Tuesday, February 28, 2012

WWHD? (What Would Hippocrates Do?)

     For those of you who think the American healthcare system is superior to that of Canada's socialized medicine infrastructure because "we don't have to wait for services like they do", let me reassure you that you are sorely mistaken. As a physician who happens to be the mother of 21 year old twins with cystic fibrosis (CF), I consider myself somewhat of an expert in what it's like to actually utilize our current system. Nick, Rory, their father, and nowadays, their girlfriends, and I have spent two decades waiting in doctor's offices, living in hospital rooms, and dealing with the ongoing nightmare of insurance companies whose main function appears to be limiting access to healthcare through the use of idiot gatekeepers who routinely use pre-printed algorithms, without rhyme or reason, to deny claims and specialized CF medications. Every hospital's billing department is a hot mess (NOT in a good way), making it necessary to go over every single bill, of which there are dozens per year, with a fine-toothed comb. Trust me, I find LOTS of errors.
     How is it that we, as a society, continue to justify healthcare as a business, profiting from disease, instead of preventing it? I wonder if the general public is aware that we are giving bilateral knee replacements to super-morbidly obese people, seemingly without any pre-surgical weight loss recommendations, just because they received a green light from their insurance provider? Clearly, these patients are not good surgical candidates for a variety of reasons. They are at significant risk for all sorts of life-threatening intra-operative and post-operative surgical and anesthetic complications, ranging from hypoxemia due to obstructive sleep apnea to cardiac arrest from surgically-induced stress. Someone who has a body mass index over 50 kg/m2 is not going to jump out of bed onto his or her new knees to go on a three mile jog. If they make it through their post-operative course without a wound infection, a deep vein thrombosis or pulmonary embolism, or a respiratory arrest, they're still just as likely to continue riding around the supermarket in their motorized scooters. At best, they'll get off of their narcotic pain medicines because their knees no longer hurt, but for the most part, they will remain just as unmotivated to modify their diets as before. Then, there's the tricky issue of smokers with lung cancer or coronary artery disease. How is it that we routinely offer operations to people who demonstrate no initiative or personal accountability for risk factor modification, e.g. a firm commitment to tobacco cessation? Isn't there something screwed up about this? Are we honoring the ethical principle of distributive justice by resecting lung tumors and performing coronary artery bypasses on people who are actively engaged in killing themselves, with absolutely no inclination to stop smoking after surgery? 
     If you think our system isn't already rationing healthcare, think again. Our rationing is the worst kind of all: people who have insurance generally get healthcare, while those who aren't insured, often because they are self-employed and can't afford it, have to pay out of pocket for it. Our rationing isn't rooted in the principles of medical ethics, it's based on the almighty dollar. In case you're a completely healthy person who's never personally reviewed a clinic or hospital bill, they are often hundreds to thousands of dollars. In the interest of maintaining an acceptable profit margin, hospitals mark up the cost of things like aspirin, usually by a factor of five, meaning that you get charged a quarter for a pill that normally costs five cents. That may not sound like much, but believe me, it all adds up. For instance, when my sons require hospital admissions for cystic fibrosis tune-ups, I receive an 8 or 9 page bill which includes a $900 charge for "self-administered" medications during a 24 hour stay. This means that every time a nurse brings my sons their pancreatic enzymes to take with their meals, they are charged not only for the medication, but for the "privilege" of administering it to themselves.
     There are millions of people in this country who are uninsured. Contrary to what you may think, many of them are everyday people, just like you and me, who by some stroke of misfortune are either unemployed or cannot afford to purchase their own insurance. If you've never had to look for a personal insurance plan, they are prohibitively expensive. Under our current system, if you have a pre-existing condition, you may wait anywhere from 6 months to a year before your insurance will cover any expenses related to that problem. (This type of discrimination is slated to be eliminated in 2014). One of my biggest concerns as a parent of children with chronic disease is what will happen after they turn 26? Both of them are musicians...how are they going to obtain health insurance once I can no longer cover them? Will they be able to find an affordable plan? They are both motivated and compliant patients who are rigorous about taking their medications and performing pulmonary treatments several times a day. Through no fault of their own, they are sick. Why are they less deserving of reasonably-priced insurance coverage than a smoker or a morbidly obese person, who happens to have the luxury of being covered by his or her company's plan? Should my sons' livelihoods be based strictly upon whether or not they can get a job that provides insurance? Is that what life, liberty, and the pursuit of happiness is all about? What if they were your kids?
