(May 22, 2009)
Readers' experience of the U.S. healthcare system suggests that care follows money,
not the other way around. Is anyone looking at the incentives and disincentives
in our model of "healthcare"?
Readers wrote in response to
Social Welfare, Socialism and Healthcare (May 19, 2009).
Please allow me to relate two medical-related events that took place with family members
In late January, my older brother Robert died of leukemia. He was 53. Rob had been
originally diagnosed some ten years earlier and had been in remission and on a maintenance
chemotherapy up until the spring of 08, when all of a sudden, his symptoms returned with
a vengeance. The lymph nodes in his neck and stomach swelled horribly. Between the
spring of 08 to just before his death, he tried four different chemo regimes including
a clinical trial. Nothing worked.
Of course during all this, he became weaker and
weaker, going from 6'5" tall and 230 lbs (Rob played small college basketball when he
was young and continued to play up until the disease returned) to about 170 lbs. He
also developed a lung infection and was on oxygen for a while. As a last ditch, my
sister and I were tested for bone marrow stem cell transplant and I was found to be
On the day of the transplant, Rob had to undergo more chemo as well as radiation to
destroy his immune system. He returned to his room ashen and barely able to sit up.
My stem cells were transplanted through a drip feed to my brother. That night he
deteriorated. His breathing became labored and they had to draw fluid out of his lungs.
It got worse and he had to be sedated and placed on a ventilator. Rob did not want to
be kept alive artificially so his partner and the family decide to take him of the ventilator
and he died within minutes. A test of the lung fluid later found more cancer.
The lead oncologist had said Rob had a 50/50 chance to survive the procedure. I think
he knew full well it was much, much worse than that. They could have said 'Rob, we are
sorry but it's the end of the line' and let him die without putting him (and by extension,
his loved ones) through the horror of more chemo, radiation and pain. The outcome was
the same but the hospital got paid through my brother's health insurance.
My 82 year old father was diagnosed with a heart valve irregularity. He is otherwise in
good health for his age. A scope of his arteries showed no clogs. Last month after
consulting with two doctors, he decided to have the heart valve replaced. This is
supposed to be a routine surgery. After a few days of recovery, he went home.
couple of days at home he said his stomach was not right. On a Sunday evening, he got
up to go to the bathroom, became light-headed and fell. He was not injured by the fall
but my mom called 911 and he was taken to the emergency room. His blood pressure was
dropping and he vomited several pints of blood and was also bleeding from his rectum.
They were giving him blood but it was coming out as fast as it was coming in.
That evening they scoped him and found two ulcers in his stomach. He was on blood
thinners, so he almost bleed to death through these ulcers (he had never had stomach
problems before). During the scoping procedure they clamped the ulcers which stopped
the bleeding and so far (two weeks later) he has been OK. He comes home - again -
What would have happened if he decided NOT to get the new heart valve?
How long would he live? Would he be debilitated? He was fine before he went in for
the surgery - able to walk, work out at the gym and work in his garden. How tough
is it for an 82 year-old man to recover from open-heart surgery? I guess if Medicare
is paying, these questions aren't asked.
I always thought a good idea for government-funded health care would be for the Feds
(or the states paid by the Feds) to open up health clinics in cities. Care in these
clinics would be totally free to anybody who walked it BUT the patient would have to
sign a waiver stating that they could not sue the clinic or the doctors and if there
was a medical accident it would be arbitrated for settlement without appeal. The
doctors would work for a reasonable wage (not get rich) for a fixed length of time
and have their medical education paid by the government in exchange for thier service.
Doctors would be allowed to practice medicine without the threat of suit hanging over them.
I am sure it would be just as cost-effective as the VA.
Another very interesting post, as usual! This one hits close to home,
as my parents, aged 87 and 89, are active consumers of both Medicare
and VA services. They've been on the Medicare gravy train for more
than 20 years, but only recently did my father discover the "free"
services of the VA. As their designated driver for long-distance
medical appointments, I've made a few observations that may explain
some of the cost differential between the two services.
With regard to Medicare, there is a growing movement among physicians
to simply stop accepting Medicare patients. I learned this when trying
to find a specialist for my mother. The patient does not have the
option to just pay the bill herself. If she has Medicare, it's a
violation of federal law for the doctor to accept payment outside of
the system. As you might expect, this limits the pool of providers to
choose from. On the doctor's side, the problem is the amount the
Medicare will pay, which is non-negotiable. After factoring in the
paperwork and record-keeping costs, many doctors have decided that
it's unprofitable to accept Medicare, period.
Although both of my parents were hard-working, conservative and
definitely against a welfare state, they simply do not see that they
are now active welfare recipients. The attitude is "We worked hard,
we're entitled." I expect they used up the full amount they paid into
the system within 3 years of going on Medicare. Now they are willing
to schedule doctors appointments for the least little symptom, since
Medicare will cover it. Any gap is covered by the insurance provided
by their pensions.
