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Your healthcare system through a different lens…

Imagine if you went to the grocery store to purchase a week’s worth of groceries – once in the store you had to select items without price tags or any labels suggesting which items were more expensive than others. In addition, all the items were behind counters, so that you had to ask for them from store personnel (and cannot inspect them at close range) who wrapped them in opaque paper and initialed them before handing them over. You were paying a monthly fee to be a store “club member” to get discounts, but were not told what those discounts might be.

So now once you’ve gathered all your groceries you stand in the check out line. The person in front of you is complaining about the outrageous price of her groceries, while the clerk responds that she didn’t force her to shop at the store or select those groceries, that it would have been cheaper if she were a club member, and that higher prices were assessed based on the individual store personnel initials that were on her paper wrapped items. The clerk also tells her that she cannot return any items (as once they’re wrapped, they’re considered non-refundable – and that she will be reported to a debt collection agency if she does not pay). The shopper is outraged, but since she doesn’t want her credit ruined, and there are no other stores within 100 miles, she pays the price and leaves.

Your turn comes to check out. You’re a club member so your bill is substantially less, but you can’t be sure what the individual items cost or which fees were added based upon the various initials written on the white paper. In fact, you have a feeling that the store staff added some additional packages to your cart when you weren’t looking, but you can’t be sure because of the wrapping. You pay your bill, go home, and find as you unwrap your groceries that at least half of the things you bought were not what you thought they were (or what you wanted), and that there were indeed extra items in there that you never asked to buy.

What kind of crazy scenario is this? It’s a simplified analogy of our healthcare system. The shoppers are patients, club membership is insurance, stores are hospitals, grocery wrappers are healthcare providers, and clerks are the hospital administrators. I also emphasized the lack of price transparency that is inherent in the system.

If grocery stores were actually like this, there would be a violent, nationwide revolt within days. Are consumers ready for a revolution in healthcare? I hope they are, because their collective bargaining power is probably the only thing that will force price transparency and system-wide improvements. But to make this happen, consumers should consider a few key points:

  1. A single payer model is nothing more than taking the grocery store system we already have and asking the store to accept a new club card whereby staff will decrease the size of the grocery items (by 50%) to those members. One of the best quotes I’ve read about the certain doom of a single payer system was recently posted in GruntDoc’s blog.
  2. Price transparency is the most important initial step to consumer empowerment and should be at the top of the lobbying list.
  3. Doctors are not the bad guys, the system is the bad guy. Physicians and patients must ally with one another to demand improvements. The AMA has taken a strong stand in favor of the consumer driven healthcare movement.
  4. Consumers must become active participants in their care. They need to educate themselves about their diseases and conditions and focus on early intervention and preventive medicine. As resources become more and more scarce, and the US population becomes older and sicker, healthy living practices provide the only real hope of relief from the complications of advanced disease. As Dr. Feld notes in his blog, 80% of healthcare dollars are spent on complications of chronic diseases!

I think that Revolution Health can play a critical role in consumer empowerment. Here at the “Web 2.0″ social network intersection between healthcare professionals and patients, RHG can help consumers take control of their health (via education and peer support), and join forces with others like them to revolt against this unacceptable and bizarre “grocery store” system that we have in place!

This post originally appeared on Dr. Val’s blog at

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4 Responses to “Your healthcare system through a different lens…”

  1. CharlieSmithMD says:


    Well said. I believe strongly in consumer empowerment, and in helping patients take more responsibility for their own health care (

    I believe the best model for this is to have a site like Revolution, along with a cadre of web-savvy physicians who stand ready to help keep patients on track, answer questions, and provide them with reliable information. The model of an empowered patient, linked with a receptive physcian who understands how this model can be far superior the “doctor always knows best” approach will truly revolutionize health care!

  2. Anonymous says:

    I think you have completely misrepresented the single-payer system. Look at your own earlier blog posts about high hospital CEO salaries and alternative uses for that money, add high CEO and management salaries for health insurers and profits for insurance company shareholders, and then compare the efficiency of this “private” system to that of Medicare. Consistently, Medicare’s overhead costs have been shown to be lower, even by those who wish they could demonstrate the reverse. (See, for example, “Medicare’s Hidden Costs” at Taking into account “hidden” costs of Medicare and removing some costs that are usually counted in private sector overhead, Medicare’s overhead still comes out to about 6 percent vs. almost 17 percent for private insurers.) Why would someone object to a more efficient system, particularly considering that in most countries that have “socialized medicine” overall costs are lower and overall life-expectancy and other measures of population health are higher than in the US? Maybe it’s because doctors are seldom the wealthiest members of society in those countries. Maybe that’s why GruntDoc objects so vehemently to the idea of assuring healthcare for all.

  3. Anonymous says:

    What a great image! I think your comments are so on target. I think some people confuse the notion of universal access to health care (which I do believe in) with a single payer health care system (which I do not agree with). I have experienced a single-payer government sponsored health scheme first hand and it was a far, terrifying, cry from the romanticized view many seem to hold. Even the US medicare system allows the participation of other payers. So much can be done to improve healthcare, cut costs, and improve access within a competitive, multiple payer system, in which patients take more responsibility for their medical “purchases” and their relative value.

  4. Anonymous says:

    The decrease in services associated with a single payer scheme might not be just 50%. When I was in Newfoundland, a province of Canada, a couple of years ago, the front page headlines in the newspaper was that the province’s MRI machine was down, ie, not working. There was no other. Newfound and Labrador does not have a huge population, but the province is a big big place. People travel for days to get an MRI, after an extremely long wait; could be as long as a year. In Quebec, there are not enough doctors, specialists, xray techs, nurses etc partly because the pay is low. People wait a long long time for a hip replacement–perhaps two years of the rest of their lives.

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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