Few topics are more widely discussed or of greater concern in the United States than the cost and quality of medical care. These topics are central in the conversations of corporate executives and third-shift workers. They are central in political discourse and in dinner conversations.
2009 was the year of "Health Care Reform." A legislative proposal to alter radically the structure and operation of the American health care system dominated the nation's interest for a year and beyond. It spawned both hopes and fears across the country. It created a spate of rumors and outright falsehoods as both its opponents and supporters fought by any means possible to win the day for their point of view. Finally it led to politically motivated compromises that virtually gutted its most important provisions. And the minute that Congress passed a bill calling for sweeping changes in how medical care is organized and delivered, there began a movement to have the entire bill repealed.
This is nothing new in America and it should not be surprising. For the better part of a century, every president has attempted to reform American's medical system. And all of their efforts have been frustrated.
Coalitions, primarily consisting of insurance companies, pharmaceutical companies, companies that manufacture medical equipment, physicians' associations and hospital corporations, have successfully convinced the American public that any alternative to the current American medical system would be disastrous in terms of both cost and care. As of this writing, it is not clear that the proposed reforms of 2010 will ultimately be enacted. Yet there is almost unanimous agreement across the country that the American medical system is broken and in need of major repair even though there is little agreement on how the fix should be accomplished.
There is good reason for this consensus on the dysfunction of the medical system. The cost of medical care in the United States is the leading cause of personal and family bankruptcy. Some 40 million Americans have no medical insurance. Many of them have chosen not to pay for medical insurance, but a great number are those who either cannot afford it or are disqualified because of a prior medical condition. Yet even as millions of Americans without medical insurance live in fear of illness, and while millions more worry that they'll lose their insurance, the majority of Americans continue to believe that the United States has the finest health care system in the world. Part of this belief relates to the idea that America must be the very best in everything. Part of it, though, relates to some widely held yet erroneous beliefs about the health care system and how it operates. We will explore these beliefs and attendant attitudes in later chapters.
The topic of health care reform dominates much of the political debate among candidates for state and national office. Through Medicare and Medicaid, our government is hugely affected by the ruinously escalating costs of medicine. Our tax dollars directly pay for medical care in two main ways. First, Medicare must cover medical costs for a rapidly growing population of older Americans with expensive, chronic conditions. Second, government programs now pay for younger Americans who survived, often with extensive, expensive treatments, medical conditions that were fatal to infants or children a couple of generations ago. Consider infants born with Down syndrome, cerebral palsy, or cystic fibrosis. In the middle of the 20th century, these children had life expectancies measured in weeks to several years. Now, with the advent of antibiotics and specialized nursing, respiratory care, and other care, these people often live into their 50s.
Almost everyone has experienced, either personally or through family or friends, the miracles of American health care. And the same is true for the horrors of American health care. Generally, though, discussion centers on the horrors: prescription errors, long struggles with insurance companies, misdiagnoses, the constant changing of physicians as employers opt for a cheaper form of coverage, patients missing necessary treatments due to lack of insurance. On and on and on the stories go, and many, mostly older, Americans yearn for that time not so long ago when doctors and patients knew each other well, when the doctor was seen as a friend as well as a healer, and when medical bills could be paid in loaves of bread or sides of beef. But, of course, that time exists largely in imagination. As one man said, "The main thing about the good old days is that they weren't." That golden time in the past is probably as exaggerated as many of today's tales of medical horror. But somewhere between those dreamy old golden days and our modern medical nightmares, you will find the true state of affairs. And the truth is that the American medical system is broken-terribly broken and with no apparent repair in sight.
There was a time when the term "family doctor" meant someone who knew every member of the family, often from the cradle to the grave. There was a time when one could approach the doctor or even hospitalization without the fear of massive bills. That was a time when grown children tended to stay in the same community rather than spreading themselves across the continent. By remaining close, families were capable of providing support when a member became sick or injured. That was a time when death came quickly after a brief illness or accident, and the doctor was there to comfort the dying patient and the grieving family. That time was probably the golden age of the patient-doctor relationship, when the doctor was known and trusted for years by the community he served.
