Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Latest Posts

Wait Times For Medical Care: How The US Actually Measures Up

Yesterday, I borrowed liberally from Dr. Seuss’ “Oh, the Places You Will Go” to describe the “weirdish, wild space” – The Waiting Place – in which we now find health reform.

This got me thinking about The Waiting Place in a different context: the time it takes to get an appointment with a physician. Anyone one of us who has had to wait weeks, or even months, for an appointment would agree that The Waiting Place is, as Dr. Seuss described it, a “most useless place” to be.

Critics of the pending health reform bills, like Conservatives for Patient Rights argue that they will lead to longer wait times for appointments. Their argument being that “government-run” health care, as exists in Canada or the United Kingdom, has been demonstrated to result in long waits for medical appointments.

I would dispute the premise that the reforms being considered by Congress are akin to the systems in place in Canada or the United Kingdom. Read more »

*This blog post was originally published at The ACP Advocate Blog by Bob Doherty*

A Scottish View Of US Healthcare Reform

I’ve been bemused by the debate on healthcare reform taking place in the U.S. right now. I used to thing that the single topic that people talk the most nonsense about is sport. You know, my sport is better than your sport, my team is better than your team etc. All good fun, but usually nonsense. And then I’ve watched pundits on TV and heard ordinary Americans talk about healthcare reform and wow….its got the sports conversations beaten for absolute gibberish.

So despite a reluctance to get involved because I recognize it’s an extremely complicated issue, I now feel compelled to say a few words. Part of it is because unlike most of the people expressing an opinion, I’ve worked and been a patient in the healthcare system in a country with “socialized medicine” (UK) and I also currently work and am sometimes a patient in the United States healthcare system.

So lets start off with a few basics. The United States has some of the most highly trained healthcare staff and by far and away the best healthcare technology in the world. Just to give an example, there are more scanners (MRI, PET, SPECT etc) within a 15 mile radius of my office in central New Jersey than in the whole of Scotland (population about 5 million). And the United States spends far more on healthcare than any other country in the world. But despite that vast wealth of resources that befits the worlds greatest economic power, the United States falls way down the league table on basic objective measures of health outcomes, and similarly down the league on patient satisfaction with healthcare. There are really very few people, (who have looked further than the end of their own nose into this issue) who don’t acknowledge there’s a very serious problem.

For many in the United States, the problem is not so apparent. So if, like me, you and your immediate family are fortunate enough to be relatively healthy, and to be covered by a relatively good employment-based health insurance package, then it may seem OK. It’s when you get very sick, or are unfortunate enough to lose your job, that some of the basic problems with the U.S. system become more apparent. It’s when you get sick that you may find that your policy doesn’t cover the kind of treatment you need, or has a high deductible (amount you have to pay before the insurance takes over). And its when you lose your job and have to start paying out of pocket for health insurance that you realize it is extremely expensive. And of course if you have a gap in coverage and get sick then the new insurer may refuse to cover your “pre-existing condition”.

To me, the single time in your life when you don’t want added financial stress is when you are sick. But many aspects of the U.S. system direct coverage and services to those who need it least (healthy, young ,well insured employees) and become a nightmare for those who need good healthcare most (aging, sick unemployed people). Now when you talk to people in countries like Britain about this, they are generally appalled and quickly see the problem. But one of the things that has surprised me most about the debate in the United States is that a significant proportion of people here seem to really believe that the old “survival of the fittest” philosophy is appropriate here. The attitude seems to be something like: “If someone gets sick and didn’t have the fore-thought to get adequate health insurance to cover the treatment, then that was their own fault. Why should I work my ass off to look after my family and their healthcare needs for some lazy unemployed person to get healthcare for free?”

So somewhere deep in the psyche of many Americans there is a basic belief that healthcare (insurance) is just like auto insurance….something we are all individually responsible for, and if we cant afford it, that’s tough. Many do not believe that healthcare access for all is a basic requirement of a civilized society (like roads and schools).

