Surviving the Medical Meltdown (2 page)

But, you say, aren’t the insurance companies and employee-based health plans and lawyers also to blame? Although it is tempting to blame them, and none are truly blameless, they can only function in their current capacity because the strong arm of the government backs up their actions. For example: Why are lawsuits so ubiquitous? Because the average patient has no skin in the game. When patients come to my office, I cannot pass on to them the cost of my malpractice insurance because the government pays me, not the patient. In contrast, when the electric company gets sued for a wrongful death, it can add the cost to your bill. If the problem becomes widespread, it can take actions to make things safer and then alert the public to the
reason
their rates are increasing. In a free market, doctors could post signs in their offices alerting people that they will be charged a surcharge to cover the malpractice costs – just as businesses do with bounced-check charges. And the more government regulators turn out things such as “Guidelines” or “Best Practices,” the more fuel lawyers have to sue those who transgress the guidelines.

Companies learn to profit from government overregulation. Years ago, we reused many items in the operating room – drills, Kevlar safety gloves, and external fixators, to name just a few. They could be resterilized and repackaged until they were no longer usable. Then the FDA ruled that if a hospital wanted to reuse items marked
for “single use only,” it had to submit the results of full FDA-mandated testing to demonstrate that their procedure was safe. Since no hospital could afford to do that level of testing, hospitals stopped reusing items that were marked “single use only.” Very quickly, manufacturers responded by labeling nearly everything “single use only”! Thus, the hundred-dollar, perfectly sharp drill bit with one minor moment of use is discarded, as is the five-thousand-dollar external fixator (which does not go inside the body) that could have been refurbished and resterilized for use on many patients.

And the real kicker is this: for all the expense, we are getting less value. The truth is, government health care has never, ever, in the history of the world, anywhere, delivered the same quality of medical care as has the free market. Nor does it care as well for the poor – no matter the shrill voices of the media and academicians calling for government-run medicine precisely for this reason. Soviet medicine was free, universal, and lousy. There were dead cats lying in hospitals – hospitals that had no running water but many HIV-contaminated needles. The only real care was in the black market or at special hospitals reserved for the politburo and high officials. (See
appendix A
for references on government health care.) Sadly, as we have lost the battle for the free market in health care today, we are traveling along the path to a centrally controlled, Soviet-style system.

The World Health Organization loves to devalue American medicine, ranking it thirty-seventh in the world, somewhere behind Sudan. But in spite of this report card, the powerful and wealthy, when sick, flock to America for care. Boris Yeltsin underwent heart surgery in a special politiburo-only hospital, by American-trained surgeons, and imported Dr. Michael Debakey from Texas to supervise. His free, universal, Soviet health care system was okay for his gray masses, but not for him. Two premiers of Canada and at least one member of Parliament have crossed our northern border clandestinely to get their health care here. And recently the former head of the Canadian health system jumped the border for care. If universal government medicine were so great, why didn’t they stay
home? When the former Sultan of Brunei needed care, did he go to Sweden or France or any other socialized, “equitable,” and more highly World Health Organization (WHO)–ranked country? No, he came here. People who know, and can afford to, vote on quality with their feet. And for good reason. They know that “fairness of distribution,” one of the major determinants of the WHO ranking, doesn’t really count when you are sick.

What really counts is outcomes. The British journal of cancer,
Lancet Oncology
, in 2007 looked at the survival from cancer around the world by country. On every chart, for every cancer examined, the best outcome, the best survival rate, was in America. And the differences were not trivial. For example, if one considers cancers that affect men, and lump all cancers into a pool of outcomes, your chance of living five years after diagnosis in America was 66 percent, but in Europe it was 47 percent, and in Britain (nicknamed the “sick man of Europe”) 45 percent. Canada fared only a little better at 53 percent, which may explain the tendency of some Canadians to jump the border to America for treatment. Breast cancer, same outcome: 90.5 percent five-year survival in America, 78.5 percent survival in Britain.
²
Similarly, you can look at outcomes for other issues, such as deaths after heart attacks or survival of strokes, and again we fare better than the Brits or Canadians with their universal health care. So, in answer to “Who you gonna call?” when you get sick, the answer is “the United States.”

Why is there a 20 percent better cancer survival rate in America? A major reason for this discrepancy is the lack of access to specialty care in government-run systems. In addition to the one million–plus patients waiting for surgery under the National Health Service in Britain, many more wait for evaluation for cancer or heart disease. The average time from diagnosis of breast cancer to seeing a cancer specialist in Canada is forty-five days. In fact, only 50 percent of women biopsied for abnormal screening mammography get their diagnosis within seven weeks.
³
In America, we worry if we can’t get a patient into the oncologist over a long weekend. My friend,
a former oncologist from MD Anderson Cancer Center in Texas, on a family visit to Sweden, visited a local, small-city Swedish oncologist. My friend was over sixty years old and was still seeing sometimes fifty patients a day in America. But the young Swedish oncologist was very different. His office waiting room was packed with patients, some of whom had traveled two hundred miles to see him on the first-come, first-served basis such offices in Sweden use. But at 1 p.m., after seeing about twelve patients, he closed his doors, and everyone still waiting would simply have to come back in the morning. Why? Because the Swedish government health system paid him for only twelve patients, so that’s precisely how many he saw.