Yet, consider this-one of the key points in this book. That golden age of the doctor-patient relationship was a time when the physician was practically powerless in dealing with most health threats. At a time when the doctor was your closest ally in the fight for survival, he had very few weapons against the wide variety of illnesses, infections, and injuries that ended lives and brought suffering. Most of what we now consider minor inconveniences were then potential killers. But doctors did their best with what weapons they had. Sometimes all they could do was be there. There was much that was wonderful and worth remembering about that time, but there was also much we are glad to leave behind.
Death tended to come early a century ago. Life expectancy was still only 54 around 1950. Many people did live well into their 80s and 90s in those days, but they were the lucky ones. Millions died in infancy and childhood from myriad diseases. They died from measles, mumps, diphtheria, tuberculosis, polio, scarlet fever, and a host of other diseases that either no longer exist or, at worst, make one sick for a few days. People died of infections spreading from simple cuts on a leg, foot, or hand. They died of injuries as simple as a broken leg from which a blood clot moved into the lungs because medical science had not yet come up with blood thinners. Everyone knew about quarantines for diseases like scarlet fever, measles, and mumps, and every city or county had a hospital solely for patients with tuberculosis.
Further, beginning in the 1950s, we began to create surgical technologies of unbelievable sophistication. I am a cardiac nurse. At my hospital, we do an average of 15 open-heart surgeries each week. "Open-heart surgery," also known as "coronary artery bypass graft surgery," or "CABBAGE," is one of the most-performed surgeries in the United States. But nobody ever woke up in the morning and said, "Geeze, it's cold, it's rainy, and I'm bored. I think I'll have open-heart surgery." No.
People have open-heart surgery when their heart disease is so advanced that they are going to die. They are probably already on cardiac medications. They probably have already had an angioplasty. They may have stents holding one or more coronary arteries open. But their heart disease has advanced, and unless they come in and surgeons open their chest and sew new arteries on their heart, they are dead. As a result, millions of Americans are walking the streets with that railroad track scar down their chests. Forty years ago they were all dead.
Modern American medicine, with all of its problems, nevertheless can cure illnesses and injuries that would have brought death 50 years ago. But these miracles come at a price. We all want the benefits of modern medicine, but most of us struggle with the costs, both financial and personal. Does our American medical system provide its miracles at a fair price? Or, perhaps a better question is, what can Americans do to gain these-and even greater miracles-for less?
Historically, to be a patient was to be under the care of a physician. The patient's role was to present his or her symptoms and to receive compliantly the ministrations of the doctor. The doctor's role was to diagnose the cause of those symptoms, to develop a plan of care, and to direct the management of the care plan. In all of this, the patient remained, for the most part, the passive recipient of medical care.
This has been the traditional role of the patient for thousands of years: to be the passive recipient of whatever care a physician, shaman, or medicine man declared necessary. And for all but the last half century or so, the physician was powerless against all but the most basic and minor maladies.
Now the medical world has changed. Medical science has evolved a means whereby, short of massive catastrophic trauma, few people in technologically developed countries need to die before attaining the full human life span of 90 or more years. It is the growing power of science that gives medicine victory over so many illnesses. And as science continued to gain strength and influence in medicine, the scope of medicine began to expand. In showing what worked to stop an illness, science began to reveal what caused the illness in the first place. Before long, medicine began acquiring the tools to achieve the "Holy Grail" of health care: prevention of disease.
The broad benefits of disease prevention are obvious. It is far more pleasant to avoid diseases-even treatable ones-especially when considering drug side effects, post-operative infections, and prolonged rehabilitation. Prevention can even save money: "A stitch in time saves nine." But that old adage contains a word that marks the divide between two worlds: time.
