In deciding what to write about, I try my best to steer clear of the political side of medicine.  But, today’s NYT has 3 articles that I just couldn’t ignore.  Basically, all three are opinion pieces that address from different directions, one of the most important problems facing U.S. health care, the question of cost.  The first piece was entitled, “What we give up for health care,” and written by Ezekiel J. Emanuel, the brother of Chicago, Illinois major, Raum Emanuel.  The second piece was entitled, ” The dangerous notion that debt doesn’t matter,” and written by Steven Rattner, a Wall Street executive.  The third piece was entitled, “The money traps in U.S. health care,” and written by Philip M. Boffey.

Basically, the Raum and Boffey articles opine on the fact that U.S. health care costs are extraordinary and that if we do not find a way to bring costs down quite a bit, we will have very difficult decisions about what other things we hold near and dear (e.g., education, infrastructure, national defense) that we will need to cut back on.  The Rattner article focuses on the long-term dangers of high U.S. debt.  I found the data in the Bossey piece on comparative costs for various medial services in Britain, Canada, France, Germany, and the U.S., particularly interesting.  For example, the average cost for cataract surgery in the U.S. (public and private sector) at $14,764 beats the closest competitor by $11,412.  It is truly breathtaking how much we in the U.S. (physicians, hospitals, and clinics) charge for routine medical services relative to the rest of the world, particularly since our outcomes are not generally superior to outcomes elsewhere.

In my opinion, based on my reading of the 3 articles in the NYT, at some point, the U.S. will have to go on a health care cost diet.  I predict the diet will be very difficult for us (the general public and the health care providers) to start and to follow.  How in the world will we be able to keep all the stakeholders reasonably happy with the process and the result?  This is scary stuff.

The other day, I mentioned that I would be writing about my experiences in dealing with my mother’s recent death.  Early in my medical career, when I was a resident physician, much of the time I treated patients in an acute care setting, and not surprisingly, quite a number of them died from the assorted problems that got them to the hospital.  If it was not a motor vehicle accident, then it was a myocardial infarction, meningitis, and so forth.  In none of the patients did I have a long-term relationship preceding the acute event that brought them to the hospital,  and my focus was primarily on the disease itself rather than on the disease, the patient and family.  Over the past 35 years I have been a medical specialist and have had only a few patient die (mostly from motor vehicle accidents or drug overdoses) and with none was I serving as a primary care physician.  So, it was mostly uncharted territory that I ventured into when my own mother became ill and was diagnosed with terminal cancer early in May of this year.

A brief medical history

My mother lived in Columbia, Missouri, not far from me.  She was born in 1919 and had been generally quite healthy.  A few years earlier, she developed a peripheral neuropathy (etiology unknown) and had to use a walker to get around.  She stayed active, swimming 2-3 times a week.  She had a primary care doctor, a general internist,who was on the faculty at the University of Missouri and whose office was only a few blocks from her home.  She had a good relationship with the doctor and the nurse who worked with him and everything was fine and dandy.  Then, all of a sudden, the doctor closed his practice and  my mother did not have a primary care doctor.  The doctor she had been seeing contacted my mother and told her that he was leaving the clinic, wished her well, and  and he suggested another physician who he had taken the liberty of speaking with, and who had agreed to accept my mother into her practice.  So far so good.

In January of this year (just after her original doctor left the clinic), my mother developed some vascular problems with her legs.  She was seen in the internal medicine clinic by the “new” physician who took a brief medical history and referred my mother to a vascular surgeon for a consultation.  From the time of the first visit with the new physician, my mother was not pleased.  I felt the problem was mostly that my mother had gotten used to the previous doctor and that over time she would warm to the new doctor.  Oh was I wrong.

As it turned out, my mother had an arterial thrombosis in her right leg and had vascular surgery at the end of January of this year.  The surgery was not easy for her (at age 90 years, I don’t think any surgery is easy); she spent a week in the surgical intensive care unit but things improved steadily.  Once out of intensive care, she was transferred to a medical/surgical ward and was cared for by the vascular surgeons and by the internal medicine hospitalists.  Every day she was seen by a different internal medicine doctor and not once did she see or even hear from her new primary care doctor.