The VA is another story. Again because of the "free" nature of it, my
father decided to start using it in lieu of a local doctor. There is a
clinic about 30 minutes away, staffed by nurse practitioners and one
or two doctors. When a routine visit produced a questionable test
result, he was scheduled to visit a specialist at the VA hospital in
Dallas. You don't call to make an appointment. They tell you when your
appointment is, some 4-6 weeks in the future. The hospital is well
over an hour's drive from his home, at freeway speeds. It's in the
part of Dallas where one is advised to keep the doors locked and the
windows up. I spent 30 minutes finding a place to park in the acres of
lots surrounding the hospital.
We waited about an hour past the
appointed time for a 5 minute visit, after which he was sent home with
no further follow-up needed. While waiting I observed a lot of
patients coming and going, and it seems apparent that most of them use
the VA because they have no other recourse. The process is so
burdensome that nobody would put themselves through it if they had an
alternative. This may be why the VA has a lower budget. A veteran who
also has Medicare would probably choose a local doctor, since his cost
is almost the same.
While I'm on a rant, there's another troubling aspect of the coming
econopolypse that troubles me. I'm 61. My meager retirement funds have
been clobbered, and likely will be sufficient for no more than a few
years at best. I expect to continue working as long as I'm able to get
out of bed in the morning, and I'm OK with that. In the unlikely event
that Social Security is still available when I hit 65, I don't plan to
file for it. My children and grandchildren are already facing crushing
debt, and adding to it would be unthinkable.
However I've observed a
number of fellow "boomers" who are retiring at the earliest possible
time in order to maximize their "take" from Social Security. One such
guy claimed that he "paid in for 40 years, and now it's my turn!" Of
course what he paid in for those 40 years went to his and my parents,
and anything he takes out will come from his own kids. Unfortunately
this seems to be the mindset of most people now turning 65, and I
expect it will hasten the crash of the entire Medicare and Social
The news this morning brings a proposal for national health care to be
funded by taxing health insurance benefits as income. The additional
taxes will fund the system, problem solved. But wait - if I can get
national health care, why shouldn't I just use that and forget the
insurance? After all, it's free!
On the Medicalization of Our Culture (Harvard Magazine)
This is an interesting article about the legal drug culture in America. Big pharma is
promoting a pill for every ill. I get tired when every time I watch TV I am bombarded
with drug commercials. I've come to the conclusion that it's abnormal to be healthy
in this society, that it's normal to be sick. I was watching a Kevin Trudeau infomercial
on his book Natural Cures 'They' Don't Want You to Know About and yes I know he's a
convicted felon and a con artist but I think he said at least one thing that was correct
when he said the drug companies don't want to cure disease, they want to manage it,
because if they cure a disease they stop making money off of it.
I think the drug
companies want everybody in America to be either physically or psychologically addicted
to drugs for life so they can make money. Witness the heavy advertisement on TV,
Magazines, Newspapers, and the internet.
I am not opposed to taking drugs if it's necessary, however adults need to look at the
side effects of the drugs to determine if it's worth taking, they need to determine if
the advantages of taking the drug outweigh the disadvantages. If I had a serious infection
I would take Penicillin despite the side effects because the benefits would outweigh
the disadvantages. However, I would rather change my diet, change my physical activity
and exercise then take drugs for Obesity, High cholesterol or High blood pressure.
For example the Obesity drug Fen-Phen caused pulmonary hypertension and heart valve
problems (https://www.fda.gov/CDER/news/phen/fenphenqa2.htm) I would think that if you
are Obese that the wise choice when looking at the pluses and minuses of taking an
anti-obesity drug is not taking it and instead change your diet and exercise.
Unfortunately a lot of people would rather take a drug for the rest of their lives
then to change their lifestyle because it's easier. When you are healthy or are trying
to get healthy by using a scientific non-drug approach then you don't have to worry
about doses, overdosing, side effects, drug interactions and finding a drug store
when you are traveling.
I really liked your quote from your "Food For Thought" May 9, 2009 article
"either we restrict the foods we eat when we have a choice, or our diet will eventually
be restricted by chronic diseases."
I think you should consider posting this at the bottom of your web page under Aphorisms.
Thank you, Galen, Jim and David for illuminating the darker corners of U.S. healthcare.
Can anyone deny that those with "coverage" from gold-plated health insurance or Medicare
will get over-medicated, over-tested and unfortunately over-"cared for" (as in sliced open)
because these services are "bill for service" items?
As noted here many times, there are few incentives for prevention and non-drug,
non-intervention treatments and lavish incentives to pathologize every aspect of
life as way of reaping vast profits off the "management" of the multitude of diseases
What few citizens are willing to accept is that the system is careening toward the cliff
of insolvency. As the U.S. economy unravels and those paying the bulk of taxes become
insolvent or opt out then there simply won't be any money to fund this stupendous
pathology-producing, "follow the money" bill-for-service system.
So the sort of non-drug treatments David mentions above will become the only option for most people
because Medicare as we now know it will be gone by 2014-2015 and Social Security as
we now know it will be gone by 2021. As we print and borrow our way to "prosperity" our currency
and debt payments will move in opposite directions; we as a nation will be insolvent.
We will be unable to pay the staggering interest payments due on our unprecedented debts
or con anyone into believing
the dollar has any value worth trading oil or gold for.
Believing we can endlessly print and borrow trillions of dollars every year with zero
consequences is to believe in a dangerous, utterly unsustainable illusion.
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