Time is the difference between treatment and prevention. Time is the divide between the world of repairing disease and the world of maintaining health. Treatment cannot start until the problem is discovered. Prevention cannot succeed unless it begins before the problem. Treatment ends when the problem is solved or there are no further treatments. Prevention ends at the end of life.
At this point, you may well wonder what has just happened. You started reading about the old days versus the new and the doctor-patient relationship, and suddenly you're pondering time as the divide between two worlds. And when you consider that the author worked in philosophy before entering the real world, only to become a nurse in middle age, you might not be surprised if the train of thought got derailed a short way out of the station. Well, dear reader, you might be right most of the time. But in this case, there really is a connection.
And, I would venture to say, this connection is the most important point of my book. Are you ready? Good. Because here it is.
The connection is you. You are the only thing connected to your health 100 per cent of the time. You and your health were born together, you've known each other practically your whole life, and you will die together. If your health is broken and you need someone to fix it, you spend a bit of your time with a doctor; when the treatment is done, the doctor is gone. But for the ongoing effort of maintaining your health over time, the only person you can count on to be there is you. From rolling up your sleeve for a vaccination to logging miles on a treadmill. From scheduling your next annual exam to scheduling time for exercise with your family. From bringing a list of questions for your doctor appointment to bringing a list of favorite healthy foods to the grocery store. The only one present through all these times is you.
That's what this book is all about. You are the only one who can control your health, and you, more than anyone else, live the consequences of your health choices. So you are responsible for maintaining your health. There's simply no other way! What I want for you and every American is to know how easily and well this can be done. But to do it easily and well, you will need to know some whys and wherefores about health and our medical system. And you will need a physician partner-someone you can trust and work well with, not just for those bits of time when you've lost your health, but for ongoing collaboration to maintain it. You will need a physician partnership that combines the trust and mutual commitment of the "good old days" with the disease-fighting and health-maintaining power of modern American medicine. You will need a doctor-patient relationship that is restored and revised for the 21st century (you'll find much more on this in Chapter 9).
This book is dedicated to helping people understand that the ultimate responsibility for health belongs to each individual, not to the doctor and the medical system. It is dedicated to assist you, dear reader, first, to understand the foundations of lifelong health and, second, to understand the increasingly important role that you, the patient, must play in the medical system.
Finally, this book sets forth a vision for the future of medical care. This vision entails changes in every area of medical practice: governmental (the role and function of the government), private (the roles of private insurance and of employers), practice (the roles of primary care doctors, of specialists, and of adjunct personnel such as nurses, nurse practitioners, and physician's assistants), and the new roles of the patient.
Note that in the title of this chapter, "The American Medical System: Something Has Gone Terribly Wrong," I do not refer to the American "health care" system. The United States does not have a health care system. The United States has never had a health care system. What it has is a medical system-a system designed to cure sickness and repair injury. And the system is very good at doing those things. But the truth of the matter is that health has very little to do with American medicine. In fact, it can reasonably be argued that we create no incentive for preventive care in the American medical system-that is, doctors are virtually discouraged from keeping people healthy.
Think of your personal doctor. If your doctor is really good and spends time and energy listening to his patients and then teaching them and helping them take charge of their own health-thereby making all of his patients healthy-your doctor is going to be bankrupt. We do not pay doctors for having healthy patients. We pay them for curing illness and for fixing things that are broken.
Many businesses reward the employees who make the most of their product. They reward the employees who sell the most product. These are called "productivity rewards." But we do not reward doctors who produce the most healthy patients. We reward doctors who order the most tests or who perform the most surgeries. The system exists to make money, and there is very little money in good health.
Consider your local hospital. A serious outbreak of health in your hometown, and your hospital is in deep trouble. We do not reward hospitals for creating healthy communities.
Consider this, too. Most doctors work for large corporations. They no longer finish medical school and return to their hometowns and nail their shingle up on the front porch and go into practice. No. Today's physician is the employee of a large corporation worth millions, and often sometimes billions, of dollars. It owns hospitals and clinics and surgery centers and urgent care centers. It employs tens of thousands of people. It exists for one primary reason: to make money. Each and every component of the system is expected to provide a return on investment.
