WhiteCoat

Archive for the ‘Funding Crisis’ Category

I’m Not Paying For It …

Tuesday, April 7th, 2009

Gramma WhiteCoat is getting foot surgery this week. She’s in her Golden Years, so her care is paid for courtesy of the Medicare National Bank.

I spoke to her last week and she stated that she was examined by 4 different doctors, 2 nurse practitioners and 3 nurses for preoperative procedures. Her primary care physician (not one of the 4 doctors providing a preoperative exam) saw her about a month prior to her surgery, cleared her for surgery, and ordered preoperative labs. Because the labs were more than 3 weeks old, the surgeon wouldn’t accept the normal results and ordered a second set of preoperative labs.

Grandma WhiteCoat’s response: “I know they’re doing all these exams and blood tests to pad the bill. But I don’t care — I’m not paying for it.”

From the mouth of my own mother.

Just another example of why any system in which the consumer has no stake in cost containment is doomed to fail.

FREE = MORE

Patients must have some skin in the game in order for any medical system to work.

ED Abuse

Wednesday, April 1st, 2009

From Statesman.com …

Nine patients.
Six years.
2,678 emergency department visits.
$3 million in bills to the taxpayers in Austin, TX.

And so many Americans won’t get basic health care because they can’t afford it.

Something ain’t right.

Ambulance Driver has some suggestions on a cure. 911Doc also beat me to the post.

The fact that so many emergency medical providers are highlighting the article should tell you something.

UTMB Closes ED, Opens Urgent Care Center

Wednesday, April 1st, 2009

236px-hurricane_ike_off_the_lesser_antillesThe University of Texas Medical Branch in Galveston trauma center was significantly damaged by Hurricane Ike in September 2008. After the storm cleared, UTMB kept its ED open only to treat patients with minor ailments or to provide stabilizing treatment and transfer to patients who needed higher levels of care. About 600 patients needed transfer since Hurricane Ike struck the area.

UTMB’s program appears similar to a program at the University of Chicago that evoked public outrage not too long ago.

According to an article in today’s Galveston County Daily News, UTMB stopped the “treat and transfer” program that it had been using since September.

Instead, UTMB decided to close down its emergency department.

Now no one has access to emergency care at the hospital. Everyone with an emergency condition must call 911 to be transferred to another hospital – apparently in Houston which is a 48 mile trip according to Google Maps.

Instead of continuing to provide emergency services, UTMB is running an “urgent care center” out of the emergency department. For those of you who haven’t read my previous posts, urgent care centers don’t have to treat any patient that walks through the door looking for care. EMTALA laws don’t apply to urgent care centers.

Oh, and by the way, the article states that “the urgent care facility will require patients to undergo financial screening.” I don’t know the hospital’s official policy, but that statement sounds like the urgent care center is doing a wallet biopsy on potential patients and triaging out those whose biopsies come up short. Sound familiar?

The comments section to the article was a mixture of desperation from patients and disgust from some medical professionals. One person stated “Many of us have severe problems and are desperate.” Another asked “Why should Houstonians suffer with longer waits in the emergency room because Galveston and UTMB can’t get their act together? They shouldn’t have to.” One PA stated that he was “really ashamed that I graduated from UTMB and have to witness this travesty of medical care to the citizens of and visitors to Galveston.”

It should be noted that UTMB stated that it plans to reopen its emergency department in 3-4 months – albeit with less services available. It should also be noted that, unlike the University of Chicago, UTMB is the only game in town in Galveston.

I predict that the speed with which UTMB gets its ED functioning will be directly related to how well the urgent care center does financially.

Welcome to the new face of medical care in this country, folks.

More On Comparing Health Care Systems

Wednesday, March 25th, 2009

I’m trying not to make this blog like a broken record, but I have several “Google Alerts” for medical-related articles and I keep receiving abstracts describing the difficulties other countries are having with their health care systems.

I know that I keep using Canadian health care as an example of what could happen if a socialized system is implemented in the US, but Canada isn’t the only country having difficulty keeping its health care system sustainable.