After discharge from hospital, my mother was scheduled to be seen by her primary care doctor.  As it turned out, after the appointment was made, the doctor’s schedule changed and my mother was seen by an internist who was just “covering.”  The clinic had known for a week that the primary care doctor would not be in clinic for my mother’s appointment, but did not inform my mother.  The “covering doctor” knew nothing about my mother’s case history and I would describe the clinic visit as a disaster.  My mother swore that she would never go back to that clinic again and she didn’t.  She insisted that I find her a new doctor, someone like her previous doctor.  I decided that my mother might do better with a family practice doctor.  I twisted a few arms and the Chairman of the Department of Family and Community Medicine, and also a geriatrics expert,  said he would be pleased  to see my mother.  An appointment was made for late April of this year.

Is it gall-bladder disease?

In mid-April, my mother developed intense itching and then her urine turned dark.  Remember, my mother was in-between primary care doctors at this time.  I ordered some basic lab tests (I was forced to order the tests since my mother did not have a doctor) and had the results sent to the new primary care doctor explaining in an e-mail that he was to see my mother for the first time in about a week for what was to be routine clinic visit.  The test results were consistent with biliary obstruction but there was also anemia and the platelet count was very high.  I as a pediatric endocrinologist was way out of my comfort zone.  Within an hour after I e-mailed the lab test results to the new doctor, he called me and told me that he wanted to see my mother the next day if she was willing.  She reluctantly agreed to the clinic visit (by this time she was tired of all doctors, nurses, hospitals, and clinics).

The first clinic visit with the new doctor

The next day, I drove my mother to the new doctor’s office and from the beginning, I knew things were going to be different.  Starting with the receptionist then the nurse, and finally the doctor, it was a completely different atmosphere than at the internal medicine clinic where it was “all business.”  First, all of the personnel acted as if they were actually happy to see my mother and made her feel comfortable.  The doctor had already reviewed my mother’s chart (we have excellent electronic medical records at my university medical center ) and the visit didn’t start out as if the doctor didn’t know anything about my mother, which had been the case every time at the internal medicine clinic after my mother’s first doctor left the clinic.  The new doctor’s demeanor was excellent.  He spoke to my mother, not to me as had been the case previously and made her think she was his only patient.  He didn’t rush and he explained things to my mother and told her what he wanted to do, why, and asked her it she was willing.  When we left the clinic my mother was the happiest woman on earth- she had found a doctor just like her first one and she had complete faith in his recommendations.

The bad news

Unfortunately, as it turned out, my mother did have biliary obstruction, not from a gall-stone but from inoperable pancreatic cancer, diagnosed in mid-May of this year.  To make a long story, a bit shorter, every step of the way from the work-up to the diagnosis and until my mother’s death on August 20, her primary care doctor “ran the show.”  He took charge and made sure she saw whatever specialists she needed to see (e.g., oncological surgeon) but he maintained control of the treatment plan.  He arranged for hospice care and was able to persuade her to do it even though I hadn’t been able to.  He worked closely with the hospice team throughout.

At the very end of April, the new doctor went out of town for 2 weeks (on a cruise with his wife), but he had informed my mother of his upcoming trip and made arrangements for another colleague to manage her case while he was away, and called her immediately on his return.  He even made a house call the afternoon before my mother died.  Remember, this is the Chairman of the Department, a very, very busy man.  But, once he agreed to see my mother, he made clear in everything he said and did that he had taken “ownership, ” something her previous doctor had not.  For me it was a wonderful experience, considering the circumstances.

My mother certainly had enough to deal with given her diagnosis and the last thing she needed was to have a lack of confidence in her health care provider.  But, my mother had complete faith in her doctor and it made all the difference in the world.  Her doctor was not an expert in pancreatic cancer and maybe not expert in anything except the most important thing, expertise in knowing what it means to be a patient’s doctor.

