LESSONS LEARNED #22: “The only problem with health care these days is that it’s approached from a cost basis more than a medical basis.” -Old Pithy

Posted by PITHOCRATES - July 15th, 2010

ONCE UPON A TIME, in a distant land, there once lived a merry people.  And life was good.  They lived together in sweet harmony.  They worked long and hard to sustain their happy life.   And when people fell ill, they went to the doctor.  And after treatment, THEY PAID THEIR OWN DAMN BILL!

But those days are gone.  We don’t pay our own doctor bills anymore.  Health care is no longer between a doctor and a patient.  There’s somebody else involved now.  Someone who says what a patient can or cannot have.  Someone that tells doctors what they can or cannot do.  And our doctors have a bull’s-eye on their backs.

Medical care has taken a back seat to medical costs.  It’s not about what’s best for the patient.  It’s about what costs the least.  Think of a graph.  Increasing along the bottom are medical services rendered.  Increasing up the y-axis are costs.  On this graph picture two curves.  One that plots costs of medical malpractice lawsuits (very high when the doctor provides no medical services and decrease as the amount of medical services increase).  The other that plots costs of doctor reimbursements for services rendered (very low when the doctor provides no medical services and increases as the amount of medical services increase).

This is what a doctor considers when seeing a patient.  They don’t want to.  But the system forces them to.  Because of the conversion of health insurance (to protect your personal financial wealth) into a benefit/entitlement (to get free stuff with other people’s money).  And the rise of that other benefit/entitlement, the malpractice lawsuit as a vehicle to early retirement.

What better way to illustrate how cost takes center stage in our health care today but by some personal anecdotes?  So here is a smattering of our collective pasts.

I WAS IN some junior officer training program.  It was the last full day.  The last training we did was a run on the obstacle course.  It was hot.  Humid.  I kept pushing myself.  Now, I’ve suffered dehydration and heat exhaustion before, but whatever hit me wasn’t that.  I looked okay.  I had one of those ‘spike driven through your skull behind the eye’ migraines.  Nausea.  Some other discomforts.  All we had left was retreat.  Where we formed, though, we faced into the setting sun.  I asked my CO if he would excuse me from retreat.  I just wanted to hit my bunk.  To die.  Or sleep it off.  Whatever it was.  Training was over.  After retreat, they were going to open the pool for us. 

Well, he denied my request.  And made me feel like a little girl for even asking.  (I regret that moment of weakness to this day).  After I was dismissed, he called me back and said, “And if you do vomit in rank, vomit with bearing.”  “Yes, sir,” I replied and saluted.  Made it through without vomiting.  Crawled into my bunk.  When my CO saw that I was not partaking in the ‘mandatory’ fun he came to see me.  Was about to send my ass to the infirmary.  But whatever I had passed.  I felt fine.  The following day it was as if nothing had happened.

When you got through something like that, you’d be surprised how it impacts you.  You ignore things.  And live with things. 

I HAD A WART once under my thumbnail.  I made an appointment with my doctor to have it removed.  The day before my appointment, though, was a very busy day at work.  Didn’t sleep well the night before, either.  So I was tired.  And drinking coffee.  Apparently, I was the only one.  In the afternoon, half a pot was still remaining.  From the morning.  Nice and black.  Thick, too.  Like tar.  Strong.  I finished that pot.  Later that night, I had heart palpitations.  I rationalized it was from drinking too much coffee.

While getting that wart removed, I mentioned in passing the heart palpitations from the night before.  Laughing about it.  Last time I drink a pot of coffee, I said.  The doctor looked up from the wart and said, “Heart palpitations?  That’s serious.  This,” he pointed to the wart, “is piddling.  Heart palpitations?  That’s serious.”  The next thing I knew was getting an EKG and sent home with a heart monitor strapped to my chest.

I now thought about those things I was ignoring and living with.  Perhaps I was being irresponsible.  I mean, I was feeling things in my chest.  When I went in to get the results of all those tests, I told him about those things I’ve been ignoring and living with.  My test results were fine.  I asked him about those other things.  He asked, “How old are you?  You’re fine. You just have some anxiety.  Here’s some Xanax.”

When I mentioned heart palpitations, he couldn’t laugh it off with me.  For one, he was a doctor.  It’s what doctors do.  Save lives.  But he also buys malpractice insurance.  He was leaving himself open to a lawsuit if he didn’t do everything expected when a patient says he has had heart palpitations.  Once those tests came back confirming it was most probably the excess amount of coffee I drank that day that gave me the palpitations, I was just a young, healthy man.  Who did not justify any further testing.  At least, my insurance company wasn’t going to reimburse any further testing.

My test results looked good.  Feeling things in the chest, though, could mean something.  A stress test might be prudent.  But unless something turned up in that test, the insurance company wouldn’t reimburse that cost.  Which meant I would ultimately end up paying for it.  And stress tests are expensive.  Of course, if I paid cash outside the bureaucracy of the health insurance maze, it could be less.  So I said let’s do the stress test.  I’m buying.  I took the test.  Did okay.  Didn’t die.  Nothing strange happened.  The cost?  About half of what they would have charged had it gone through the myriad levels of overhead that process an insurance claim (at the health insurance company, at the hospital where the test was done and at my doctor’s office).

