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Ok, I'll bite. I had planned to sit this one out and just observe from the sidelines. For some reason, I feel compelled to get sucked in at the end of page 6. Having spent my entire adult life as a physician, including more than a decade as an ER physician, this certainly strikes home. All the more reason I wanted to sit this one out. "Sorry I already gave at the office today." I tend to come to this site to forget about medicine, not discuss it.

It's interesting that no one has thought of the fact that this country already has its own version of socialized medicine. It's known as the VA. In April, I got my 20 year pin for service to the federal government. It's scary to think that the VA is a potential model for health care in this country. Although alot of veterans swear by the VA - of course it is free to them. In that, comes alot of the abuse of the system. Every day I see patients coming into my ER for their chronic non-urgent problems. "How long has your back been causing you pain, sir?" "Since I injured it in the boot camp in 1961." "Well our triage nurse contacted your clinic and they can see you at 2 pm today." "But doc, I'm not going to wait four hours." And why does this happen? No disincentive for overusing the ER - other than adding to our increasingly long wait times.

I love the comment about wait times of one hour to be seen in the ER. For my ER we have been mandated by the hospital's directors office to decrease the percentage of patients waiting six hours in the ER.

It's not uncommon to see a patient with an inginual hernia that is not incarcerated and not in need of emergent surgery. I'll put in the referal to general surgery who will schedule the initial clinic appointment in six weeks, after which elective repair may be scheduled 6-8 weeks after that. If that is a 70 year old retiree, maybe it's not the end of the world. However for a 40 year old construction worker who can't work until he has surgery, it's a different story. You get what you pay for in life.

We have also seen a tremendous increase in our patient numbers in the last 6 months. Some of that is due to veterans returning from Iraq. However most of the increase is from people losing jobs and health insurance who previously would never have come to the VA. This comes at the same time that our budget is being slashed and we are facing a $15 million deficit for this fiscal year. We are down ~50% of our ER physician positions and there currently is a hiring freeze.

I'm not pretending I know what the answer is. It is much more complicated than can be imagined.

A couple items in response: "No disincentive for overuse of the ER." - absolutely agree 1000%. For vets, indigent/unemployed, those otherwise underinsured or uninsured, and just an enormous number of people without the skills/knowledge needed to access healthcare in another (certainly more cost-effective) way.

"If that is a 70 year old retiree, maybe it's not the end of the world. However for a 40 year old construction worker who can't work until he has surgery, it's a different story." - this gets rather touchy, but it's weird tome that the 70-year-old, on Medicare or military or other "good insurance", will almost always get that surgery, whereas the construction worker may likely have no insurance (pretty common in the field). So often that's the case, the one that's more likely to NEED medical care is the one without access to it.

"I'm not pretending I know what the answer is." - I am pretty sure there is no singular answer to a problem of this *staggering* complexity. The idea that a magical answer to all your problems with any complex issue is pure snake-oil thinking. Great for kids who still believe in the tooth fairy, but we're all over 13 here.

My way of thinking is that you approach the mountainous task by attacking on several fronts. A "health czar" is too overwhelming a task for anyone. More likely, we need task forces with strong leadership to oversee various aspects - financing, access, patient advocacy, social work aspects, connections to other social services, etc.

Yes it's a HUGE problem, but we have thousands of brilliant minds, people who really care, committed to serving the public whether they come into their doctor's office, a walk-in clinic, or the ER. There are advances in IT that really have helped to compile vast amounts of useful data on service provision, cost, and health outcomes. I'm very hopeful (insanely optimistic?) that with the new commitment to "outcomes-based medicine" that we will eventually follow the path of least resistance and let the best outcomes drive us backwards to the correct course of cost-effective and health-promoting policies. OK, clearly I'm insane....but even a broken clock is right twice a day. :)

Finally, I wanted to say thanks for the job you do, sws... and that sometimes bringing the work home just shows a belief in the purpose of the job... :)

edited for paragraphs - and apologies to anyone who has a headache from viewing this as one ginormous block of text. :)

sws said:
For some reason, I feel compelled to get sucked in at the end of page 6.

I'm glad you did - really good stuff to add to the list of things to consider.

rollergator said:
Finally, I wanted to say thanks for the job you do, sws... and that sometimes bringing the work home just shows a belief in the purpose of the job... :)

Thanks, gator. I appreciate that. Actually, I was kind of in a pissy mood because I'm having to work extra shifts in the VA's ER this holiday weekend because we're short staffed. Then I realized it's probably fitting since it is Independence Day and that should be considered a good thing. I'm working with one of my friends who is a retired colonel in the army reserves. I thanked him for my freedom today.

Ok Gonch. I'm going to give you the ultimate example of rationing care in a universal health care system. When viagra first came on the market several years ago, the VA would not provide it for veterans. It was too expensive and deemed non-essential. Erectile dysfunction is a "huge" problem in our elderly male veteran population (pun intended). However the VA urologists would still perform surgery for penile implants to correct the same problem. Eventually, levitra and other meds came on the market driving the costs down and the VA will now cover the meds. However they only provide 12 tablets for a 90 day supply. Thus if an ex-marine wants to erect his flag after capturing Iwo Jima, he can only average one conquest per week. If a vet wants more frequent invasions, he will need to provide his own popsicle sticks and duck tape. Now that's un-American. :) Brings up a whole new meaning to the concept of an exit strategy.

My father spent many years of his life in care of the VA - most notably, his final five after he was diagnosed with lung cancer.

He never needed little blue pills. I hope that's hereditary. :)

Here we are on the 7th page, and I can't see where anybody, anyone has suggested that maybe the PATIENT should have some input on whether the cost of the care is worth it? If you want to control costs, I can think of no better way than the patient having some skin directly in the game.