This in-depth article from the McKinsey Quarterly (free registration required to read the entire article – definitely worth doing so) [hat tip to Head. S p a c e] notes that Japan’s health care system “has come under severe stress” and that its “sustainability is in question.” Demand for health care in Japan is increasing and Japan is having difficulty allocating available medical resources. As a result, patients are finding it more difficult to “get the care they need, when and where they need it.”
Japan’s emergency rooms turn away tens of thousands of people every year who need care – something which is beginning to happen in this country.
There is also an “ER [cringe] crisis” in Japan – because too few specialists are available for ED consultation.
Hospital reimbursements are low.
There is no incentive to modernize treatments.
Many poorly thought out cost-control measures Japan implemented have actually cost the system more money. Hmmmm. Where have I heard of that happening before?

When we switch to socialized medicine, we must be very careful not to replicate formulas for a failing system. Giving people unlimited access to free care seems to be a common denominator in more than one floundering national health care plan.

OK … as long as I mentioned Canada, I’ll throw in the latest article.

This article in the Calgary Herald describes how median wait times for available hospital beds are now 16.6 hours. In other words, half of Calgary patients wait more than 16 hours to get a bed. There is a shortage of nursing homes, sick elderly patients get sent to hospitals, and there are little if any “funded” beds available.
One story described an elderly patient who was experiencing a stroke and had to wait 24 hours to see a physician – by that time, the damage would have been long irreversible.
As with many health care articles, I think you can learn a lot about the underlying issues by reading the comments section. Comments to this article painted a vivid and familiar picture.
Many Canadians complained that nonurgent cases contributed to wait times and made statements such as “The emergency room [cringe] is for emergencies.”
Other commenters blamed the state of affairs on elected political parties. Sound familiar?
One of the ways that the hospital systems are apparently recouping some of the costs of care is by charging patients for parking at their facilities. Several commenters expressed their disgust with “paying for parking.”
The comment that made the biggest impression on me was one that claimed the Canadian government is “cutting costs/services, and making it look like it is in the red by underfunding it, only to make a greater case for PRIVATIZATION.”

I’m not sure if we should be telling Canadians to be careful what they ask for or if they should be making that statement to us.

Massachusetts’ Next Step

Tuesday, March 17th, 2009

According to this article in the NY Times, Massachusetts is getting crushed by health care costs. A vast majority of people in the state have some form of insurance, but the costs of providing health care in Massachusetts is expected to increase by 42% in 2009 alone.

Now Massachusetts is looking at whether it can regulate insurance premiums – i.e. limit what insurers can charge.

Massachusetts is also deciding whether or not to “bundle” payments for health care. In other words, if you need your appendix out, Massachusetts pays the provider one price to take care of you from beginning to end of treatment for that problem. If you get it done cheaper, the provider keeps the change. If there are complications or if expensive testing is needed, the provider pays out of pocket for whatever costs go above and beyond the flat fee. In theory, providers could lose significant amounts of money by treating high-risk patients who are prone to develop complications or bad outcomes.

This prepayment idea was also tossed about by Michael Canon at the CATO Institute.

On its face, the idea sounds good. But underneath the surface, I think that such a system encourages skimpy medical care and encourages cherry-picking of healthy patients.

Remember the HMOs that paid physicians a flat fee for taking care of all the patients? Remember fighting with physicians for appointments and testing because the physicians had to control costs? How will the system proposed in Massachusetts be any different?

In addition, I think there will be a lot of gaming of the system.

I was going to give examples of how the system could be gamed, but will hold off for now until more about the proposal is disclosed.

I continue to think that “prepayment” or “bundled payment” ideas will have an adverse effect on medical care.

Healthcare policy experts interviewed for the article hit the nail on the head:

Changes in payment practices will not be enough to slow the growth in spending, even when combined with other cost-cutting strategies. To truly change course, they say, the state and federal governments may need to place actual limits on health spending, which could lead to rationing of care.

“Really controlling costs requires just stopping spending,” said Stuart H. Altman, a professor of health policy at Brandeis University.

Taking Care of “Them”

Monday, March 16th, 2009

Tummy Time!This is a stream of consciousness post, so I’ll apologize in advance for rambling. As I read through the post, it jumps around a bit, but it really does get to a point … eventually.

I’ve resigned myself to the idea that our medical system is going to become “socialized”. People want change. Our medical system needs change. President Obama has already stated that we’re going to get change.