And I continued to ignore and live with those things I was feeling in my chest.  Even stopped taking the Xanax.  If I was feeling any anxiety, it was from my little episode in the health care machinery.

BUT THINGS SEEMED to only get worse after a year or so.  I started wondering that maybe I was only making things worse by ignoring them.  So I went to the doctor.  I explained what I was feeling.  He did the perfunctory tests that shrunk the lawsuit window.  Again, things looked good.  “How old are you?” he asked.  “You’re fine.  Look, we can keep doing tests but it’s going to get expensive.  Your insurance isn’t going to pay for them if nothing turns up.  And, I gotta tell you, I don’t think anything’s going to turn up.”

Again, he was looking at the cost-service tradeoff.  He felt he had minimized his costs.  He did enough testing to protect himself from a frivolous lawsuit.  And he didn’t do more testing than the insurance companies would reimburse.  Further testing would be on my dime.  Not that I didn’t think my life was worth the investment, but more tests would mean more missed work.  And with me feeling he wasn’t going to do anything but throw darts in the dark, I didn’t pursue additional testing.  It didn’t appear that anything big was wrong so I continued to live with those feelings.

THIRD TIME’S A charm.  After another year or so, I went to another doctor.  Again, I thought I might be doing more harm by ignoring these things.  Being further away from my original heart tests, I didn’t really discuss them this time.  Which was good.  It was a red herring.  You start talking ‘heart’, you look at all things ‘heart’.  High risk.  High costs.  But if you don’t start from ‘heart’, you can explore things that are lower risk and lower costs.  I had some serious acid reflux.  Acid regurgitating up your esophagus can mimic heart attack symptoms.  Who’d a thunk it?

HAVING AN INTERMITTENT problem is hard to diagnose.  All but impossible if you’re young.  I was a young college student.  With intermittent stomach pain.  I went to a doctor.  He felt me up to see if it was appendicitis.  I didn’t feel anything when he pressed over my appendix.  So he ruled that out.  “How old are you?” he asked.  “You’re fine.  You just need to get drunk and get laid.” 

A couple of years later, I was still feeling that intermittent stomach pain.  So I went to another doctor.  (It was a clinic.  The doctor I saw last since retired.)  He felt me up.  Ruled out appendicitis.  Sent me for an upper GI (where you drink a cup of barium and they x-ray your esophagus and stomach).  Test came back.  Everything looked fine.  “How old are you?” he asked.  “You’re fine.  Just drink some Maalox.”

So I drank some Maalox for awhile.  Didn’t seem to help.  Another year and another trip to the doctor.  And another upper GI.  The instructions this time called for a wait time before one last x-ray.  This x-ray showed an ulcer.  Just past the stomach at the beginning of the small intestine.

MY MOTHERINLAW WENT into the hospital with chest pains.  She was in her mid-sixties.  She spent the night in the ICU.  The next morning they transferred her to the cardiac care wing.  They did just about every test they could.  She was elderly.  Elderly people have health problems.  So doctors do ALL the tests to slam shut the lawsuit window knowing that the health insurance company or Medicare will reimburse for most of those tests.  They found nothing.  She went home.  Without them doing anything or being able to explain what had happened.  They had practiced due diligence to protect themselves legally.  And the health insurance company would rule that any further testing would be frivolous and unnecessary, only to produce additional revenues for the hospital and doctors. 

This repeated a few times until they found pancreatitis and stones in her bile duct. 

IT’S NOT THE doctors.  It’s not the hospitals.  Or the insurance companies.  It’s the system.  When other people pay your way there has to be rules.  For a free ride is not free.  We just make other people pay.  The problem with all things free?  We over consume.

How many plates of food do you eat in a restaurant when you pay per plate?  One?  How many plates of food do you eat when you eat at an all-you-can-eat buffet?  The answer?  More.  It’s happening in health care.  Those with insurance don’t care a whit about cost.  Don’t give me generics, I have insurance.

But someone is paying all those bills.  And they see this over-consumption.  They raise their premiums to cover it.  But when they do, they find some people stop buying their health insurance.  Which means they have to raise their premiums again.  More people stop buying.  So they need to raise their premiums again.  But they can’t keep doing this.  So they have to put in some kind of spending rules.  Say what they will reimburse and what they will not.  And they force the poor doctor to police this mess who is trying to help you get well at the same time.  All the while trying to keep the lawyers off his back.

It’s worse on the Medicare side.  For private health insurance has some young, healthy people paying for insurance who aren’t consuming medical care.  Everyone in Medicare is sick and/or old.  Big consumers of medical care.  The trend has been to micromanage the rules more as the consumption of medical care has outpaced the taxes collected to pay for that care.  And with an aging population, those costs are running well ahead of tax receipts.  It’s not a question of if the program will go bankrupt.  But when.  And a national health care system will only be worse.  The added costs will require massive taxation and cost management worse than any hated HMO.

AND LOST IN the shuffle is the patient.  Who, once upon a time, went to his doctor.  And the doctor did what was best for the patient.  And the patient paid the doctor for his services.  And everyone lived happily ever after.

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