In response to my past two ennui-ridden posts, I got several comments asking the question, what can we do?
Ellen asked this:
Now that I read your blog, I once again wonder what I can do. I do believe the public is sick of the \”lying sacks\” – which is what my daughter calls politicians. I am sick of their lies and self-serving ways, too. If you have suggestions, please let me know. I do not believe the politicians represent their constituents – they represent themselves and those who bribe them with political contributions.
Another reader emailed me this:
So I am coming to you, with admitted ignorance about what my role is, and asking you what we as patients, consumers or recipients of Medicare/Medicaid can do to help implement solid change in the system? I want to make a difference in the health care system and am a pretty good advocate. Wearing the pink ribbons for breast cancer awareness is not my calling, I instead want to use this energy to advocate for real change. Any direction or advice you could offer would be greatly appreciated.
Good questions.
When I hear people saying that we need to get involved and not just sit around and gripe, I think at least I am writing about it in a forum where people actually hear about the issues. There is truth to this; blogging has offered me a great soap box to stand on that an otherwise average primary care physician would never have had. My posts being republished on the Better Health Network, MedPage Today, and The Health Care Blog allows my voice to be heard at a level I never could have imagined.
Yet I stop when faced with questions like the ones my readers posed. How can we turn a cry for sanity into real change? How can we make a real difference by affecting a change in our system? It\’s all fine and good to raise awareness, but being aware the boat is sinking is not the same as fixing it.
I don\’t really know. The problem is that the nature of real change is a subject of much debate. Some would say that real change must include government-run care for all. Some would say that we should fix the tort system. Some would say that primary care should be encouraged with better reimbursement. Some would say that the government should stop meddling so much. But all (except for those in total denial) would agree that our system is on the verge of collapse.
What is the common ground? What are the nonnegotiables that are not politically polarizing? Are there any? Or is this just a political battle, and not a battle of wisdom over folly?
So I turn the question back to my readers: can we come up with a list of non-negotiable changes that our system must have? Can we create a healthcare (or health care, if you are that kind of person) declaration of sanity/bill of rights?
What do you think? I really want to know what you think are the things that we could actually all agree on. Rhetoric is fine (and I am good at it), but at some point we need to step beyond the rhetoric and actually work together. We are asking congress to put down partisanship, yet can we do the same? Can we do better? Can we give a cogent and reasonable list that both Democrats and Republicans could agree on?
I want to know too.
I think that the national politicians involved are not nearly as concerned with fixing a problem as they are with getting reelected and increasing their power and wealth. I think the most useful thing would be to get rid of the incumbents.
I would like to see the middle-man eliminated. That is, insurance carriers. I don’t know that single-payor (gov’t) is much better than for-profit insurance companies.I would like to see individual healthcare consumers/patients make individual contracts with doctors and hospitals, as well. (We seem to be able to make individual contracts with employers and with marriage partners . . . Why not with doctors and hospitals and nursing homes and home care?) As in, this is my fee for an office visit: $$$. Please pay at the time of service.
Next: An MRI costs $$$. Does the patient need/want it? Can s/he afford it? What is the risk/benefit ratio?
A cholesterol screening is $$$. You should have one every 3 years or so . . . Do you have the money on-hand?
A chemistry panel is $$$. How necessary? How often?
Antibiotics cost $$$. Generic antibiotics cost $$$. Can you afford the cost? (Keeping in mind that you are NOT paying an insurance premium of $200-$800/mo, you must then save/budget this money for healthcare.)
Next: This surgery is urgent, necessary, necessary within the next year/5 years. Do you have money saved in your HSA for this surgery? Can you plan to save for it? Etc.
Likewise, skip the TV in every room of the house, and redirect the money towards your HSA. Pay directly for what you want, what you think is important. (A TV is more important than your yearly physical? Really?)
Fees for all these services listed on the wall at the doc’s office, at the admitting office in the hospital, at the visiting nurses’ org’s website, etc. Easy to see. No surprises.
You can save for the things you want/need.
You can go face-to-face with your healthcare providers and pay them for what they have done for you–directly.
You can eliminate all the smoke and mirrors and impersonality that is created by paying insurance who then pays the docs, nurses, hospitals.
This is the direct approach. This approach de-mystifies and simplifies as well. Healthcare consumers can then understand what they are buying and decide what has value for them, depending upon their health status, projection of future needs, values with respect to preserving health. (Some people are “natural” and never go to the doctor, and want to avoid taking a lot of medication. Some people have chronic conditions and are very dependent upon the doc/meds . . . Each story is different.)
What do you do if the bill is too high. That was the point of insurance in the first place. If I’m in an auto accident and my medical casts come to $500,000, I don’t have the money to pay. So do we just let everyone go who is unlucky enough to have an accident or is born in a poor family?