As I work my shifts in the emergency department, I see a rather perverse distribution of health care in this country. People who work all of their lives contributing to our economy have little or no access to medical care because it is too expensive and they cannot afford insurance premiums. They make too much money to be covered under Medicaid, they don’t have a disability to qualify for Medicare or disability insurance, and they are too young to meet Medicare’s age limits. In an emergency, the people who sustain our economy worry about how they will be able to pay all of the medical bills. Just being in the emergency department and knowing that soon they will receive a huge bill is as traumatic for them as their illness is. I will never forget about one patient complaint I read that said “As soon as I saw the bill for your services [meaning the hospital ED charges], I almost needed your services again.”

Meanwhile, I see many perfectly healthy people who do not work and who contribute little to the economy who are fully entitled to walk into an emergency department and receive millions of dollars in medical care. Expensive evaluation for coughs, runny noses, pregnancy tests, work excuses, prescriptions for Motrin (so it can be picked up a the pharmacy at no charge), sometimes even follow up care – all at no cost to them in the emergency department.

I dislike the idea of a “socialized” system, but I dislike even more the lack of access to medical care that occurs with so many working families solely because their situation isn’t deemed “dire” enough to receive government handouts.

So socialized medicine, you win. We must take care of our own better than we are doing so now.

Then I sit back and try to imagine how future medical care systems in this country will operate.

I mentioned previously that once socialized medicine arrives, we’ll have to change the way we think about medical care in this country. Here’s another article about how our values affect medical care. I foresee a system in which futile care won’t be provided unless the patient pays for it. I don’t think that’s a bad thing … except we have to come up with a definition for what care is and is not “futile.” It won’t stop there, though. A lot of expensive care will have to be rationed. If patients want expensive care, they’ll have to pay out of pocket for it. Cancer treatment will be limited. Kidney dialysis will probably also be limited. Advances in HIV treatment will be curtailed – if you want expensive medications that have only a small benefit in outcomes, you’ll need to pay the $12,000 per year out of your own pocket. Ditto for the MRI to find out what’s causing your shoulder pain – just go to a government physical therapy program instead.

One good thing about such a socialized system is that once the government stops paying for expensive testing and treatment, market forces will kick in. If there’s no demand for a service because of high prices and lack of government reimbursement, then the entity providing the service either maintains its high prices and caters to the rich few, goes out of business, or lowers its prices to sell more of its product to the masses at less of a profit. Walmart created billionaires with high volume and low prices, not high profit margins.

A socialized medical system will also restructure the insurance industry. Who’s going to want to pay $1000+ per month for insurance to cover routine medical care when you can get routine medical care for free? Maybe boutique practices will become more common – there patients can pay cash for routine medical care rather than endure the wait for free medical care. Cash-only practices will also give patients a greater chance of maintaining their anonymity if they so choose.
Those who want insurance can purchase it so that they have faster access to major surgeries or more access to specialist care. Everyone will get all their care for free, but in the “fast care, quality care, free care” paradigm, people should be able to purchase a right to faster and higher quality care.

Socialized medicine will inevitably bring up new inequalities and new issues. There will be a fundamental unfairness in access to medical care that is not unlike the system we have now – only in the next iteration, everyone will have the same access to some level of government-sponsored medical care … the care will just be time-rationed. The focus of people’s angst will be on the speed at which those with insurance can access their care while those without insurance are forced to wait.
Civil rights groups will complain, but just as with every other private industry in this country, there is not and should never be an entitlement to the best of any product, whether it is luxury dining, luxury autos, luxury housing, or luxury medical care.

I also think that there will be another shift in focus – one that gives me hope, but that also concerns me.

Doctors and hospitals will no longer play the “bad guy” role. Instead, in almost every scenario, the government will take over the role as the “evil villain” that limits care. If a socialized system will pay hospitals and doctors for everyone’s care, providers will have no incentive to limit testing or treatment. Similarly, if patients are getting the care for free, the patients have no incentive to limit their demands. That leaves the government as the source of cost-containment. No longer will patients become outraged at hospitals and doctors. Instead, patients and the healthcare providers will fight the uncaring government.
As in …
The government wouldn’t pay for treatment and let him die.
The government says that the treatment “isn’t supported by evidence.”
The government “couldn’t afford” a costly cancer medication.

My guess is that the system will pit patients and doctors versus the government bureaucracy. Hopefully doctors and patients will be able to work together more as a team.

“Us” against “them”.