The CEO of Safeway has been in the news lately talking about how his company has controlled health care costs. You can search for the story, but briefly the plan has incentives for employees to be healthy, and employees have to bear some of the costs to give them a reason to shop wisely. (Preventive care is covered 100%, and all medical costs beyond some point are also covered 100%.)

The heavy hand of the govt controlling healthcare should scare everyone.

sws said:

It is much more complicated than can be imagined.

That's the truest thing that's been posted in this thread. :)

I should really just let this thread die peacefully, however when I read some of the earlier notes, I got such a chuckle that I couldn't pass it up. Brandon, I'm not trying to pick on you, but I just had to comment.

djDaemon said:
I know its an absurdly simple point, but does it mean anything that the WHO ranks Canada's health care system as better than the US's (PDF)?

Hmmm, under overall health system performance, the US ranks #37 and Canada ranks #30. So for us to overhaul our health care system, which will cost over a trillion dollars, we will be able to go from 37 to 30. My response, "F*** Canada." (Isn't that the name of a South Park episode?) I want to know what France and Italy are doing to make them numbers 1 and 2. Hell, San Marino is #3. That sounds like a fun place; we should all go there.

And while the WHO's study has generated expected criticism, those critics have been answered by a peer-reviewed medical journal:

I love the reference - Open Medicine, Vol 1, No 1.

Open Medicine??? I can promise you that the 95% confidence interval for the percentage of physicians who have never heard of Open Medicine is 99.999998-99.999999. I particularly love how the first two authors of the article are on the editorial board for Open Medicine. Translation: "Our article was just rejected by the 53rd journal we've submitted it to. We'll never get tenure at this rate. Let's start our own on-line journal so we can get published. I'll review your article, you review mine, and we'll claim to have a peer-reviewed journal."

It gets even better when you look at the tables that list the various articles included in the meta-analysis. They lump studies looking at outcomes for cancer, hip fracture, coronary disease, AIDS, etc, etc. That is not the way you do a meta-analysis. The methodology is inherently flawed. No wonder it was published in Open Medicine. I particularly like the Wolfe, et al, study that was listed in the table. It collected outcome data from the US 1965-1990 and Canada 1955-1990. In spite of 35 years of data collection from Canada, the sample size was #905, ie less than 3 patients per month over a 35 year span.

I have done peer-review for medical and scientific journals. This one really made me laugh.

Overall, results for mortality favoured Canada (relative risk 0.95, 95%confidence interval 0.92-0.98, p= 0.002) but were very heterogeneous,and we failed to find convincing explanations for this heterogeneity.

You asked what 95% confidence intervals mean, and I'll try to explain it. If you compare mortality between the US and Canada and have a relative risk of 1.0 that means they are equal and there is no difference. A relative risk of 0.95, means there is a 5% reduction for Canada vs the US. 95% confidence interval of 0.92-0.98, means that you can conclude with 95% certainty, that the true mortality reduction is between 2-8%. However the methodology of the study is so flawed, the statistical analysis is worthless. There is also no control for differences in life-style between the two countries. It may have nothing to do with health care, but rather be a reflection of lower rates of obesity, smoking, alcohol, etc.

Again Brandon, I'm not trying to pick on you. I just found the references amusing. My conclusion, let's all move to San Marino.

sws said:
San Marino is #3. That sounds like a fun place; we should all go there.

San Marino is indeed a fun place... I wasn't sick when I was there, but they have an awesome indie record store.

I thought San Marino used to play for the Dolphins...

(Sigh, that was bad)

sws said:
So for us to overhaul our health care system, which will cost over a trillion dollars, we will be able to go from 37 to 30. My response, "F*** Canada."

I hate when I've tried to say something seemingly 100 times over 7 pages of discussion and someone comes along and says it better in two sentences.

I don't know if anyone has brought up the issue of scale (I just skimmed over a few pages of the discussion).

(numbers in millions)

France - 65

UK - 61

Germany - 82

Italy - 60

Canada - 33

USA - 306

Its easy to say "Hey UHC works in (insert country here)!", but that completly ignores the fact that they only have to implement it for a fraction of the people. Heck, right now we have almost as many people on unemployment (9.1% = 27mil) as Canada has for a total population.

I don't mean this to say that we can't find a way to make healthcare available for everyone (we're America dammit, we don't know CAN'T) but to think that because a system works in Europe or Canada it should work here is asinine.

Again, forgive me if this appeared somewhere in pages 4-6.

Interesting that I was just having this discussion with a friend yesterday. He's had epilepsy his whole life and just recently became too old for his parent's insurance while still in college. In Ohio, college students are required to have health insurance. However, due to his pre-existing condition, nobody will take him not even the school sponsored plan. So now he runs the risk of possibly being kicked out of school if they happen to ever bother asking him for proof of insurance.

His anti-seizure medication is nearly $600 a month. That's not something a typical college student should ever be able to afford. He told me he's supposed to take 600 mg a day, but he usually rations it to 50, and even then only takes it when absolutely necessary. He's also taken to smoking pot about once a day because he swears it's just as effective as the medicine and sadly, is a hell of a lot cheaper.

I certainly don't even want to pretend that I know where to start with fixing healthcare, but I do believe that President Obama is the best chance we've had at reform in a long time. I think a good place to start would be to outlaw the idea of pre-existing conditions and make it illegal for these companies to deny service based on them. Also, immediately start to identify ways to lower that 31% overhead cost and implement them as soon as possible.

I'm not sure if a government run plan is the best way to go, but I do know that something seems really slimy when people's health is being treated as just a pawn in the game these corporations play called "let's find ways to make our CEO and shareholders a bunch more money."