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Healthcare In The US Vs. Europe: Quote Of The Day

My friend and fellow medblogger Peggy Polaneczky, MD had this to say after returning from a medical conference in Salzburg:

We had lots of conversations about healthcare in our respective countries. And all I can say is, despite all the issues we have in the United States, I wouldn’t want to be practicing medicine anywhere else but here. Not when I hear tale of docs whose only way of surviving financially is to take tips from patients who pay to squeeze into the surgical schedule ahead of the cue. Or of abdominal emergencies handled in hospitals that don’t have a CT scanner. And not a single fellow has a microscope in their office, forcing them to rely on gram stain only for management of vaginitis. (A poor substitute for an in office wet prep in my opinion.)

Most of these docs would give their eye teeth to spend some time learning medicine in the United Sates, be it something as simple as an observership or as complex as a second residency. Unfortunately, visa regulations in their countries and ours make this extremely difficult. But all of them will be offered observerships in Vienna and in Germany at the Institute’s expense.

President Obama Needs You!

By Stacy Beller Stryer, M.D.

We are asking a lot of President Obama. We are asking him to end the wars around the globe, help societies in need, bring jobs and prosperity back to the United States, provide healthcare for all Americans, improve our children’s education, and so on. In his inaugural address, President Obama agreed to tackle many of these issues. We must remember, however, that he is not Superman. He has told us many times, including yesterday, that he cannot make these changes alone but needs the help of all Americans. As he said, “What is required of us now is a new era of responsibility – a recognition on the part of every American, that we have duties to ourselves, our nation and the world …”

Why am I, a pediatrician, discussing an inaugural speech on a website about healthcare? Because, as the President said, each and every one of us has the responsibility of contributing as much as possible to our society and to the world-at-large. As a pediatrician, one of my responsibilities is to guide mothers and fathers toward being the best parents possible. As a parent, each of you has the responsibility of doing the best job you can in raising your children, even before they are born. This means eating well, and refraining from smoking and drinking during pregnancy. It also means providing for them in as many was as possible. This includes, not only giving them appropriate clothing and food, but also stimulating their minds and hearts. It means treating them with respect, acting as positive role models, and teaching them right from wrong – why smoking and having sex as a teen is wrong, why doing well in school is important, and why all people should be treated equal, whether they are black or white, straight or gay, fat or thin. It means boosting your children’s self confidence and letting them know how much you love them. It means becoming involved in activities which help the environment, community, and those in need. And when children become teens, parents must also change their ways – they must learn to recognize when teens need space and when it is time for them to develop their independence.

President Obama is certainly asking a lot of us. But I know we can rise to the occasion. By being good parents and role models, we will not only have fulfilled our duties and responsibilities, but we will also have prepared the next generation to do the same. Here’s to President Obama – and to each and every parent in America.

Moral Hazards: What Happens When You Think Healthcare Is Free

By Alan Dappen, M.D.

“Doc, you’re the best! You saved my life, and my wife’s. You delivered my kids and brought them through sickness — time and again. I trust you, and can confide in you … Hey, wait a minute … Are you still a Preferred Provider?”  

This is a statement I heard all too often as a primary care doctor beholden to third-party providers. When a long-time patient asked this question, I felt like the mythological Damocles, who precariously sat beneath a sword suspended by a horse hair, for if I answered “No” to that question of “Are you a Preferred Provider” the sword would fall, swiftly.

No matter skill, knowledge, talent, caring, quality, experience, price or level of trust of their current primary care practitioner, 90-95% of patients who ask “Are you my preferred provider?” paradoxically will exit one primary care provider’s office to entrust the decisions of their day-to-day health care to another physician picked by their insurance company, even though this new doctor may be a stranger who signs a contract to do the job for less money.

For decades now patients have been led, like lemmings, by the belief that the vast majority of healthcare is virtually free because they have health insurance usually wholly and partially funded by someone else, like their employers of the government. Furthermore, patients trust that the providers of this health insurance know what is best for their care.