When you think about it, though, just like the identical twins in the picture, “us” and “them” are pretty much the same people. “We” will be fighting against a government comprised of “us” who are there to protect “our” interests.

Who really is the “them” part of this equation, then?

Those who use the most medical resources. The chronically ill. Those with severe illnesses.

All that separates “us” from “them” is a serious medical illness.

This is where “we” have to be very careful in designing a medical system for all of “us.”

Those in the “us” camp want to limit payouts from the system – keeping money away from those sickly “them” people who are disproportionately using the system resources.

The care that “we” agree to provide to “them” now will be the same care that “we” receive if we become one of “them” in the future.

Just how well will “our” new system take care of “them”?

That concerns me.

Can Americans Change Health Habits?

Tuesday, March 3rd, 2009

I wasn’t as clear as I could have been in my previous post regarding Canadian emergency departments.

The intent of the posts was not to say that one system is “better” than the other. Comparing two completely different medical systems and declaring one “better” is similar to comparing a Hummer to a VW Bug and declaring one “better.” Different people will have different opinions depending on the needs of the user. Where a Hummer would be “better” for towing a boat, a VW Bug would be better for saving money in gas. Similarly, American and Canadian medical systems (as well as others around the world) each have their pros and cons.

When I said that we are kidding ourselves if we think care will be better, I was referring to the silliness of the concept that, once medical care is nationalized, the US will have less waits, more comprehensive care, and a lower price. Because wait times are hitting the headlines in the US right now, I illustrated that wait times are also bad in Canada where they have a national health system, but I didn’t really expand on my thought process. As several people noted in the comments, neither system is perfect.

An article just published in the New York Times illustrates the concept better.

Americans spend more than twice as much on healthcare as many countries in Europe, but we still have a huge void providing care to those who need it. To expand services, we must cut costs. There is no way around it. Cutting costs will necessarily cut services being provided.

Are we ready to give up our designer medications and immediate access to comprehensive testing so that more people have access to care? Are we ready to pay more for the treatment we receive?

As David Newman states in the NY Times article:

“You can make policy changes till you’re blue in the face, but if patients and doctors don’t change the way they think about medicine, we’ll never change medicine.”

We’ll find out soon whether the experiment works.

As an aside, Emergency Physicians Monthly is fortunate to have Dr. Newman as one of its new contributors. He is author of the book “Hippocrates’ Shadow” and is a talented writer. I’ll link to his articles in EPM when they’re published.

Emergency Medical Care in Canada

Friday, February 27th, 2009

I read a couple of recent articles regarding the free emergency medical care available in Canada.

In one, the author’s husband waited five hours to be evaluated for excruciating chest pain and was later diagnosed as having pulmonary emboli. The author stated that her husband’s challenge was to “survive the bureaucratic barriers long enough to benefit from this care.”

In the other, the author noted that so many hospitals were going on “bypass” (where they could divert patients coming to the hospital by ambulance) that ambulances were having difficulty finding a hospital available to take patients. The Canadian government “banned” the ability of hospitals to go on bypass, regardless of the number of patients in the emergency department. Now “critical congestion within ERs has become the norm.”
The author notes that “The problem is not the hospitals – the problem is the system.”

I think we’re kidding ourselves if we believe our emergency medical system will somehow become “better” if health care is nationalized.

Obama’s Speech – Healthcare Reform

Wednesday, February 25th, 2009

I wasn’t able to watch President Obama’s speech last evening.

I did read it at Politico.com, though, and I have hope in him that he can pull our country through this giant morass that we are in.

The part of his speech relating to health care is below.

For that same reason, we must also address the crushing cost of health care.

This is a cost that now causes a bankruptcy in America every thirty seconds. By the end of the year, it could cause 1.5 million Americans to lose their homes. In the last eight years, premiums have grown four times faster than wages. And in each of these years, one million more Americans have lost their health insurance. It is one of the major reasons why small businesses close their doors and corporations ship jobs overseas. And it’s one of the largest and fastest-growing parts of our budget.

Given these facts, we can no longer afford to put health care reform on hold.

Already, we have done more to advance the cause of health care reform in the last thirty days than we have in the last decade. When it was days old, this Congress passed a law to provide and protect health insurance for eleven million American children whose parents work full-time. Our recovery plan will invest in electronic health records and new technology that will reduce errors, bring down costs, ensure privacy, and save lives. It will launch a new effort to conquer a disease that has touched the life of nearly every American by seeking a cure for cancer in our time. And it makes the largest investment ever in preventive care, because that is one of the best ways to keep our people healthy and our costs under control.

