Different Lunatics, Same Asylum

The top vote-getting answer on my poll about what people feel about the election: Different lunatics, same asylum. We are getting jaded by our system.  Being the \”flaming moderate\” that I am, I find it hard to hear the substance of the rhetoric on either side, just the shrillness and rancor of the voices.
From the physician\’s perspective, it is very hard to know who to favor in this election.  The democrats seem to love lawyers and hate tort reform, and they also favor an expansion of government.  The republicans love big businesses and \”free market,\” accepting the bad behavior of insurance and drug companies as \”the market working itself out.\”  They both seem hell-bent on sticking it to the other party at the expense of getting anything done – and this in a time of crisis for our industry.

The results of this playground brawl between the two gangs of bullies is that all of us wimpy kids (the ones without power) end up lying bloody in the dirt.  Here are the facts as I see them about healthcare in our country:

1. It costs far too much.  The top item on the agenda needs to be cost control.  The only way to control cost is to stop paying for things that are unnecessary or for which there is a cheaper alternative.  I know that\’s not simple as it sounds, but so much of the discussion is about coverage and how things are paid, while the real issue is not who pays, it\’s what and how much gets paid.
2. Too much of the cost is hidden.  How much does it cost to see the doctor?  That\’s an incredibly complicated question.  It depends on the insurance carrier, the doctor in question, the way the doctor codes the visit, and the nature of the doctor\’s ordering practice.  The same thing is true on a grander scale for hospitals.  Drug costs are hidden by copays (allowing companies to wheel-and-deal to get drugs on formularies).  Insurance companies hide their administrative cost and pass on any increases on to the people buying the policies.
3. It is totally disorganized.    Nobody knows what anyone else is doing.  As much as people rail against the mandated EMR, the coordination of care will be impossible without it.  We need to know what has been done using clinical information, not billing data.  Up to now the insurance industry has controlled the information about what is done on patients, using the withholding of payment as the club to change physician behavior.  While there is risk that doctors might get screwed with the recording of our behavior, not doing so makes the chance of real improvement nearly impossible, leaving the payors with the data and hence with the most power.
4. Nobody is pointing out the naked emperor.  It is insane that drugs cost as much as they do.  It is crazy that we pay what we do for technology.  What exactly is it in the 2 day ICU stay that costs $100,000?  Price gouging is rampant because it is allowed (and even encouraged by our system).  Why can a drug company raise the price of a gout drug by 5000%?  Because the FDA lets them.  Why can granny in the nursing home with alzheimer\’s get put in the hospital and spend a week in the ICU?  Because Medicare pays the hospitals and physicians who put her there.  The credit card bill is shooting up, yet we are not asking why we keep spending so much?
5. The people with the most at stake are those with the least power.  Patients (and primary care physicians) are the ones with the most at stake.  The discussion is being run by politicians (who don\’t have to use the plan they pass), hospitals, specialty organizations, insurance companies, and other health-related industries.  Those with money can most influence the process to their advantage, and patients are definitely not the ones with the money.
6. We cannot afford gridlock on this issue, but that is undoubtedly what we will get.  I have not met one person, liberal or conservative, who is optimistic about the next two years.  We are living with a cancer but are unable to do anything about it.  That cancer is not going to sit around and wait for the politicians to agree, it will spread and will choke out any hope of survival.

I am not too charged up this election season.  It seems that very few people look with optimism on what\’s going to happen over the next 2 years.  The best thing we can do?  Raise your voice.  Vote in a way that will change the process.  We need to change the asylum and make it into a place where things get done.  We need people with the political gonads to work with others not in their party.  We need more sense and less shrillness.

If we don\’t get this fixed soon, the patient will be beyond saving.