So why have we not started a movement for term-limits for congress? We probably need a constitutional amendment, but I am pretty sure that well over 66% of Americans think that it’s a good idea. That would remove some of the corrupting power of Washington. The problem with throwing out incumbents is that the folks who take their place become incumbents.
I think the important point is to somehow remove the veil that is over how much things cost. We need far more transparency. I would personally love to be able to put up my charges for procedures for patients. Hospitals should do so as well. There is no reason a hospital visit should cost as much as it does, but they can charge that much because they are gaming the system to get as much money as possible. The system is set up in a way that almost demands that the participants game the system. We charge way more than we expect to be paid so we can get the maximum from insurers. The system is confusing, and there is a lot of gouging that happens in the shadow of that confusion.
Drug costs are also a huge topic of discussion. We need cheaper drugs. We need to get the cost down for all medications. How can we do this? The FDA is probably corrupted by the pharmaceutical companies, and some of the laws regarding generic meds drive the cost up significantly. Right now we are protecting the manufacturers of the drugs more than we protect consumers. This is not right.
I would certainly help if there were a viable movement for term limits. I have no idea how to start a movement.All the large corporations would be against such a movement so why would the politicians ever vote for it?
This is why it needs to be a constitutional amendment. Legislators won’t cut their own business.
I think that description also applieas to the leaders of the major medical societies as well. “Photo-op” leadership as it’s called (“Mommy, I had my picture taken with Kathleen Sibelius!”)
I don’t know what the answer is either, all I have are more questions. A big one being, is patient access to doctors going to suffer? Will doctors’ independent decision making be diluted even more? I’m afraid the answers are yes. Should doctors be at the table talking about this stuff? Definitely yes, but many of them are not, according to my oncologist, who follows Congressional movements very closely. Thank goodness for him, and for doctors like you who are speaking up.
I totally agree with you on cost transparency. In my own stab at transparency, I included charges for my breast cancer surgeries in my book (without breaking them out by specific doctor or hospital) because I haven’t seen anyone talk about this and I thought other people might be curious like I was. My mastectomy/related surgeries (two attempts at breast conserving surgery, mastectomy with sentinel node biopsy/stage 1 reconstruction, stage 2 reconstruction with implant/lift on the other one, and nipple reconstruction) cost right around $83,000 (not including a $4,000 MRI to make sure the other breast was okay). I was shocked by how much it cost, particularly the bioengineered tissue used to create a better platform for my post-mastectomy implant ($22k). Just to clarify, these are all the charges before insurance determined what they would pay and what they would write off. Just thinking about trying to figure out that math gives me a headache. (I just thank my lucky stars I had insurance!)
Very interesting post, Dr. Rob, and interesting comments as well. I don’t have all the answers either, but I think the answer lies in our ability to decide what it is we really want.First, I think much of the problem would be alleviated if our congressmen were required to carry the same insurance they are creating for the populous. When they personally experience the system, they are more likely to fix it. Our congress and political leadership has conveniently created their own elite healthcare system and is disassociated from the real problem.
Second, as long as we look at healthcare as a civil right, it will be treated as and dispensed as “welfare.” (Yes, welfare; any financial aid in the form of goods, services or finances provided by the government.) I realize this is controversial, however, social security, Medicare, and Medicaid are all forms of government issued welfare. We have become more and more dependent upon this “welfare.” We now have a third of our country dependent upon this welfare and most of their physicians significantly dependent upon this welfare as a third party payer system. We have attempted to take a private industry governed by principles of capitalism and science and dispense it as welfare. History demonstrates that any industry converted in this way will fail.
There will not be a solution to the healthcare crisis, until medicine is either fully socialized or fully privatized. The practice of medicine is an art. Socialism is diametrically opposed to the free practice or expression of an art. The two are incompatible. This is my perception of the underlying problem.
The problem with looking at healthcare as a right and dispensing it as welfare, means that you thereby removed some of the rights of those rendering the care. You removed some of the rights of the physicians dispensing it. You take away the physician’s ability to practice their art “because all must receive everything equally.” You have to give identical service to everyone whether they really need it or not, whether they want it or not.
If you look at a truly privatized capitalistic system, it will correct itself, balancing need and demand as well as cost and expense naturally. It will identify and remove fraud and abuse on its own for this is the nature of capitalism. This works and has worked for thousands of years because medicine is a service not a right. The consumer will pay for what it wants and what it can afford, and the rest will fall out of the system.
When you try to merge the two systems, some of those in the private system will “milk” the welfare side of the system. This is the fraud and abuse portion of our current medical construct. When you socialize the system, all will receive equally, but there is no incentive for improvement or growth other than what is mandated by the governing body.
The Solution?
We as a country must first recognize that medicine is a service, not a right, then we must decide what we want – socialism or capitalism. We can’t have it both ways. Our current healthcare system demonstrates that. Personally, I entered medicine to practice the art and to render services because I can and I care and I want to, not because it’s someone else’s right to receive it from me.