So President Obama and others who are currently trying to change the U.S. healthcare system have a tough task ahead. It is currently being made much tougher by some bizarre reporting on this topic by the right wing media (Fox etc). We hear weird stories about “death panels” of government bureaucrats who will decide which sick people should have the plug pulled on their healthcare under government healthcare. We hear weird stories that in countries with socialized medicine it’s the government, not the doctor who decides on what treatment is provided. Well I can tell you that I never saw “Big Brother” interfering in doctors’ clinical practice until I came to the United States. In this country it is bureaucrats working for health insurance companies, generally with no medical qualifications, who deny coverage for appropriate medical treatment hundreds of thousands of times a day.

Often coverage is not denied on clinical grounds, but rather for a whole series of “technical” reasons (wrong diagnostic code, doctor not part of that health insurance plan, pre-existing condition, patient already used annual entitlement for that type of care, patient had that treatment already for longer than policy will pay, treatment carried out at a non-approved facility [go to one 30 miles away], patient hasn’t completed the 6-monthly confirmation of details form, health insurance company doesn’t cover that type of illness/service etc etc). But the underlying strategy is to make it so difficult to get a treatment covered and paid for, that fewer people will go for treatment, and fewer doctors will provide certain procedures because it is so much hassle for them to get paid for it. So the insurance companies hire more people to try to find ways to deny coverage and payments, and doctors have to employ billing specialists to figure out how they can get paid for providing treatment. And the result is an extremely inefficient beaurocratic mess.

Surely a country like the United States can do much better than this?

Now you might be wondering what any of this has to do with smoking? Well one link is that many health insurance policies in the United States do not cover a range of interventions they call “preventive” or “wellness enhancing” interventions. Frequently that means that patients cannot get tobacco dependence treatment (medicines or counseling) covered and so they don’t get the treatment. This is despite the fact that such treatment is one of the most cost-effective clinical interventions available. So an important part of the new proposals for healthcare reform is an increased emphasis on preventive healthcare. This is certainly a step in the right direction.

This post, A Scottish View Of US Healthcare Reform, was originally published on by Jonathan Foulds, Ph.D..

A Banker Describes The Size Of America’s Debt

Out of the Federal Reserve Bank of Dallas, comes this excellent presentation by its President and CEO, Richard Fisher about the fiscal disaster we currently find ourselves living in. Found  (Via Grand Rants)

Happy’s  summary.  We are all screwed.  Every last one of us.  Unless a massive shift of policy is instituted today, we leave no future for ourselves or our children.  The entitlements we currently support are ponzi schemes a thousand times larger than Madoff and his thieves.

Tonight, I want to talk about a different matter. In keeping with Bill Martin’s advice, I have been scanning the horizon for danger signals even as we continue working to recover from the recent turmoil. In the distance, I see a frightful storm brewing in the form of untethered government debt. I choose the words—“frightful storm”—deliberately to avoid hyperbole. Unless we take steps to deal with it, the long-term fiscal situation of the federal government will be unimaginably more devastating to our economic prosperity than the subprime debacle and the recent debauching of credit markets that we are now working so hard to correct.

Stating the obvious, we are screwed.  But how is Social Security you ask?

Now, fast forward 70 or so years and ask this question: What is the mathematical predicament of Social Security today? Answer: The amount of money the Social Security system would need today to cover all unfunded liabilities from now on—what fiscal economists call the “infinite horizon discounted value” of what has already been promised recipients but has no funding mechanism currently in place—is $13.6 trillion, an amount slightly less than the annual gross domestic product of the United States.

Sounds like a lot of money, but that’s the good news.  Read on:

The good news is this Social Security shortfall might be manageable. While the issues regarding Social Security reform are complex, it is at least possible to imagine how Congress might find, within a $14 trillion economy, ways to wrestle with a $13 trillion unfunded liability. The bad news is that Social Security is the lesser of our entitlement worries. It is but the tip of the unfunded liability iceberg. The much bigger concern is Medicare, a program established in 1965, the same prosperous year that Bill Martin cautioned his Columbia University audience to be wary of complacency and storms on the horizon.

You should be afraid, very afraid of where we are heading.

