WhiteCoat

My View

I started blogging because I enjoy telling stories. Always have, always will. I think that many people read what I write because they like reading stories.

A recent comment by Max Kennerly, an attorney that frequently comments on this blog, made me sit back and think quite a bit. I don’t always agree with Max or with Matt, the other attorney whose comments drive me nuts sometimes, but I do respect their opinions. Another goal of this blog is to create an atmosphere of debate and debate runs deep on some posts. That’s a good thing.

Max wrote:

I still don’t understand your EMTALA obsession; the Chicago example makes quite clear an ER can cheaply and quickly comply, and still engage in profitable patient dumping. EMTALA isn’t a big deal from the policy perspective, you just find it personally annoying.

Frankly, the ease with which you (and other physicians) conflate issues makes it very hard to take any of you seriously. Do you want to be treated like a private industry or like a public utility? In the same breath you complain that the state is not providing funding and that the state imposes too many limitations on you. Who you think you are, Wall Street?

Normally, we do not give an industry state funding without substantial controls on it, including controls to ensure widespread availability of the industry’s services. But you apparently want the former but not the latter. Well, so do I. I want taxpayer money to go about my private business. Ain’t gonna happen.

I, personally, favor the public utility route, and would be happy to pay the extra taxes to fund it. Where do you fall?

After reading Max’s comment, I read back through my most recent posts on this blog (some imported to this blog – see Archives at right). Then I read back through the earlier posts on my old blog. Max is right. My mindset has definitely changed.

Then I thought about why my focus has changed.

I’m worried about health care in this country. I’m not worried for myself, but I am worried for so many hardworking people  who are denied health care or who have no access to health care. Policies like “never events,” agencies like JCAHO, misguided and medically unsubstantiated sites like “HospitalCompare,” and laws like EMTALA all start out with noble intent (I presume), but they all end up causing ripple effects that degrade the practice of medicine.

So in answer to Max’s comment, my “EMTALA obsession” wasn’t intended to be focused on EMTALA. Rather, my focus is on the ability of every American citizen to access healthcare. I have several Google news feeds that arrive in my e-mail each day. One of them is for the term “emergency room.” I know. I know. I cringe when I type it, but people haven’t caught up with the times. “Emergency department” hardly gets any news … yet. Every day I read posts about how hospitals are closing or losing money because of unfunded medical care. At the heart of unfunded care is EMTALA. So many of my posts reference EMTALA because EMTALA is abused to the point that medical care in this country is doled out arbitrarily. Patients that need urgent care are often neglected or do not seek timely care because they cannot afford it while patients who want “free” pregnancy tests or narcotic prescriptions pillage the system.

I have repeatedly said that a free market approach to medicine is the only way to save the system. Patients must have some “skin in the game.” Unfortunately there will never be a truly free market because, unlike almost any other industry, medicine is a human “need” – not a human “right,” but a human “need.” What other industry has such a closely entrenched human need? Those who can’t pay for a Lexus simply don’t get their Lexus. They can ride a bike or hitchhike. Those who can’t afford a civil lawyer may have their rights trampled, but they still get to go on with their lives. Those who can’t pay for health care – especially emergency health care – will die. Lack of medical care has an immediate and significant effect on morbidity and mortality. I can’t think of any other industries more necessary than medicine – including law. Sorry, Gerry Spence, you’re just flat out wrong.

The intent of all my policy posts is to make people think about the secondary effects of the choices they make, not to force my opinion down anyone’s throat. For example, many who clamor for true “socialized medicine” have this dream that they will get fast, free, and quality care. Such a system will never occur. NEVER. Rationing will be necessary and significant in any socialized system. I try to emphasize that point by illustrating all of the cuts taking place in our current system as we move toward socialism and by showing articles about the lack of access to care in other socialized systems. If we’re going to choose this system, at least we should have an idea of what we’re in for.