It is such a tangled mess, it is hard to know where to even start. This post I wrote a while back addresses our particular experience with some of the problems in the current system, but it is much more extensive than our situation (which is shared by many in some incarnation or another) alone can illustrate.
i know you may mean well and probably are a caring doctor but this kind of smacks of social darwinism to me and i rather thought i deserve to have a life just like you deserve to have a life, wether it is practicing your art or letting me have access to your art……………… me not being able to afford it only hurts everyone in the long run because eventually someone will pay for it when i collapse on the sidewalk. i dont want to get political either but i kind of see your post as someone who has most or all of the answers to health care, and those answers keep me out of the whole system. i believe health care is a right and i dont believe that the conclusions with that answer are automatically your conclusions…….. i think it would be helpful if all of us think outside our boxes. i believe doctors should be compensated, and in other develped countries with universal health care they are compensated………. it certainly is not the case where the primary doctor is going through what doctors like dr rob go through……………. i think one big thing is we have to stop being so afraid of changing this system or it will break very very soon. and to stop the middleman, and the office paperwork. that takes up so much money. and it makes the office manager almost as important as the doctor. doctors loose patients when the om is a brash person and the doctors are afraid to fire them becaue they dont know enought about business and insurance to do it, they want to be doctors not cpas!!!!!!! another problem i have is the endless paper work for me when i go to a new doctor or even with my doctors ive had for ages, they always want more and more hoops for me to jump through and i cant do it anymore when im getting sicker……….. its just crazy, my elderly parents also its the same thing, and many others i talk to……………. its almost like the medical machine is already a big huge business rather than a special calling…………….. you go to complain about a bad knee and you get a referral and then another and another…….. and on and on to the point where honestly, i dont even mention most stuff anymore………. no one seems to want responsibility for much. a truely capitalized system, as you say, has NOT corrected itself, but only gotten worse.
I always was for term limits too………. until we did that in my state and then what has happened is then the good ones have to leave after a certain time and then further when that happens you are left with the unelected staff people who revolve from official to official who are the real elected officials then since they know the system in and out………….. most of us in my state have regretted voting for it into our constitution now. i guess everything has a down side………….. elections are really supposed to serve as the ‘term limits’, and to me the real problem is the lobbyists……………….. that is what it think should be outlawed or at least put limits on them. because once the incumbents are no longer such they become lobbyists (or their families are )and then lobby their friends……….. i also think that to try to get the corruption out of the system and the closed door agreements that elections should be publicly funded………… no one gets to buy their way in, either with blasting an opponent or by outspending them………….. i know its on the socialist side but that is part of our balance of power, it cant all be capitalist all the time because human nature is human nature……………… thats my two cents on this.
Start with this: “But all (except for those in total denial) would agree”
A critical component of brainstorming is to set aside judgment until after you have gathered the wisdom of the crowd.
Setting a scope for a discussion can be a good idea but one must be careful that it has good delineation. In this case, the understanding of what the “system” actually is and how “collapse” might be expressed could possibly lead to some insight in themselves.
But starting off a discussion by labeling those who don’t agree with your viewpoint in a negative way is not a way to learn much of anything, I think.
Problems are often not as clear cut and simple as many would like to think. That is a reminder that the first step towards finding solutions is always within ourselves.
DR ROB, i kind of assumed that hospitals and doctors were doing this. the hospitals doing it makes me mad, but when primary care doctors do it i have always understood why, primary docs are only trying to keep going for the most part………… and they charge more to get more………. and probably most primary docs feel badly about this but also feel mad that they have to do this………id love to have costs be the same all over, like at a chain store……… so i go back to my original confusion, in how to help to change the problem with my choices rather than making it worse…………. i dont know what goes on behind the scenes and i just do what i pretty much know i have to do to get any kind of care or get the equipment i need or drugs i need…………….. i see little pockets of doctors and nurses fighting for change and patients too but then its all scattered about and its too little compared to the big insurance and drug lobbies…………… and even the doctors are fighting amoung themselves………………. id think the specialists would want to help out the pcp but they dont seem to want to give up what they have now. the only way i see it changing is if all of us work together and give up a little of what we have but in the climate of our country now i dont see that happening…………… that is what makes me frustrated. and yer darn right that the system is confusing. for doctors and patients ………. i think only the office managers understand it. and that confuses and scares me. i also dont like when i am in the waiting room of my doctor and i see tissue boxes, pens, signs, literature, and all that from drug companies. it makes me wonder if the next drug my doctor wants me to go on is one from that company. it puts the thought in your mind and it is confusing because im not a fly on the wall so i dont know where my doctor draws the line or how much money he wants to make in his or her life or how easily he is maniputlated. i dont like the feeling of thinking my doctor is much like a politician accepting donations for favors ……………….. its a yukky feeling and i have no idea how to get all of us together that want to chang3e it…………. it has to be changed. so its fair for all of us……………… all i have are questions and frustrations unfortunately .