This budget builds on these reforms. It includes an historic commitment to comprehensive health care reform – a down-payment on the principle that we must have quality, affordable health care for every American. It’s a commitment that’s paid for in part by efficiencies in our system that are long overdue. And it’s a step we must take if we hope to bring down our deficit in the years to come.

Now, there will be many different opinions and ideas about how to achieve reform, and that is why I’m bringing together businesses and workers, doctors and health care providers, Democrats and Republicans to begin work on this issue next week.

I suffer no illusions that this will be an easy process. It will be hard. But I also know that nearly a century after Teddy Roosevelt first called for reform, the cost of our health care has weighed down our economy and the conscience of our nation long enough. So let there be no doubt: health care reform cannot wait, it must not wait, and it will not wait another year.

The gist of President Obama’s plan is to provide comprehensive health care for everyone (i.e. “open access” to health care) while reigning in costs. We’re going to spend more money to implement electronic medical records, to find a cure for cancer, and to invest in preventative care.

These are all laudable goals, but a system with increased expenses and decreased costs is difficult or impossible to attain without significantly affecting access to care and quality of care.

Want to take a bite out of cancer deaths? The cancer caused by smoking cigarettes kills a quarter of a million people each year. Put a $10 “advance health care tax” on every pack of cigarettes sold to pay for future health care costs. That will cut down dramatically on smoking and will increase funding for future smoking-related cancer cases.

Electronic medical records will help in the administration of health care, but only if the records are universal, complete, and easily accessible. No health care provider is going to spend tens of thousands of dollars to implement an electronic medical records system when there is no unified records system and when the return on the investment amounts to decreased productivity and increased costs. Kevin MD has posted a lot of information on this problem. Read more about his posts here.

The thing about President Obama’s speech that worries me the most goes back to the Engineer’s Triangle.

There is a dynamic tension between quality medical care, timely medical care, and free medical care.

If the government is going to make medical care free or low cost, that leaves two other variables in the equation.
Are we going to settle for free and timely care and take a hit in quality?
Or are we going to get free and quality care that will be difficult to access?

I’m betting on the second option – one in which care in this country will become time-rationed like in every other socialized medical system. It won’t be that you can’t have the medical care, it’s just that you may die waiting to receive it because so many other people are also in line to get the same free care. After all, we only have “limited resources” and we have to contain costs, you know.

Much of the medical care that some take for granted now, such as expensive lifesaving drugs and expensive end-of-life care, will become unavailable.

Not sure how I feel about this one. I think that our nation wastes exorbitant amounts of money on expensive care that has little or no effect on patient outcomes. That money could be put to much better use by providing primary care services to patients who cannot afford and currently have no access to it.

I’m just concerned that the pendulum is going to swing too far in the other direction and that increasing amounts of expensive but reasonable treatment will also be curtailed to cut costs.

Emergency Care – Where’s The Line?

Wednesday, February 25th, 2009

rat-under-yellow-lines-in-streetThe University of Chicago case is getting a lot of press and is polarizing the people on either side of the argument about Dontae Adams’ care.

Read about it at one of my previous posts, at ShadowFax’s place, over at Kevin’s blog, or at Scalpel’s blog. The Chicago Tribune is getting a lot of play out of the controversy. It has published several articles already and just put up another one last night.

Just by the sheer number of people writing about the topic, you should be able to tell that the outcome of this topic is going to help define how medical care will be provided in the future.

On one side of this issue is Dontae Adams and his mother.

Dontae happened to be in the wrong place at the wrong time. He was bitten in the mouth by a pit bull and had a large cut on his lip. It is obvious that he needed medical care. Dontae’s mother took him to the emergency department at the University of Chicago where she alleges that they began asking her about their insurance soon after they arrived. Dontae’s mom works and he has medical coverage through the Illinois Medicare program.

Stop here for a minute.