Ownership and Medical Homes

These days there is considerable discussion about the need for each patient to have a “medical home.”  The idea is that all patients, particularly those with chronic diseases, need to be part of a medical care system that can meet all of the patient’s care needs and that the patient care is provided in a organized and efficient fashion.  Who can argue with such a concept?  With my mother’s illness, I learned that having a medical home is not enough; it is also necessary that one person, be it a physician, nurse, social worker or whomever, needs to take ownership of the patient and do everything possible to be certain the patient’s medical care needs are being met within the medical home.  For my mother, getting excellent health care could not keep her cancer from taking her life, but it made the final days and weeks of her life far better than they would have otherwise been.  There is a lesson here for all of us.

One last thing.  For those of you who are particularly interested in end-of-life issues, I highly recommend a recent article in the New Yorker, entitled “Letting Go.  Rethinking end-of-life treatment,” written by our old friend, Atul Gwande.  I warn you in advance- the article is long- but very well done.

For people who have so-called” preexisting” medical conditions,  finding affordable health insurance can be mission impossible.  Most if not all states in the U.S. already have so-called “high risk” pools for people with a variety of medical conditions.  Unfortunately, the premium costs for these pools are far above what most people can afford.  In the near future that situation may change for the better.  Under the recently enacted health care reform legislation, on July 1, 2010, all states must offer health insurance through new high-risk pools with rates no higher than those available to a healthy person.   This provision of the new law is apparently supposed to offer help until the new health insurance exchanges begin in 2014.  It is unclear how helpful this temporary fix will be.  The rules require that a person must be without health insurance for at least 6 months and the pool of money set aside by Congress to fund the program is unlikely to to be enough for more than a year or two.  Anyway, there is a nice article in today’s New York Times (26 June 2010) summarizing these new insurance pools and how one can get up-to-date information on the high-risk pool in his or her own state.

FYI: There was an interesting article in the New York Times on April 12, 2010.  The article was entitled “Could Health Overhaul Incentives Hurt Some?” and was written by Roni Rabin.  The article reviewed the potential impact of some provisions in the new health care legislation that focus on financial incentives for good health care outcomes (e.g., weight loss, smoking cessation).  The idea is that it is not fair for healthy people to share the cost of health care expenditures that are the result of  certain unhealthy lifestyles.  It’s sort of like good driver discounts for automobile insurance.

In my opinion, this is a very tricky issue.  For example, as I have discussed in previous entries, for many people who are overweight genetics plays a very important role; their obesity is not just the result of willful unhealthy behaviors.  As employers and insurers pursue the idea of promoting desirable behaviors, they need to be very careful not to place an unreasonable burden on people whose health problems are more the result of “bad” genes and bad luck than bad behaviors.

I want to call to your attention a series of very interesting and important articles published in the New York Times Science Times Section yesterday (Tuesday, March 30, 2010).  The articles do a pretty good job of summarizing what’s what about the new health care bill passed by Congress.  I would particularly recommend two of the articles.  The first is entitled “What you need to know in the first year” and was written by Tara Parker-Pope.  The second is entitled “Law may do little to help curb unnecessary care” and was written by Gina Kolata.  Some of the other article titles include:  “No matter what, we pay for others’ bad habits,” “Overhaul will lower the costs of being a woman,” and “What the health care overhaul could mean for you: do you have health insurance now?”  I think the various articles provide a fairly good overview of what the new law is likely to do and not do.  I will offer no opinions on the subject except to say that I hope the new health care legislation is “a work in progress.”  What I mean is that if the new health care bill was a college course exam, the grade would be “incomplete.”  It is interesting, however, that so far every patient I have talked to has  told me the new law would help them out.  We’ll see.