The doctor is a component of the system. Patients have become, to a large degree, the raw material out of which the corporation generates profit. Even not-for-profit hospitals evaluate their success as well as the programs they offer primarily in terms of profit: of the degree to which their revenues exceed expenses. Emphasizing the shift to managing medical care using a business model is that today the doctor has become the "provider" and the patient has become the "consumer."
One of the most dramatic changes in the American medical system has been the demotion of the primary care doctor. The primary care doctor is the doctor the patient sees when entering the medical system. That's the doctor known in the mythology of the American medical system as the "family doctor." That's the doctor portrayed on early television and radio as a close family friend, full of wisdom, available at a moment's notice, and almost a member of the family from the cradle to the grave.
With the advent of modern corporate medicine, the family doctor no longer exists. In his place is the "provider" who sees 25 to 30 "consumers" every day. In his place is the doctor whose primary job is to handle the most mundane and routine medical complaints and to refer everything else on to a specialist. In his place is the doctor whose relation to his patients is determined by the employer's decision to go with the lowest-cost provider of medical care. To make matters worse, that decision may be reviewed every year or two with the result that the consumer has a new doctor just that often.
While specialist salaries have been increasing rapidly over the past 20 years, the salaries of primary care physicians have been declining. Medical schools find it increasingly difficult to recruit students who want to go into primary care medicine. Primary care medicine is the bottom end of the totem pole. Between 1997 and 2005, the number of U.S. medical school graduates entering primary care medicine dropped by 50 percent. More and more the primary care doctor has become merely the gatekeeper who provides referrals to the specialists. And since the primary care physician's compensation is often determined by the number of patients seen, it becomes far easier and less costly (for the doctor) to send a patient to a specialist rather than to take the time to explain to the patient the nature of a problem and what the patient can do herself to deal with it and to prevent its recurrence.
This is a tragedy. It is primary care medicine that can and must be the center of medical care. It is the primary care doctor who must be given the opportunity to know his patients and to have his patients know him. It is the primary care doctor who can teach about issues of health and prevention. It is the primary care doctor who is the key to building a more healthy society and, perhaps, of equal importance, to controlling the destructive costs of medical care. In a time when the costs of medical care threaten patients, families, and society itself, it has been demonstrated that the degree to which primary care medicine is available, costs go down, patient satisfaction goes up, and outcomes improve.
The American medical system is broken. Possibly it is broken beyond any reasonable hope of repair. And yes, we must each of us understand that system before it can change or before it can be, for us, a genuine health care system. I say a lot more about this in Part IV of this book, "A Vision for the Future of Medical Practice in the U.S."
By the way, we are constantly being told that America has the finest health care system in the world. We are told that people come from all over the world to participate in America's health care system. We are assured that we certainly would not go to Canada for our medical care. In Canada, we are told, people are dying because they cannot receive medical care. In Canada, we are told, people have to wait a long time before receiving even basic medical care. In Canada, we are told, people leave in large numbers to come to the United States to receive medical care, which is both quick and better.
Let's consider some facts. In Canada, life expectancy is also greater than in the United States. In Canada, healthy life expectancy is greater than in the United States. In Canada, emergency care is equal to or better than the emergency care provided in the United States. In Canada (we are not usually informed of this) the per capita costs of medical care are substantially less than in the United States.
It has been suggested by some that saying these things is wrong, perhaps even unpatriotic. The facts, however, cannot be denied. The World Health Organization is the source of statistics through which we can compare medical care in the United States with medical care in all the other countries of the world. The World Health Organization tells us that the United States ranks 27th among developed nations in life expectancy and that it ranks 37th among developed nations in healthy life expectancy. In 36 other countries, including some Third World countries, people stay healthy longer than they do in the United States.
To point this out is far from being unpatriotic. Given the tens of millions of Americans who have no access to medical insurance, government or private, and the tens of millions of others whose medical conditions are, in principle, preventable, this is a criticism intended to speak to those who can make a difference-a difference that will make America even greater than it is.
