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In August I began to discuss the serious, but difficult, questions we must consider in order to create viable health care policy. This month, as we enter the “silly season” (of the election), we’ll tackle the remaining three areas: workforce, the legal system and finances.

In terms of health care policy, both presidential candidates have the same problem: Neither is willing to explain to the American people what they won’t get. Also, neither has addressed the issue of the shift in the dependency ratio – an issue that far too few Americans understand – and how this shift in demographics is driving us into recession. Health care is a victim of its own success. The number of old people is unbelievable and the fastest growing area, on a percentage basis, are those 80 and above. We cannot separate a discussion on health care from an understanding of this tidal shift in demographics.

Let’s start with the workforce question. No one has seriously asked who should be doing what jobs, what information needs to be maintained and by whom. It has long been my opinion that EDs need to run with fewer nurses and more techs. The differentiation between handwork and headwork is going to be essential, particularly with the obtaining of specific types of specialized procedures. However, since everyone is invested so heavily in their part of the system, these questions won’t be raised easily. The other workforce obstacle is that health care has failed to adapt, essentially running the same way today as it did 80 years ago. Think about it. We don’t assemble cars anywhere near the way we did when I was a child. U.S. automakers can produce the same number of vehicles with one-eighth the number of line workers as they needed in the 1950s. The world has changed and medicine has been slow to ask critical workforce questions.

The legal system is another major impediment to viable health care reform. First, every death cannot be a litigatable event. Questions of negligence need to be settled by panels of physicians and not tried in the general courts. This has essentially taken place in most of the world and we are, again, lagging behind. The fact that we continue to litigate so many frivolous issues is ridiculous and it stops us from actually concentrating on those physicians and other health care workers who truly are dangerous and should be removed from the system. The adversarial system is taking us nowhere, fast, and it’s about time we stood up and demanded better for the patients and ourselves. Physicians who would generally do the right thing do the wrong things simply because they think it’s medically-legally wise. It’s not medically-legally wise to spend money that does not need to be spent and put patients through procedures which are both time consuming and dangerous simply because they believe it might “protect their ass” in court. Nothing could be farther from the truth and we need to take aggressive steps to see that the current system is reevaluated and redirected. 

Lastly, finances are always a part of the health care reform discussion. The major problem with the current presidential candidates is that they both want to use phrases like “total government health care”. What does this mean? Where does the money come from? How are we going to finance this type of activity? Here’s a little history lesson. Over the last 60 years, the United States has developed an employment-based model of health care insurance, which started as a direct result of World War II. At the beginning of the Second World War, less than five percent of people actually had a health insurance program. During the Second World War, wages were frozen and controlled by a price and wage board for the duration of the war. What were not controlled were benefits.
 
Kaiser Permanente in California became the first major employer to, without duress, offer health care services as a way of inducing workers to participate in their various industries. Between the auto industry and Kaiser, by the end of World War II the United States had developed the model of the employee-based health insurance which we now know in this country and assume will be the way to go. Let me be clear: I am absolutely against employee-based health care. People change jobs more often than they change their socks! This movement between jobs should not interfere with a health care product.
 
We need some universal standards as to what will be provided, and it should not be based solely on who you work for or whether you’ve lost your job. This kind of discussion would require a major shift in thinking, but one which is not opposed by major industries. The auto industry in the United States, for instance, feels it is at a competitive disadvantage with Asian producers because it must shoulder a relatively high cost of health care where other industries do not. You would be amazed on which sides of the line people will be found if this type of debate could ever come to fruition.
 
Well, there you have it; making health care policy isn’t simple. Churchill once commented that there are two things which people should not watch being made: law and sausage. The laws that will be required and the changes that will be needed for us to move into this century with a financially sound and well-funded health care product are enormous. It will take great courage and a challenge to conventional thinking for us to move in these areas.

Greg Henry, MD, is the founder and CEO of Medical Practice Risk Assessment, Inc. Dr. Henry is a past president of ACEP and directed an ED for 21 years.
 

