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Wednesday, 15 November 2006 00:00

Looking for ways to fix the health care system

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By Mark Jaben

Last time, we talked about EMTALA (the Emergency Medical Treatment and Active Labor Act), managed care and how far the pendulum has swung, leading to decreased capacity in the system. The availability and provision of health care is not determined by system planning, but by unintended downstream effects, resulting in uneven, unfair health care rationing. Do the rules of the system still work?

 

Some would argue that this is exactly what we should have expected. Decreased capacity means less care is provided, resulting in less money spent. Cost cutting is the mantra of our health care system. And to this goal of cost cutting, we add the consumer. The consumer can only fulfill his role when he has all the information about a product or service and can shop between the options. Therefore, TV ads make perfect sense. Educate the consumer and then he or she can have an intelligent conversation with their doctor about whether the product is right for them.

But remember that in the free enterprise world, the buyer must beware. This assumes that a poor decision can be corrected by just switching to a different product that better provides for the consumer’s need. All that is lost in the transaction is money, right? But with increasingly less access to care, the consumer does not have these options and certainly has less opportunity to talk with a doctor, the most significant aspect of health care, as we have discussed.

In a free enterprise model, someone would figure out how to expand access in a less expensive fashion. We have seen this attempt with urgent care centers in the 1990s and now the in-store clinics, small shops set up in stores, staffed by a nurse practitioner, prepared to provide services for only minor problems. This assumes the consumer triages their own health problems and chooses the proper venue for their care. Is the consumer prepared to accept the risk for this decision? Is this really the path to success in providing comprehensive health care? It certainly may be if cost cutting is the goal.

Should cost cutting be the mantra of our health care system? We spend less in the short run, but do we save any in the long run? The business model doesn’t really care about the ethically or morally contradictory and complex issues of caring for people. It cares about profits for its shareholders. These other issues are just the cost of doing business.

By the way, there is nothing wrong with this. These are the rules. At a time when we need more research to help doctors answer our questions about how and when to apply a certain treatment to a certain person (the art of medicine, referred to in a previous article), we have less research, as funding has plummeted and research is now the in hands of those with a product to sell.

Rather than help doctors understand the proper use of a drug, we get slanted studies that spin the use of that product and worse. We doctors get sucked in all the time by this. When a drug company spends its advertising dollars, it expects to recoup this expenditure in sales. Rather than educate consumers about the benefit of a drug, we get an ad that tries to justify the sale of a product.

What about the legal system? Does it provide a valuable societal benefit by being the watchdog of the health care system? It’s not their fault. They are just playing by the rules, rules that cost our society valuable resources, both financially and emotionally.

Don’t get me wrong; I hate wasted resources and wasted motion as much as the next guy, but we will never be able to exactly match capacity to need. As a society, we will have to decide if we want to err on the side of overcapacity, where neither you or your family member gets lost in the shuffle, the EMTALA goal.

Or do we tolerate under capacity and live with the reality that sometimes, you or your family member will fall through the cracks, the managed care reality? This is a decision for all of us to make because you will never be able to predict where you or your family member will land.

What we decide will have a profound effect. For instance, if we accept that occasionally one of us will fall through the cracks in the interest of cost cutting, then how can doctors and hospitals be held responsible by the legal system to make no mistake and miss no case, which is the current reality. If we decide that no one gets lost in the shuffle, then how do we organize and provide access in such a comprehensive system. How will we pay for all that unfunded care? We can’t really have it both ways as we are trying to do now.

The irrational, haphazard, uncoordinated decision making we now employ in the allocation of our health resources is a testimony to the failure of our current health care system. Until our society comes to grips with these realities, we will continue to spend the most money without realizing the best health care consistently for you and me. The rules need to change.

Next week: Along with cutting cost, we have inadvertently cut something much more fundamental.

(Mark Jaben is a physician with Haywood Emergency Physicians and can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it. .)

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