14 Jul 2009
9 minute read
agk’s Library of Low Resource Medicine
Back to Health Care Crises Part 1
And what of those doctors and hospitals? There are two very different agendas at work here. On the one hand, existing doctors and and hospitals and other providers are quite happy being paid, and want to see their insurance premiums (for malpractice etc) go down. Partly this depends on change in the culture of health in America (ha!) but partly this will lead to stipulations and protections (against those evil trial lawyers and their disabled clients) in any health care bill. Will doctors voluntarily lower their incomes to pass the savings on to you? Ha!
Hospitals, in direct conflict with insurers, want patients to seek treatment, by ER if necessary. Under fee-for-service structures, they (and their associated providers, though not their staff) are paid per-test and per-procedures, which means that any law that restricts providers to a given protocol will run up against the insurers in a direct head to head. And who will win? Who can say? Doctors can make a good case that the American health care crisis is caused by poor early detection of hidden illness (catch it when its cheap, save the expensive surgeries later) and win a lot of public sympathy that statisticians can’t really marshall.
So, lets recap – the government thinks the problem is people not able to access health care. The insurers think the problem is people getting health care they don’t need from overpaid doctors, and the providers think the problem is not enough of the right health care being provided. What do consumers want? We’ll get to that, but there’s something else I need to talk about first.
Remember when I said that the health care industry is the life raft onto which the entire collapsing American economy, beset with layoffs, failing industries, unretirement, and evaporating investments is jumping? (oh just end your damn sentences with prepositions, Anne) This isn’t just a matter of autoworkers becoming transcriptionists, or kids dropping out of computer science classes to become nurses. Health care institutions are still somehow a growth industry, in fact they are almost something of a bubble.
There is a perception that clinics, dialysis centers, ambulance companies, nursing homes, urgent care centers, specialty surgeries and other assorted health care detritus make lots of money. As a result, people with money to invest are paying to open them all over the place. Each facility hires a given number of nurses, receptionists, janitors, and other professionals, which make them very attractive to municipalities looking for something to subsidize to “bring jobs.” In a surprising number of cases, the majority owners are actually doctors and hospitals, who are (of course) in a position to direct patients to their new investments. This can get ridiculous- while never proven, there are rumours that a unnamed nursing home in my old service area was partly owned by a given doctor because anyone who came to the hospital for any reason and drew him as an attending got sent there. The end outcome of all this investment is, of course, more people who are directly benefitted – and in the case of low-education employees, dependent – on more and more people getting more and more “care” for whatever reason.
There is an even more disturbing side to this, which is the suspicion that health care may actually be a bubble. Right now, much of the operating expenses of the industry are covered by investments and growth-subsidies, all of which are paid on the assumption that they will eventually be repaid once the clinics et al are established enough to turn a profit. However, it seems entirely likely that without a steady flow of investments and subsidies, there would be no profits, and in fact the industry would collapse or be forced to contract severely. Not only are all these new facilities, far too young to be paying for themselves out of revenue, at risk there is also a trend in the design of hospitals that parallels the rise in satellite specialty clinics – the regional center movement.
Hospitals are fabulously expensive, fixed, and dependent on their immediate geographic area. To compete with each other for patients, and more importantly for bond issues and investments, they have to show not only that they are good facilities but also that they have something the surrounding hospitals do not. There are a number of designated “centers” hospitals can aspire to become, assuming there’s nothing else like it in their region. For instance, a regional cardiac center, a regional stroke center, or a regional cancer center can draw patients away from other hospitals, instead of relying on those who get sick in their immediate twenty-block radius. The problem – or rather the opportunity – is that qualifying as such a center requires a fantastic outlay of cash – 24-hour prepped operating rooms, on-site specialists, extra rooms and facilities and machines… So hospitals have to qualify for enormous loans and bond issues, which jobs-hungry municipalities and rich people without any real estate to bank on are more than happy to provide. And so the immediately available cash pool goes up for a few years… along with the long-term debt which will eventually have to be repaid from unproven (and unlikely) profits. Which will have to come from… you.
And that’s a bubble.
So, finally, the last possible health care crisis I want to talk about today: what is this “care” being provided in the first place? Well, mostly late-term interventions, based on a modernist disease model that identifies “disease” with measurable derangements in a physical body, for which the treatment is generally the transfer of custody of that body from the individual to an institution which endeavours to reverse or compensate for those lesions. Does it work? Sometimes – this is a huge issue, but there is reason to believe we just aren’t doing it right, that there is no Platonic Body without lesions (body without organs? oh shut up) and that no institution, no matter how thorough and empathetic, can effectively take custody of a living human body. Alternative health care is usually very close to western (for instance, the idea of the disease being caused by a physical “imbalance” or variation/injury, and the cure coming in the form of a non-customary substance or intrusion into the body.) I’m not meaning to rag on any system right now – pressure sores are real, but so is levaquin.
However, plenty of people are more than willing to say that the crisis in health care is in the way that we conceive of health care. Often this is little more of a suspicion that doctors don’t know what they’re doing or that treatments are more likely to cause problems than to cure them (a particularly common meme is the idea that doctors choose treatments that manage the effects of a disease while allowing it to continue, to assure themselves of future business or because its all they know.) More knowledgeable people can make good arguments on these points, but also talk about how we don’t focus enough on prevention.
Folks? Preventive health care sucks. If you think we can’t do acute and chronic disease management well in this society, we can’t do prevention worth a goddamn, and for many of the same reasons. It isn’t just a matter of resource allocation or training – we don’t, honestly, know why people who move from a traditional culture to a westernized society suddenly get Type II diabetes up the waz, or why high blood pressure causes strokes, or why high vitamin D levels prevent cancer but vitamin D supplements don’t, or any of that crap. Its an unmapped country- we can see mountains but the hell if we can get there. Should there be research? Of course, but lets look at a few things we do know and consider for a minute whether knowledge is actually the problem.
What does the doctor always tell you, that the acupuncturist and the, I dunno, shaman always agree with? Stop smoking. Well sure – if you smoke. Also? Reduce your sugar and fat intake, eat more vegetables, and exercise more. There is so much research supporting these lifestyle changes that isn’t even worth citing here. And compared to spending the rest of your life (after, say, age fifty) on an oxygen hose or paralysed on one side of your body? Jeez, how hard could eating vegetables be? And yet, after something like a hundred years of public health research and practice, we have a negative success rate in getting just that to happen. People are more sedentary, eat more sugar, less vegetables, and have predictably higher rates of disease as a result. Can we manage the worst effects? Of course – antihypertensives work, so do antidepressants and other drugs. And I’m not saying all these diseases would disappear if people all lived like Lance “even Lance Armstrong got cancer” Armstrong either. But where the gap appears is in the distance between knowing what preventive and lifestyle changes to promote and throwing literally gobs of money at their promotion on one side, and people actually doing those things on the other side.
Cue the excuses – brain addictions! Advertising! General unworthiness of Americans!
But this is beside the point, which is that we don’t yet know how to do preventive medicine right. So until somebody comes up with a plan that actually gets people doing the things that prevent disease, starting with the above but continuing on to other proven strategies, like spending time in groups with friends (which you would think would be fun) I disagree with the proposition that the problem with preventive medicine is that it just isn’t done. It isn’t done because we don’t know how to do it.
Anyway, a few thoughts. Thanks for reading.
A
----------------------------------------------------- from HUCK FINN ON ESTRADIOL © . My friend Anne's old blog, available via http at tagonist.livejournal.com -----------------------------------------------------
agk’s Library of Low Resource Medicine is hosted on sdf