Kevin, M.D. – Medical Weblog: The Happy Hospitalist: All for one and none for all

Kevin, M.D. – Medical Weblog: The Happy Hospitalist: All for one and none for all
The Happy Hospitalist: All for one and none for all
The following is a reader take by The Happy Hospitalist.

All for one and none for all. That is the state of the current government program called Medicare. The entitlement program that threatens the financial security of our nation. On March 25, 2008 the Boards of Trustees released their Annual Report of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. In this 43rd edition, the Trustees note a government program covering just over 44 million people at an expense of $425 billion dollars during 2007. That equates to approximately $10,000 per beneficiary.

The Medicare Crisis has the potential to kill this economy, and something has to give.  Read the whole article: it’s well written, it’s a good prescription to avoid the oncoming disaster train, and there’s essentially no way it’s going to happen.

Too bad.  We’re all going to pay for this, literally and figuratively.

Grinding to a Halt

I’ve been in a foul mood of late at work, and it’s because I see the beginning of the end of the health care system I know and respect.

I am not involved in health care policy, or planning, just the trench-line delivery of modern, ‘high-tech / low touch’ American medicine. I realize it’s terrifically inefficient and at the same time realize I am individually powerless to change it. However, I’ve been thinking more and more about our future, and it’s not at all good.

I’ve recently had several interactions just like this one from Australia:

Sometime during the night they were moved out into a corridor to make room for the incoming. I saw them again the next morning. There was no longer any room to sit beside her, so he stood at the foot of her bed. He was angry. “This is disgraceful” he shouted. “I’ve had top private health cover for as long as I can remember….and now I need it, I can’t even get a bloody bed for my wife!”

He sat, red faced and embarrassed at his outburst. It was all beyond him.

Since November, with few exceptions, we’ve been ‘holding’ admitted patients in the ED. Yesterday we had about 1/3 of our physical rooms occupied with patients ‘admitted to the hospital’ who were going to be cared for in the ED. No windows, no TV, no phone, just a real hospital bed, real hospital food and their medications. It’s the biggest shock to people who haven’t been to an acute care hospital for a while, and just assumed there would be space in the hospital for their loved one. This is, by the way, after we’ve been putting admitted patients in the hallways of the upstairs wards to try to relieve the ED overcrowding.

So, 1/3 of our space is now dedicated to inpatients, therefore the hallways were lined with gurneys of the actual ED patients. Four years ago this was an occasional, ‘surge’ thing and now it’s everyday and around the clock there are patients being cared for in the halls. (Mental exercise: describe how much fun it is to give a history in a busy hallway with people and other patients / families constantly walking by, and I’ll leave the thrill of the physical examination to your imagination).

There’s no incentive for hospitals to add beds, unless you happen to have one of those really-well-billing cardiac diagnoses, and there’s money for that, so hospitals are building cardiac units that are closed, meaning if you don’t have a cardiac diagnosis and a cardiologist on the case you lie in the hall. We have, simultaneously, the best and worst healthcare has to offer.

I’m of the opinion many of the problems of modern healthcare do stem from a complete absence of a market in medicine. I wouldn’t take my car to the shop and just say “fix it” without at least discussing the costs (unless I had the insurance / medicare system for my car, then I’d drive it like a nut and sue if it wasn’t perfect when it came out of the shop). I’m 100% for posting signs in the waiting room, patient rooms (and, regrettably hallways) outlining what these tests they’re getting charge. It’d be eye-opening, and it might just cause a few people to think about need vs. want, and would make my job a little harder. I’m okay with that. I’d like to discuss the pros and cons of ‘do you really need me to CT you from stem-to-stern’ with an alert patient who’s able to make informed decisions.

People ask me what I think the future of medicine is when we’re staring at the overcrowding, and ask what I think will happen. I don’t think it’s going to be anything cataclysmic, we’re just going to grind to a halt at this rate. Money continues to be poured down expensive therapies of marginal benefit, there’s no barrier to asking for more healthcare, “now!”, and have a quick peek at nursing demographics if you’re in doubt about the short and long term problems we face.

The Wall Street Journal (may require subscription, sorry) has an editorial about healthcare today, and here’s the money:

[Shifting to a market system] won’t be easy, especially given the ideological stake that so many politicians have in a government-run system. They like the leverage of determining payment rates to hospitals and doctors, not to mention being able to take credit with voters for providing more benefits. But there is no free lunch in health care, any more than there is in any other part of the U.S. economy.

Health care is either going to be allocated by prices or by government, which in the latter case means price controls and waiting lines. Though it represents one-sixth of the U.S. economy, health care is the one industry in which the purchasers actually have no idea what anything costs. An individual market for health insurance would allow more freedom of choice while making consumers more cost conscious.

If we don’t do something, soon, there not only won’t be a medicare system, there won’t be anyone in the hospitals left to take care of us. If we can get out of the hallway, that is.