Specialists – Putting Patients First

Friday, July 24 2009

The last panel at “Putting Patients First” was composed of specialists: Dr. Wes, who posted his comments on his blog; Dr. Rich from Covert Rationing; Dr. Jim Herndon; and Kim from Emergiblog. As for the primary care panel, I’ll put the Q&A in a separate post. On this post, I’ll first summarize the remarks, then add my comments at the end.

Dr. Wes was first. He began by saying that a patient does not want to see a “nurse coordinator” in the ER, referring to a remark by Peter Orszag. Then Dr. Wes showed the Boehnergram of health care reform, and blamed the current economic crisis on government intervention in housing. Dr. Wes said that ‘patients don’t fit into boxes’, and “coercive enforcement” to mandate treatment is an assault on the doctor/patient relationship. Dr. Wes is also anti-EMR, and pointed out that the coding schedule developed by the AMA requires him to enter one of 17,000 codes correctly, or risk insurance denial for the claim. He also said that schedule is going to balloon to 155,000 codes in the near future. He argued that such data is too tempting to ignore for hospital administrators looking for places to make cuts and increase margins. He described our health care system as a gravy train of special interests, insurance companies, pharma companies, and hospital builders – and said that doctors don’t have a financial stake in the industry.

Dr. Rich began his remarks by noting that we’ve been talking about putting patients first, but not about “rationing” – which he defined as withholding some care from some patients. Dr. Rich called rationing an ‘economic imperative’ – but Americans don’t have rationing. Instead, we have covert rationing, which Dr. Rich said ‘corrupts everything it touches’ – it maximizes waste and inefficiency. Dr. Rich said that a bank robber has more rights than a patient; specifically, the criminal has the right to an advocate. Dr. Rich pointed out that sick people are not capable of navigating a health care system, no more than a felon is able to navigate the court system. He argued that third-party payors cannot abide the doctor/patient relationship, and that 3rd parties coerce the primary providers in the interests of payors, not patients. Dr. Rich warned patients: you’ve been completely marginalized. He said the current bill will make it worse. Dr. Rich said that physicians aren’t advocating for patients, so you need to educate yourself. He warned that we need to ‘ignore the blandishments of a broken health system’.

Dr. Herndon – a surgeon – recounted his conversations with young residents. He said they all agree all Americans should have health insurance for basic care, and maybe a second-tier for elective surgery. Dr. Herndon said that older surgeons believe everyone should have care, too – but all are against single-payor, and think the public plan is a step in that direction. Dr. Herndon pointed to the physician shortage in Massachusetts as a warning. He also brought up the ‘other issue’, which is cost. Dr. Herndon said that patients have a responsibility to pay, and that patients have an appetite for new technology that is unproven and untested, and they will go elsewhere if they can’t get it. Dr. Herndon said that ‘Americans have an obligation to be informed patients’.

Kim began by stating the basics: the patient. ‘We are the patients; it’s all us. Not patients vs. doctors.’ Kim asked, what does she as a patient needs to know so that she can make the best decision? She warned patients will circumvent any plan by showing up in the ER – that if we can’t get the care we want and need, we will go to the ER. She explained that in MediCal (California’s MedicAid program) there is a 3 month wait for primary care. Kim said she would like to see patients get the money – that we should be giving the patients the money. She argued for HSAs that don’t expire, and that we shouldn’t pay through the back door (which is presumably different from paying out the ass). Kim argued that Congressman Ryan’s plan does that: it gives patients the money.

So, my reactions: Of all the panelists, I felt like Dr. Wes was the most ideologically motivated. I’m not even sure what a nurse coordinator is, but I suspect Dr. Wes is overstating his availability to his patients. In any case, if the choice is between a nurse coordinator and the doughy administrator who has to xerox my insurance card every time I go to the same hospital, I pick the nurse coordinator. Moreover, showing Boehner’s chart was a mistake. It’s scary because it was designed to be scary, but it’s a trivial exercise; give me a couple days with Photoshop, and I can make taking a dump look like the most Byzantine and bureaucratic thing you’ve ever done in your life.

Dr. Rich, on the other hand, seemed to have a grasp of the problem, but not a real solution. Yes, rationing in one form or another is an economic imperative. To say, however, that we are going to let doctors and patients do the rationing is to say we’re going to soak patients spend for as much as they can afford on health care – see Dr. Herndon’s remarks on patients appetite for unproven technologies. Decisions about rationing – about what works, what’s effective, and what’s efficient – have to be made systematically, or else it isn’t rationing. At present, we let insurance companies make those decisions through an arbitrary and opaque set of criteria that focus on their business, not patients’ well-being. Whatever the arguments against vesting government with the power to make these decisions, we at least have the benefit in this country of a nominally democratic government. Most of us can’t outvote our insurance executives. Right now, we can’t even be informed patients because insurers, drug makers, hospitals, and – yes – doctors put a lot of effort into keeping important information from us.

I totally appreciate the spirit of Kim’s remarks – we are all patients – but I disagree on the facts. For ‘Putting Patients First’ to mean anything at all, not everybody can be a patient. I’m also not convinced that the ER makes it so easy to circumvent lousy health insurance programs; for every person that does end up getting routine care in the ER, I would bet there are dozens who do without until it’s no longer routine. I have definitely put off routine care instead of going to the ER – and even resisted going to the ER when I needed it – simply because of the high co-pays my insurance charges. So I worry the view from the ER is a little too specific to draw conclusions about all of health care. That said, I know Kim is not just an ER nurse, and I really appreciated the chance to meet with her and talk to her after the event.

That’s it for the remarks. My next post will be the Q&A.

Tags: care, docs, ppf

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