You want me to pick public versus private industry? I pick private industry. You pay me, I treat you. No third parties. Screw the government. Every medical provider would have free choice to choose who to treat and who not to treat. No provider would have to treat patients without insurance any more than a grocery store would have to give groceries to someone without money. “Patient dumping” wouldn’t mean anything other than a medical provider making sound business practices. Lawyers couldn’t threaten health care providers with EMTALA violations or all of their other creative iterations of negligence solely because providers choose to make a profit. If patients can’t afford their cardiac catheterization or their expensive medications, they die. Sucks to be them. Is that the system you want? You wouldn’t hear very many providers complaining, but at the same time, thousands of people would die because they had no money for medical care. I’m all for free market, but we can’t let purely “free market” medicine happen to patients.
So let’s impose strict “state controls” on medicine. Everyone is a comrade and gets their government-sponsored Yugo and bowl of gruel. We can already see what happens with a purely government controlled model. Look up North or across the pond. Sure, care for healthy patients is easily accessible. But become one of those “high utilizers” and it’s a different story. Long waits. Less care. People die waiting for surgery. Expensive treatments for sick patients are denied because some government accountant says the treatments are “not medically necessary.” Impose your controls. Go ahead. You won’t be able to pay enough in extra taxes to fund a system that provides good and timely care to every denizen in this country.

What I foresee happening is a system similar to the legal system in this country. For emergency care and surgical care/hospitalizations, there is a “public defender” type system. If you can’t afford to pay for a top notch “defense” physician, then the “courts” appoint a “public defender” physician for you. You get average care if you don’t have the cash, but you have the option to pay for Mark Geragos if you can afford him. Top surgeons or emergency physicians could demand and receive a premium. Just like the Mayo Clinic or M.D. Anderson, now. People pay extra for extraordinary care. Market forces at work. The “public defender” system is already emerging in emergency medicine with the proliferation of freestanding emergency departments that can cherry pick paying patients. Those without money go to the “public defender” emergency departments at public hospitals that still fall under … EMTALA laws. See, I mentioned it again.

Routine medical care will drift toward the “civil law” practice model. Pay to play. No money, no care. Maybe you can go to public clinics – the equivalent of law schools or charitable organizations – to get primary care if you demonstrate a need. Once the governments decide to cut funding to public clinics, patients will either have to pay up or go sit in the untenable lines in the emergency departments for their care.

I will be able to care for myself and my family regardless of the system that is chosen in this country. I have the contacts, the resources, and the knowledge to do so. One of the benefits of having a six figure student loan debt, I guess.
I truly fear for the health and livelihoods of those who aren’t as fortunate as I am.

That’s where my posts are coming from.

On the flip side, I really do have to get out of my writing rut. Thanks for setting that straight, Max.

16 Responses to “My View”

  1. scalpel says:

    Well said. I couldn’t agree more.

  2. paul says:

    wow, they say “don’t feed the trolls” and you gave them a gourmet meal.

    i applaud you for trying, anyway.

  3. BK says:

    Rationing will be necessary and significant in any socialized system. I try to emphasize that point by illustrating all of the cuts taking place in our current system as we move toward socialism and by showing articles about the lack of access to care in other socialized systems.

    when did the myth that we don’t currently ration care begin? when did the myth that everyone currently has access to care begin? when did the myth that private insurance companies aren’t making “cuts” begin? I am if nothing else a curious person.

    Let’s be honest here, every flaw you point out in “socialized” systems (and yes, that word does belong in quotes in this context) occurs in our system. the whole debate is about which of the many flawed systems is best for the population as a whole. wouldn’t you agree, comrade?

  4. JK says:

    “Expensive treatments for sick patients are denied because some government accountant says the treatments are “not medically necessary.” ”

    Isn’t that exactly what insurance companies are doing already? If it’s not pre-approved, it won’t be covered and they get to play God with your care.

    That’s not “socialized” medicine. That’s Third Party medicine.

  5. Libby says:

    You say that medical care is a human ‘need’, and I disagree. The culmination of each and every human life is death. The timing and vehicle in which death arrives is unimportant (to the deceased. When you’re gone, your troubles are over, one way or another. To the family well, their troubles are just beginning).

    Now, don’t get me wrong. If I have an emergency, you can bet I will perceive a ‘need’ for some medical care. When my husband had a heart attack last year we perceived very strongly that he ‘needed’ bypass surgery. Except that I wouldn’t and he didn’t. We don’t ‘need’ to live.

    I know this is simply not how we are trained to think. And many people will dismiss this manner of thinking. That’s OK. Except that I think it’s very true. Death is not immoral (unless murder is involved). It is not wrong to die. It is inevitable.