For every one million people in America, one thousand are receiving dialysis. In Europe it is 537 per million, and in England, 328 per million. Those untreated suffer and die. As reported in a study by the National Kidney Research Fund and Sheffield University, “If the doctors responsible for those patients cannot find a unit to take them, then the only option is for the doctors to keep them comfortable in hospital until they die.”
⁴
And while American cardiologists debate the best noninvasive ways to stratify cardiac risk in asymptomatic patients, Canadian medical journals publish articles concerning the best way to keep people from dropping over dead while waiting in line for care.
⁵

But we are rapidly converting our health care system to a European/Canadian model. Already Medicare is denying care (read: rationing) and paying physicians and hospitals at levels that decrease their willingness to take on more or sick patients. The father of the vice president of my hospital needed a special form of pacemaker. He was having intermittent heart arrhythmias (rhythm problems) and was at risk of sudden death. Medicare denied the pacemaker because his “cardiac output” was too high. Now, any physician knows that cardiac output measured during the normal times between arrhythmias will be normal. Cardiac output applies only for chronic arrhythmia, not intermittent, but government bureaucrats without any medical training can’t know that. In spite of pleas from
several cardiologists, he remains untreated. And since Medicare pays for the service in general, the Medicare recipient is prohibited from paying cash out of his own pocket to any doctor or hospital that accepts Medicare. His only option is to go overseas or wait to die. To government statisticians, death is the cheaper alternative.

If you want a glimpse into government-run health care American style, just look at the Veterans Administration (VA). My friend was a nurse practitioner at a VA clinic a decade ago. She saw a patient who, two weeks previously, had undergone a total knee replacement at a VA hospital several hours away. The patient complained of increasing redness, warmth, and swelling of the knee – signs of a possible post-operative infection. Knowing that infections in total joints are very serious, she tried to get him back to the VA hospital for urgent follow-up care. She was unable to get an appointment without violating standard appointment protocol, but she finally got him an appointment for two weeks later. (In civilian practice such a swollen red joint would be evaluated emergently – generally within hours – by an orthopaedic surgeon.) After being shuttled nearly five hours on the VA van and after waiting two weeks, the patient arrived at the VA hospital only to be told he had no appointment. The appointment he had been given was for
the following year
. I don’t know the clinical outcome in this case, but my nurse practitioner friend was disciplined for violating VA protocol, and she subsequently quit. I’m sure someone got a pat on the back or monetary reward for rigorous uniformity of scheduling or some such nonsense.

The Veterans Administration (VA) has had problems since its inception. Congress sought care for WWI veterans and created the Veterans Bureau. The bureau lasted a whopping nine years before being dissolved because of rampant corruption. The Veterans Administration was created to supplant the bureau in 1930, but the VA was in trouble from its inception, at one point spectacularly protested by veterans over pay.

In 1945 the VA head administrator resigned amid accusations of substandard medical care at the VA hospitals.

It seems nothing much has changed. At present, the VA medical system remains a top heavy, bureaucratic, corrupt organization where lip service is given to quality medical care, but medical care takes a backseat to self-sustaining paperwork that ensures bonuses for VA administrators.

Problems range from contaminated colonoscopic equipment to misidentified graves. As reported by CNN, “At least 40 veterans died while waiting for appointments to see a doctor at the Phoenix Veterans Affairs Health Care system…. The patients were on a secret list designed to hide lengthy delays from VA officials in Washington, according to a recently retired VA doctor and several high-level sources.”
⁶
Veterans were waiting futilely in line for care while records were fudged so performance bonuses could be paid.
⁷
Administrators benefitted from shorter “average waiting times,” so that’s what they got – truth be damned.
⁸

There are various reasons for the failure of the VA to give quality medical care, but the truth is that no one cares more about your health than a
private physician
whom you pay directly, who knows you and your family, and who took his/her Hippocratic oath seriously. Hippocrates taught that “Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief.” Hippocrates knew nothing about Medicare or the VA, but he knew that there would always be those “third parties” who would be whispering into the doctor’s ear, but who might have an agenda other than the health of the patient. A wife might want the patient dead to get his estate. A neighbor might want him dead to scoop up his wife. Government might want him dead to save money. In the case of the VA, the government administrators chose between giving themselves bonuses or upgrading an operative suite, adding physicians to deal with the backlog or providing better pharmacy services. Private physicians are not perfect. They may not always know the right answers. But with rare exception, they are really committed to seeing their patients do well.

Government-run health care cannot be fixed by new administrators
or by tweaking the system, because it is flawed in its very definition. Government makes budgetary decisions that determine who gets what, and in the case of medical care, government bureaucrats see medical care as simply a negative cypher on the financial bottom line.

THE FUTURE OF MEDICINE IN THE UNITED STATES

If you are reading this book, you are wisely concerned about your ability to get medical care in the future. Oh, you may be signed up to this or that health plan, or you may get your medical care through some government agency, for example Medicare or the VA. But you are smart enough to realize that having an insurance card in your wallet does not necessarily get you a doctor when you need one, nor does it magically produce the medicine you need.

You may or may not be aware of the first cracks appearing in the system. Like cracks in the fuselage of an aircraft that can be detected only by X-ray, there are certain telltale signs occurring in medicine today that presage catastrophic failure.

• Shortages of everyday supplies are occurring: tetanus toxoid, Valium, propofol, Levaquin, thyroid, other common drugs, and standard items of medical equipment are not always available.

• Wait times for routine specialty care are dramatically increasing; it is not unusual in some areas to wait six to nine months for an appointment with a rheumatologist or spinal surgeon.

• There are not enough specialists to cover emergency room calls.

• Hospitals in inner cities or poorer regions around the country are closing their doors rather than face economic ruin.

• It is difficult in some areas to find a primary care physician, especially for Medicare or Medicaid patients.