Please sit tight while I walk you through the math of Medicare. As you may know, the program comes in three parts: Medicare Part A, which covers hospital stays; Medicare B, which covers doctor visits; and Medicare D, the drug benefit that went into effect just 29 months ago. The infinite-horizon present discounted value of the unfunded liability for Medicare A is $34.4 trillion. The unfunded liability of Medicare B is an additional $34 trillion. The shortfall for Medicare D adds another $17.2 trillion. The total? If you wanted to cover the unfunded liability of all three programs today, you would be stuck with an $85.6 trillion bill. That is more than six times as large as the bill for Social Security. It is more than six times the annual output of the entire U.S. economy.

And how much is that for you and me?

Let’s say you and I and Bruce Ericson and every U.S. citizen who is alive today decided to fully address this unfunded liability through lump-sum payments from our own pocketbooks, so that all of us and all future generations could be secure in the knowledge that we and they would receive promised benefits in perpetuity. How much would we have to pay if we split the tab? Again, the math is painful. With a total population of 304 million, from infants to the elderly, the per-person payment to the federal treasury would come to $330,000. This comes to $1.3 million per family of four—over 25 times the average household’s income.

What would you have to do to get the unfunded mandates funded?
  1. Either increase federal tax revenue 68% starting today, and continue it forever.    Good luck with that.  When you tax something, anything, you will get less of it.  Nobody knows what tax rate could support that without destroying the economy in the process.
  2. Or cut discretionary spending 97% (that includes defense, education, environment and everything else under the sun), forever.
The issue isn’t not enough taxes.  The issue is a government that cannot say no to its constituents.  Now, I know some of you view Obama as your messiah, but I’m sure even he knows he can’t generate 99 trillion dollars on the backs of the rich.   So the question is, does he have the guts to tell you no before it’s too late? It takes a real leader to tell his followers no.  Right now, our leaders are promising everything and they will ultimately be able to deliver on nothing.

*This blog post was originally published at A Happy Hospitalist*

April Is National Organ Donor Month

I was reminded that April is National Donor Month by a post over at Donorcycle.  I am a strong organ donation advocate.  My driver’s license is signed.  My family has been informed of my wishes.

It is a point of a contention in my family, hopefully a small one that will be resolved (or never come up for real).  My niece, K, who is in nursing school has signed her driver’s license to be an organ donor.  Her mother, my sister, J, will not give her permission if asked – not readily anyway.  “I don’t want my baby cut up.”  That is her reason.

My niece, K, is a giving soul.  Her wishes should be honored.  She should be allowed to make that last gift if the time ever arises.

I need to find a way to reassure my sister that we don’t “butcher” the body when donor organs are harvested.  I need to get her to read Dr Cris’ blog post “Organ Donation from the Inside

Transplant surgeons care about donors. Staff respect them, and the decision they have made. Their job in this case is to implement the wishes of the donor and not waste their sacrifice. …… I have assisted at an organ retrieval for transplant, and that is why I am on the Organ Donor Register

Another of my sisters recently was widowed when her husband died of heart failure.  He had had many heart attacks over the last several years.  In the end, he was told he needed a heart transplant.  He didn’t live long enough, but I use this to show that the need it there.  The need is great.  If we would be receivers of the organs, then we need to be givers when able.

**This blog post was originally published at Suture For A Living.**

Lobsters Of Medicine

I’ve never cooked lobsters but was reminded of the trick to the recipe today: if you try to put lobsters into boiling water you’ll have a big fight and it won’t go well, but put them in cool water and slowly turn up the heat, by the time they realize there’s a problem they’re cooked.

I thought about this while turning sideways between gurneys in the hall to get through to the next patient of many.

The temperature in my ED continues to climb, but I’ve been here so long it just seems like it’s getting a little warm.

ED’s everywhere have rising census, increasing demands, physical plants that aren’t keeping up with the crush.

Coal mines have canaries.  Medicine has lobsters.

It’s getting warm, but there’s plenty of time.


Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

Read more »

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

Read more »

See all interviews »

Latest Cartoon

See all cartoons »

Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

Read more »

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

See all book reviews »