  6. GlenStef says:

    Greatings, Thank you! I would now go on this blog every day!
    Thanks

  7. k says:

    Rationing exists, whether you want to call it 3rd party preauthorization, unintended consequences (e.g. EMTALA abuse), or something else. EMTALA abuse can take the form of UCMC dumping Dontae Adams onto County’s ED because the poor kid had Medicaid (not to mention Blago’s spat with the legislature meaning reimbursements averaging 9 months late), or it can take the form of the 6 TX patients(presumably mentally ill and not receiving community care) racking up $millions of ED bills, averaging at least one visit/week.

    In an ideal world, there wouldn’t be any of this ‘negotiated rate’ nonsense where Provider X bills 3rd Party Payer Y some ridiculous amount for Service Z, and the EOB you get shows Y paid X $5 as the negotiated rate for Z. Cut that crap out of the equation and set reasonable rates most people can afford that allow a reasonable profit to the provider. This is as likely to happen as my winning the lottery, but hey, everyone’s got a right to dream!

  8. SeaSpray says:

    Well said WC.

    It all seems so logical and yet so complicated.

  9. Max Kennerly says:

    Glad it made you think.

    I’ve posted some longer thoughts about EMTALA in particular at my blog (linked via my name) for anyone who is interested, but I want to address a particular issue here: “Every medical provider would have free choice to choose who to treat and who not to treat” is fundamentally incompatible with a concern about “the ability of every American citizen to access healthcare.”

    A wholly-private medical system will no better ensure every American access to healthcare than a wholly-private retirement system would ensure adequate savings for every America. It’d be great if everyone had well-paying, stable jobs from which they prudently diverted a reasonable amount to insure themselves against illness, injury and old age. But that’s not the case.

    Moreover, we already by and large have a private system, which is why over 40 million Americans don’t have any health insurance at all, and a larger number are inadequately insured. Do you believe they are all purposefully trying to freeload, despite the obvious risks to their lives?

    Ensuring everyone’s welfare requires collective action. Whether that’s fair or efficient isn’t the issue; an all-private system simply won’t give us universal coverage.

    • WhiteCoat says:

      “an all-private system simply won’t give us universal coverage”
      Exactly my point – hence the “legal system” example. On the other hand, FREE=MORE and always will. Are you suggesting that those who have unlimited free access to medical care will not demand more care? If so, you’re misinformed or disinformed.
      Our system is far from “private”. In our ED, we see 0.5% patients with commercial insurance. About 15% have HMO or are worker’s compensation. More than 60% have either Medicare or Medicaid. The rest are self-pay. How exactly does that translate into a “private” system?
      We need to create a system where everyone “prudently diverted a reasonable amount to insure themselves” – that system does not exist now. If people have a choice between receiving time-rationed “free” care and quicker, higher quality “paid” care, the value of investing for one’s future medical care will become apparent.

  10. ERDoc says:

    How does a “free market” healthcare arrangement reflect on our society? I’d argue it’s not progress at all, but a sad day in our nation if we were to go this route. See every third world country as evidence of how this works.

    Whether mandated by the government or self imposed by a “free market”, patients will have to accept a system where cost is considered before the “mega-workup” is ordered, and be willing to tolerate some small risk on themselves.

    Every day in the ED we all order a lot of tests on people, which are low yield in a good fraction of our patient population. Why do we do it? Because it’s the standard of care. Because we can’t afford to miss anything, from a medicolegal standpoint.

    It’s not acceptable in our culture to say, “well we didn’t do the test because it’s expensive, and I’m sorry you had a bad outcome. This is probably a 1 in 100 type situation. You were the unlucky one.”

    How this can be accomplished is beyond me.

    I’ll agree that many medical blogs (not only yours) have so much of the “the sky is falling” type rhetoric that at some point people just don’t listen. But I suspect you’d have PLENTY of issues with a free market system that you may not even fully grasp.

