Physician Assistant for thirty years.  His "Marginal Notes" column appears periodically in the Cell2Soul Blog. The title "Marginal Notes" is taken from a quote by Henry David Thoreau: "I love a broad margin to my life."