Because someone else is footing the bill, we as patients have absolved ourselves of the responsibilities associated with finding and consuming good care. Instead, the hope of getting what appears to be virtually free health care trumps all other considerations of care, whether it is quality, level of expertise, convenience or accessibility. Few of us are immune to wanting to get something for less, or better yet, something for nothing. This behavior leads to moral hazards, which are most easily explained by the WIFM (“What’s in it for me”) concept, and best exemplified by the way we eat at a buffet, drink at an open bar, or most recently by how the banks flocked to the sub-prime market to make easy, big money.

In health care, these moral hazards mean patients do not hold themselves accountable for finding the quality of care they desire at a price that makes sense. Instead, patients often rush for more health care believing that more care is better care; or to specialists because this means more competent care; or to more tests because this translates to more comprehensive results; and finally to more drugs and more treatments because these mean a longer, happier life. And patients do so because they believe their care is “free.”

Most patients are loathe to believe the numerous studies contradicting many of these beliefs. Due to the set up of the current “free” care healthcare system, patients are shielded from the actual costs of care, so they do not carefully consider these costs when assessing care. Take, for example, that a new chemotherapy drug for colon cancer cost $40,000, and yet only adds an average 1.5 months onto a patient’s life. Or that the newest brand name antidepressant costs 6 times more than its older, generic cousin (Prozac), with no evidence that it works any better. And finally, consider this example: a 70 year-old man with severe, irreversible chronic end-stage heart and renal failure, who has been bed-ridden for 3 months with numerous deep bed sores, and whose family demands “keep him alive no matter the cost.”

Unfortunately, the WIFM game doesn’t end with the patient.  Imagine the beauty of running a business when all your customers say, “Don’t worry, just send the bill to Mom (the employer) and Dad (the government) and they’ll pick up the tab.”  It is not rocket science to understand how this led physicians to a business model that guaranteed customers as long as they played by the providers’ rules; nor to understand how drug companies produce more and more “me too” drugs that offer no advantages over generic precursors but cost 6 times more; nor to see primary care physicians moving to specialization, with little difference in training compared to primary care while doubling or tripling fees; nor insurance companies keeping 30-40% of all collected money for “administration, policing, and profits,” and their executive team pocketing exorbitant rewards, like the United Health Care CEO who amassed almost $2 billion in just a few years.  How dare he?!

This then is the systemic toxic effects of our health care system. The moral hazard of free healthcare binds us into one big dysfunctional family. Whatever happens, let’s make sure someone else is paying for care.

Here’s the rub: insurance has a social value for protection against large or chronic, recurring costs to help ensure your financial well-being. Primary care, on the other hand, is something all of us need, on average 1-2 hours a year and a can cost the patient as little as $300. What minimal cost to pay for staying healthy today, building for a healthy tomorrow, and ideally decreasing our need for more expensive healthcare later on. Yet few are willing to pay only a little bit today for their day-to-day care – no matter its level of quality, accessibility or convenience, unless it is “free.”  So, in a world of moral hazards, what is going to happen to typical primary care?

Stay tuned and we’ll review the dirty little secrets primary care plays to survive and why it really does matter to you.

Until next time, I remain yours in primary care,

Alan Dappen, M.D.

Dr. Val’s Inaugural Photos

Today I live-blogged the inauguration via Twitter. Thanks for all of you who followed my personal anecdotes and to those who felt it was TMI, sorry. I chatted about everything from Susan Sarandon’s Visine addiction, to police security instructions, to a near fight that broke out in a group of cold and frustrated people who weren’t allowed onto the parade route. And best of all, I speculated as to whether there may be an official “inaugural pooper scooper” to clean up after the horses in the parade.

I promised the folks on Twitter that I’d have photos on my blog later today. So here they are. Photo 1 was taken of me and my “peeps” in our parade perch at 601 Pennsylvania Avenue (thank you, AHIP). The rest are pretty self explanatory. It was a really fun and momentous occasion.

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