    Imagine having a lengthy discussion with every patient as to why their Chest X Ray is a necessary expense, when it is clearly indicated. That’s going to run them several hundred dollars after all, and for the average hard working American that’s a lot of money. Are you prepared to have those discussions? Only the wealthiest segment of society will not care about costs such as these when it’s coming straight out of their pocket. “Doctor, I’m OK with getting the chest X Ray, but does the radiologist have to read it? I’d rather not pay for the extra radiologist’s fees and let you read it yourself” Are you going to turn this patient away and lose the revenue, or take the liability on yourself as the one and only X Ray interpretation? How would you defend that in court, if you’re not board certified in radiology? Would your hospital have a strict policy about radiologists reading ALL X Rays? Does a free market mean such policies are good for business or bad for business, when your facility is advertising to offer cost effective care?

    This is only one example as to how this can of worms could be more than you know what you are getting into or asking for…..

    • WhiteCoat says:

      I challenge you to examine the utility of your “megaworkups.” How often do they result in finding something requiring intervention in a stable patient? Perhaps doctors *should* be required to describe the utility of each test and the likelihood of finding a positive result to patients before extensive testing is ordered.
      How often do radiologist over-reads change the initial ED physician’s reading? If more than a couple of times per month, the emergency physician needs some remedial training. So you tell the patient “This is my impression. If you’d like, you can pay to have a radiologist expert double check my reading. Otherwise, you can sign this informed refusal stating that you’ll go with my interpretation.” Do you get a cardiology consult on every chest pain patient or every patient with hypertension? Call trauma for every bump and bruise? Pulmonary for pneumonias? Ortho for every sprained ankle? You’re taking on liability in each of these cases. Granted that there are complicated cases where consultants are necessary, but most ED physicians get along fine without consultants for most ED problems. Why should radiology be any different?
      You discharge patients all the time with a higher likelihood of disease than 1 in 100. Look at PE patients. A negative CT is only 83% sensitive in detecting PEs. You order pulmonary angiograms on everyone? Even those will get you only to low-90% range. I don’t believe that “megaworkups” serve the interests of a lot of patients. Low yield testing is not the “standard of care” and shouldn’t be.
      I’m not saying that we should go to a strict fee-for-service system. You’re right that there would be many more people falling through the cracks. But any system that is created must let patients control the spending. Not doctors. Not insurers. Not the government. Until that happens, whoever controls spending will ration care. Guaranteed.

  11. ERDoc says:

    I don’t order the “megaworkup” on everyone to cover my tail. Didn’t mean to imply that. I use clinical suspicion and current evidence as best I can. But I’ve been surprised enough by people who had CT evidence of appendicitis, with an unimpressive exam and a normal appetite, to have a low threshold. This is just one example that comes to mind. Two people in the last year, after I told them they had appendicitis asked me if they could eat something…..

    My entire point is when you go to a “free market” it could be a pandora’s box in many ways. Good nationwide tort reform could limit some of the problems. But people in our society just don’t have a tolerance for not ordering the best tests available in a given situation, if there is even a small chance they may have X or Y—without looking for it with the appropriate studies.

    • WhiteCoat says:

      The question should be whether the expense and radiation involved in catching an “early” appendicitis in a patient with unimpressive exam and normal appetite would have changed the outcome versus just having the patient come back for a re-examination in 12 hours. How many dozens of CT scans have you ordered with unimpressive exams that were entirely normal? If the exam is unimpressive, why order the test to begin with?
      Is making a diagnosis 5% more or less likely worth the inordinate amount of money spent on low-yield testing? How would it change the outcome if we treated many problems conservatively? No one knows because right now FREE=MORE.
      Your comment makes my entire point. People don’t tolerate not ordering the latest and the greatest because they aren’t paying for it. Require a patient to pay $200 each time they get an MRI for their back pain or pay a percentage of the $250/month cost of the newest hypertension medication and they’ll eventually make a value judgment – “am I willing to pay for the latest and the greatest even though it will probably make little difference in the outcome of my condition?” Maybe exercise and something off the $4 list at WalMart will work just as well.
      Part of making medical care more accessible and less costly is changing the paradigm of diagnosis and treatment. Either we’ll do it ourselves or someone else will do it for us through rationing.

  12. Matt says:

    Why would “good nationwide tort reform” do anything when “good” (from a physician’s perspective) statewide tort reform hasn’t? Are physicians in California, which really screws the injured and has for a couple decades, doing anything differently than physicians anywhere else?

  13. Bali says:

    Great post as usual, long time lurker here, first comment! Thanks for the great blog.

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