Comments   

# MDAlan Kenwood 2008-10-04 17:29
As I have advocated before, the number one issue is to "follow the money." The single biggest difference between our health care system and numerous other systems is the huge administrative expense of our multitude of health care plans. It is estimated that there are well over ONE MILLION workers in the United States in the administrative side of health care finances. Just consider how many people in any private practice office that are devoted only to finances!
If there were a system based on single payer, this would eliminate most of this overhead so that many extra dollars could be devoted to actually paying for health care. This is such a potentially huge savings that it could pay to insure everyone, without adding a cent to the budget. Amounts saved (this could be substantial) could be returned to caregivers (especially physicians) as incentive bonuses for supporting the transition to a new system.
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# ER PhysicianChris Louisell, M. D. 2008-10-04 22:08
One issue that no one seems willing to talk about is frivilous use of the ER & 911 by people who do not pay anything for their health care. I've seen people having an MI drive themselves to the ER because they have no insurance . At the same time I've seen people on entitlement programs call 911 after stubbing their toe ! No linkage between use of a resource & payment for it, is a sure fire way to ensure massive waste and abuse. I firmly believe that everyone should have access to quality healthcare .However, there can be no " rights " without reponsibility.
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# ER Physician 2Scot DePue MD 2008-10-05 01:33
I absolutely echo what Dr Louisell said. Between EMTALA and Medicaid, many people believe that ED care and transport are free, and thus, they devalue it to no worth whatsoever. I have seen parents call an ambulance for a 1 cm cut on the forehead of a child, then follow the ambulance in the family car. This system needs some personal accountability -- a 20 dollar copay for an ambulance, 20 dollars for an ER visit, and 10 dollars for a prescription order (months worth) would be a good place to start.
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# MD, ER Physician in Sandpoint, IdahoWilliam Wheeler 2008-10-07 16:26
Thanks Dr. Henry for your article-good as always. I feel that one of the major contributors to our health care crisis is that people feel that they have the legar right to abuse their bodies and then have the legal right to live forever. They can smoke 3 packs a day for 30 years and then sue us when we miss their MI. What about a standard of care that patients need to live by? I feel that we need a health care system where your benefits are linked with how well you take care of yourself!
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# ED Doc in SE PennsylvaniaFred Kotalik, MD 2008-10-09 00:15
Excellent thoughts and ideas by Dr Henry. I have been disgusted for years with the legal underpinnings of the practice of medicine. We over-test to a ridiculous/ludi crous point to "protect our ass" costing billions which has helped to dramatically escalate the cost of health care. Taking very small additional risk, we could treat and release many pts with little or no testing AND send home many pts, who are being put at risk by being hospitalized and further medicated and tested as they have little or no disease or no new disease. Under the current (and going nowhere mighty fast) medicolegal environment in the US of A, we can't afford even a minimum of risk, so we will continue to CT Scan,MRI,US, get blood work, etc. even though the pt. doesn't really need it.
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# John D Lewis, MD, FACEP 2008-10-10 02:55
Hopefully the winner of the current Presidential contest will appoint Dr Henry as Secretary of HHS!!
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# agreement and disagreementalexander kuehl MD, MPH,FACEP, FACS, 2008-10-16 20:00
I totally agree that tax-adavantage employee based health care makes no sense and should be discouraged.

What I believe few health planners are willing to accept is that PAs and NPs already are delivering much of the primary, emergency and urgent care in the rural US; and could do most of it nationwide at a third the cost and a quarter of the post high school education.
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# Emergency PhysicianEvan Weinstein 2008-10-16 22:30
I echo many of the commments previously made, but would add a couple. The first is that patients have to be put into the position to have to pay for the convience of being seen in the ED. Had a cold for a week, don't feel like waiting for your PMD, fine come to the ED, but just like overnight shipping from LL Bean costs more, your choice to come to the ED should cost you. Also, hospitals, and ED administrators have to realize that we must protect the funds used to pay for the people who truly belong in the ED, thus it is ok to tell the pt "This is not an appropriate use of the ED", or standing behind their docs who don't think an emergency ultrasound is needed for the patient with years of pelvic pain, when the pt gets mad and writes a complaint letter.
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# comment on G. Henry's quote in the Nov, issue of Best Practicesmoney wasting paramedic 2008-10-29 23:44
Dr. Henry says, "EMS is the largest hoax ever foisted on the American people." Why is it that you wonder why we pay the costs for fire departments and EMS sytems to keep up their ACLS cards, you wonder why we go beyond the level of EMT-I and do more than carry a defibrillator? What about the costs for your RN's to keep their ACLS cards current? Do ER RN's need ACLS cards? No. We are at least out on the streets without a MD barking down our neck to push this or that so we need to know what the current standards are for ACLS. Stop wasting money on renewing your RN's cards. We sometimes have long transport times, over 45 minutes to an hour until we get to an appropriate ER and practicing at a level above EMT-I is needed. We fly long distances with patients and they need a high level of care throughout transport- this is still under the EMS umbrella which according to you is "a so-called necessary healthcare expenditure."

Do the ER's need to be stacked with high dollar MD's in order to operate efficiently? No. PA's are efficient enough to run an ER as long as they have an MD in the back office to sign off on their orders. Where is your data or study to say MD's are an absolute necessity in an ER. You are nothing more than a corridor to the OR if it's bad enough and we could save billions in high dollar salaries if we limit the unnecessary staff in ER's. In fact, we are starting to take patients directly to the OR or cath lab instead of stopping in the ER because ER docs aren't able to handle the case anyway.

There are questions as to why people call EMS for stupid things like stubbed toes or little cuts to the forehead. There is nothing more frustrating than getting called at 3am for a person with a swollen toe but do you know what their reason is for calling us? The reason is because these 24 hour nurse lines you set up tell the patient that they need to call 911. That is why these people are following us in their car because they think they have to because the ER nurse lines make them think that is their only option. So take a minute to bash your ER systems before you bash those of us that are out here performing an honest, LOW paying duty that not a whole lot of people want to do. Choose your words carefully next time you decide to criticize the prehospital profession.
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