As those of you who have been reading my various entries over the past 18 months may have noticed, I have been a bit heavy on the U.S. health care debate and light on the endocrine issues.  I apologize to those of you who are weary of hearing anything more about health care , but for me as an endocrinologist who cares for many patients with chronic medical conditions, particularly those with diabetes, having a first rate health care system is important; it doesn’t matter how brilliant a physician I might be if my patients can’t afford to get the services they need or to buy the medications they need.   Anyway, I wanted those of you who may be skeptics about the  benefits of health care reform as proposed by President Obama to check out an op-ed piece that deserves attention.  The article was written by Paul Krugman, the Nobel Prize-winning economist and entitled “Health Care Reform Myths,” and published in the New York Times March 11, 2010. I agree with most of what Dr. Krugman wrote and I liked the fact that he kept the rhetoric reasonably apolitical.

My Westminster College Lecture

As long as I’m writing about health care, I might as well tell you that the other day, I gave a lecture at Westminster College in Fulton, Missouri.  Fulton is only about 25 miles from my home town, Columbia, Missouri, and the county seat of Callaway County, named for James Callaway,the grandson of Daniel Boone.  Fulton (population 13,000) is  known mostly for having 2 excellent colleges, Westminster and William Woods, and for the Winston Churchill Memorial and Library(WCML).  The WCML is located on the campus of Westminster College and is the site of Churchill’s famous “Iron Curtain” speech.  Many world leaders have visited the site and have given important speeches, including the one by then Soviet President Mikhail Gorbachev who announced the end of the Cold War and the fall of the “Iron Curtain.”  My not yet famous speech in Fulton was entitled “Chaos theory in action: The U.S. health care system.”

I spoke to a class of about 35 students in a course that examined a wide range of controversial contemporary issues.  I have no idea why the course director, Professor Margot McMillen thought U.S. health care might be a controversial issue.  Anyway, I tried my best to provide the students with a framework for understanding the current U.S. health care reform debates rather than focusing on my opinion on how to fix the problems.  I tried to keep the discussion apolitical which, I have learned, is the best way to get people on both sides of the debate to listen.  I focused primarily on describing the cost-generating components of the system.  I divided those components into 2 large categories, government and non-government.  On the government side was Medicare, Medicaid, U.S. Public Health Service (Indian Health, Etc.), Veteran’s Administration, Military (active duty members and their families), and miscellaneous (e.g., Community Health Centers).  On the other side was private insurance and self-pay (this included out-of-pocket health care expenses for even people with insurance or Medicare or Medicaid).

For each  component I tried to describe its history and current status, including costs and my take on its weaknesses (e.g., difficulties that many people on Medicaid have in finding physicians willing to see them).  I then tried to address what most experts feel are the 2 most important problems with the current U.S. health care system, lack of access and high and ever increasing costs.   By the end of the hour, I think most of the students understood enough about the issues to critically critique the various health care proposals that  bombard us if we read newspapers, watch television, or listen to the radio.  Apparently, each student will be required to write a paper about the lecture.  If Professor McMillen will give me permission, I want to read the students’ papers.  Did I actually teach them anything or do I need to “go back to the drawing board” to find a better way to educate people about the U.S. health care system?  Maybe, as the title of my lecture suggested, I should just give up trying to bring order to chaos?

FYI

I strongly encourage all of you to read an article that appeared in last Sunday’s New York Times Magazine section.  The piece was written by David Leonheadt and entitled “Making Health Care Better.”  The article discussed in some detail the work Intermountain Health Care (IMHC) was doing to improve patient care.  IMHC is located in Salt Lake City, Utah and is a consortium of hospitals and clinics in the region.   For quite a number of years, the organization has focused on developing treatment protocols based on data and analyzing their outcomes.  The article focused on Dr. Brent James, the Chief Quality Officer of the organization and the extraordinary successes the group has had in improving patient care.  There is much for all of us to learn by reading the article.  After you finish the article I suggest you read “The Bell Curve,” written by Atul Gwande as it ties in nicely (if you are feeling worn out after reading the Leonheadt article, you could cheat a bit by reading my entry last year about the Gwande article, but I’d rather you read the article itself).