     Indeed, the American dream, at least in terms of access to healthcare, seems to be limited to those who can afford it. Opponents of socialized medicine want you to believe that people in dire need of medications or operations are dying because they have to wait for them, that physicians in those countries are grossly underpaid, that it's cumbersome and inefficient. My Canadian cousins, as well as several American-trained Canadian physicians that I know personally, heartily disagree. They shake their heads in disbelief at the state of healthcare in the United States. Indeed, one may have to wait for an elective procedure, but elective procedures aren't "necessary" in the first place. They know that if they are sick, they will receive treatment because their government considers healthcare a right, and everyone taxpayer pays for national coverage. In case you're unaware, we have an abundance of healthcare horror stories and inefficiency in this country. We have an unacceptable number of homeless women walking around with huge, fungating breast cancers, who don't seek care until their disease has metastasized because they don't have insurance...they're not in possession of the necessary "golden ticket." The only means of help available to these women is to stand in line all day at a free clinic, if there happens to be one available. Stories like this sometimes get national attention on shows like Dr. Oz. We sympathize with these women, but then, we go back to our business and forget about them, and the thousands just like them, who are living amongst us from coast to coast. Would you feel the same if one of these women were your mother?
     Even those of us with insurance have to wade through shitpiles of bureaucracy to get the help we need. Yesterday, my son, Rory, went to Emory to get a PICC line (long term IV catheter) for home IV antibiotics. We found out at 5 p.m. that the antibiotics never got ordered because of multiple layers of miscommunication within the clinic system. What should have been a simple, straightforward coordination of services between the clinic and the home health provider turned out to be a day long ordeal, disrupting not only his life, but resulting in an unacceptable delay in his therapy. We were only able to speak to his doctor after I threatened to register a complaint with the patient care representative. Unfortunately, our system can't handle simple matters like this because there are too many middle men, too much red tape. The whole idea behind keeping Rory out of the hospital was to prevent him from being unnecessarily exposed to the hospital's nasty germs, to prevent him from missing another day of work, and to avoid being charged for inpatient hospitalization, which because of the way deductibles work, would have ended up costing a couple thousand dollars. Everything that needed to be done for him could have been done at home. The only glitch was that Infectious Disease (I.D.) is the hospital service that writes the antibiotic orders, and because their clinic has "manpower" issues, it's easier for I.D. to have Rory admitted and have him evaluated by them there. This is not only ridiculous, it's unacceptable. To subject a motivated, compliant patient like Rory to hospitalization out of convenience for the institution, not because it's what's best for him, is ludicrous.
     I'd like to invite everyone who opposes national healthcare to spend a day in Rory's shoes. He, and his brother, Nick, have spent their lives waiting, waiting again, and then, waiting some more. Not only have they waited, but as adults, they now have to worry about whether they'll be able to procure health insurance after they turn 26. No one in this great country of ours, a wealthy superpower with one of the most advanced healthcare systems in the world, should EVER have to worry about something like this. Health care is a right, not a privilege. It is also a personal responsibility, something which our current system does very little to emphasize or reinforce. As a society, I believe we all shoulder the responsibility for ensuring that American citizens have equal access to healthcare, whatever it takes. I'd personally prefer paying for universal coverage for all Americans, than paying into a system which continues to make millionaires out of insurance and hospital CEOs. Twenty-five hundred years ago, Hippocrates said, "Wherever the art of medicine is loved, there is also a love of humanity." I think he'd probably agree with those of us who support national health insurance. A humanistic society puts its people, not the love of money, first; to me, that's what ensures that all of us can enjoy life, liberty, and the pursuit of happiness. If we truly loved our neighbors as ourselves, we'd find a way to make universal coverage work.

1 comment:

  1. I agree, Kris, decent and affordable universal healthcare coverage is a priority. What's astounding is the rising costs of healthcare, and this could be largely due to emerging technologies. I am sure there is a way to make healthcare affordable to all, without it you have one sick nation. Like you, I think prevention is better than cure, anyday. And sufficient awareness has to be spread about preventive measures. At an individual level any one can only hope that these measures get as much value and attention.