But let's look at some facts. The United States currently spends two to three times more per capita for health care-that's two to three times more-than any other developed country on the planet. And yet the United States ranks 27th in longevity. In 26 other countries, people live longer on average than they do in the United States. Even more significantly, the United States ranks 37th in healthy longevity. There are 36 other countries, including some Third World countries, where people stay healthy longer than they do in the United States. The United States ranks close to last among developed nations in infant mortality. It ranks at the middle or below the middle in virtually every measure of medical outcomes. And yet we spend two to three times more per person for medical care in the United States than anybody else.
These discouraging statistics are not solely to be attributed to the American health care system. The United States has a more ethnically diverse population and more poverty than other developed nations. Sadly, these facts contribute to these mediocre medical outcomes.
To put it most simply, there is very little money in maintaining health. Our medical system is not designed to promote health. It is designed to cure sickness and repair injury. It is designed to make a profit for its participants: hospitals, pharmaceutical companies, manufacturers of medical equipment, and insurance companies. Now there is nothing wrong with profit except when the goal of profit puts health and lives at risk. The dollars we spend for medical care are dollars spent almost entirely to cure and repair, not to promote health.
Primary care medicine, has, throughout most of the history of medicine, been exactly what its name says, "primary" medical care. But with the creation and growth of specialty medicine, primary care medicine has lost its preeminent position. Today the primary care physicians live at the bottom of the medical pecking order. Both in terms of prestige and income, the primary care physician is at the bottom of the ladder. Fame and the wealth go to the specialties. But the specialties are designed to deal with patients who are either sick or injured. They have little or nothing to do with patients who are healthy and who hope to remain that way.
Rick's mother had gone into the hospital, had a baby, and spent an entire week bonding, healing, resting, and learning. She went home with a bill for $67.25. You say, "Yes, but that was in 1942!" And yet, if nothing had changed from then until now except inflation, a woman should be able to enter a hospital, have a baby, spend an entire week, and go home with a bill for about $950.
I check at my hospital every so often. The last time was about six months ago. A young woman came in to have a baby on Monday morning. She was not allowed to come into the hospital until she was ready to deliver. I remember that when our daughter, Elizabeth, was born in 1967, Rosalie had called her doctor and told him her water had broken and that she was ready to go into labor at any time. She asked if it was okay if she just came in to the hospital. Her doctor responded that that was just fine. The young woman to whom I just referred called her doctor and told him that she was having contractions.
He asked, "How far apart are they?"
She responded, "Well, right now they are about 12 minutes apart."
He responded, "Call me back when they are five minutes apart."
She was not allowed to come into the hospital until she was truly ready to deliver. She came in on Monday morning, and had her baby, and on Tuesday afternoon, the mother and baby were discharged from the hospital with a bill for $5,000 that did not include the cost of the doctor. The system is out of control.
Let's acknowledge that lots of things have changed since 1942. The quality of the medical care that the mother and baby receive is far greater than it was then. We are far more able to handle difficulties in the birthing process. And today, given the growing presence of antibiotic-resistant bacteria, it is important to get the mother and the baby out of the hospital as soon as possible. Yet even with all of this, the increase in the cost of this care far exceeds the actual cost of the services provided, while the United States ranks last among all of the developed nations in infant mortality.
One reason for these out-of-control costs is that in the U.S., it has become very hard to die. Chapter 2 explores this disturbing situation in detail.
John Shier is a Registered Nurse and Doctor of Philosophy who entered the profession of nursing at the young age of sixty and after having two prior successful careers.
Prior to his nursing career and his work as "ThatGuyNurse," John was an Assistant Professor of Philosophy at the University of Wisconsin - Green Bay for fourteen years. John also served eighteen years as the Executive Director of the Lake Michigan Area Agency on Aging as well as providing leadership as the Executive Director of the United Way of Brown County.