If you read through the comment boards at the Chicago Tribune web site, they are rife with people who criticize indigent/uninsured patients who may or may not be citizens of this country for “clogging up the emergency department” by going there for “routine” care. It’s easy to look down on someone is viewed as “abusing the system.”
So let me ask you this: Suppose you lost your job tomorrow and had no insurance. Suppose you had to take a minimum wage job at WalMart to keep food on the table for your kids and you weren’t eligible for health insurance. What would you do for medical care?
If you called a random doctor’s office and told them you needed an appointment for “routine” care and could only pay a small amount of cash, what are the chances that you’d get seen that same day? What are the chances that you’d be seen at all? Our family has good insurance, my daughter needs to see a specialist, and the earliest appointment is 4 months away.
Let’s say you’re living on a fixed income and want to pay for your doctor’s visits in cash. How can you afford to spend well over a hundred dollars for a single doctor’s office visit?
Ah, but there are free clinics all over the place, right? In the rural hospital where I moonlight, the closest free clinic is about 40 miles away and has very strict criteria on who it will treat at no cost. Cook County, IL, where the University of Chicago is located, is in the midst of a budget crunch and has closed down many free clinics. See articles HERE, HERE, and HERE.

There’s also an issue of whether or not the care some people seek in the emergency department is “necessary.” Clearly, much of the care that emergency physicians provide is not “emergent.” But I can say that because I have had eight years of medical training plus all the continuing medical education each year. Going to the emergency department to get an excuse for missing work, or trying to get a three day government-paid babysitter for grandma so you can leave on a trip is one thing, but in general, we have to give the benefit of the doubt to the patients.

Back to Dontae.

According to federal EMTALA laws, patients must receive a medical screening examination when they present to an emergency department seeking care. If an emergency medical condition is found, the condition must be stabilized or the patient must be transferred. If no emergency medical condition exists, the hospital’s duty under EMTALA ends.

From what I’ve read in the newspapers, according to EMTALA, Dontae’s injury was not an “emergency medical condition,” so the University of Chicago did not have a legal duty to treat Dontae once the emergency physicians determined that no emergency medical condition existed.

Now let’s look at things from the other side of the coin: Outside of federal EMTALA laws, what services should hospitals and physicians be “required” to provide?

Some believe that medical providers should be on the hook for everything. Expand EMTALA laws to require that patients receive everything they ask for. We need to provide for all of a patient’s needs. Whether it’s cardiac stents, kidney dialysis, Vicodin prescriptions, Lasik surgery, hair plugs, or a sex change operation, all medical care should be free to everyone. Sound silly? That’s the way our system is headed. If you think that some things should be free, but others should not, then you’re engaging in the same thought process that the University of Chicago used when it discharged Dontae Adams. Where ever you draw the line between free and not free, someone who would have to pay is going to criticize you for your decision.

That “free care” medical system is akin to expecting government to provide services with no one paying income taxes, expecting cities to provide services without anyone paying property taxes, expecting newspapers to run all of your advertisements for free (and to be delivered for free, too), or expecting professional medical societies to stay solvent without charging membership fees.

If we head down the free-for-all route in medicine, then why have insurance? If hospitals are required to provide all services to everyone regardless of the ability to pay, there’s no need to have any insurance. Hospitals can’t refuse care and all we have to do is show up at the front door to have access to the latest and greatest medical technology.

That’s a great idea, except for one problem: Who’s paying for it?

Medical care isn’t cheap. Government reimbursements for medical care are shrinking or nonexistent. New York pays a whopping $17.50 to physicians who provide lifesaving care to patients in the emergency department. California’s whole medical system is in shambles. Very few patients can afford huge medical bills. That leaves the physicians and hospitals holding the bag.

A “provide everything” approach becomes a system where hospitals and doctors are essentially paying for patients to come and receive medical care. That type of system is unsustainable. Providers have gone and will continue to go bankrupt. In addition, the more we lessen the incentive to go into medicine, the less physicians we will have. Who will want to spend twelve years of their life for medical education and take out several hundred thousand dollars in loans just so that they can provide unreimbursed care to anyone that demands it?

Do an internet search about hospital closings. Here’s a list of 50 hospitals that have closed in Illinois since 1980. Here’s another example of a hospital closure this month in Queens, NY. Is the University of Medicine and Dentistry in New Jersey next?

Where do we draw the line between care that must be provided and care that doesn’t have to be provided?

The line is already there. We just have to stop trying to redefine it.

The more we try to force medical providers to provide comprehensive free care for everyone, the closer we get to a system in which fewer and fewer patients have access to any care.

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