Okay folks, in part 3 of this series on my plan for intelligent health care reform, I promised to try and keep this 4th post a bit shorter. I will endeavour to do that.
Up till now, I’ve been basically pointing out problems with our health care system, and also ranting about all the horrible plans and ideas being floated out there in the mainstream media and political land to “fix” them.
Not to sound like a broken record, but if you haven’t read parts 1-3 in this series, please do so now so this one will make a bit more sense and be read in context.
Anyway, to bring folks up to speed since it’s been almost a week since my last post, this whole series owes it’s life to an editorial I read in the Journal of Family Practice in which the editor, Jeff Susman, outlines his pleasurable experience with taking his dog to the veterinarian.
He basically details how he was able to see the doctor in a timely fashion, the doctor did a thorough unhurried examination, the dog was appropriately treated and when it was all said and done, there was a single, easily understood and quite reasonably priced bill with no confusing insurance papers to file, etc.
Dr. Susman concluded his editorial by asking if perhaps we (in the human medical profession) should try to emulate our veterinarian friends.
I sent Dr. Susman an email detailing to him some of the problems that I perceive within our health care system and basically opining that the reason veterinarians are able to provide such a superior product (at least from a customer service standpoint) and at such a reasonable price is because of the absence of all the outside interference physicians face from the likes of third party payers (both private insurance and government), monitoring agencies, trial lawyers etc.
I mentioned to Dr. Susman that veterinarians basically operate in a much more laissez-faire environment and therefore their service is much more influenced by free market forces. I mentioned that this same laissez-faire environment also unfortunately allows certain problems to exist within the veterinary medicine world.
It is my contention that the positives of veterinary medicine can be created within our human health care system, but only by largely emulating the free market laissez-faire environment. I also contend however that safe-guards must be put in place to protect against the emulation of the problems that exist in veterinary medicine. These problems, while arguably somewhat acceptable in the world of animal health, would be unacceptable for our human health care system.
I am convinced such safeguards can be put into place. I am convinced our nation’s health care system can be dramatically reformed, with the result of a dramatically improved system, both in quality of care and financial cost.
As promised, this post will be shorter than those preceding it. In this post, I wish to briefly touch on these unacceptable problems within veterinary medicine, which much be addressed before any similar free market based, laissez-faire, environment can be implemented (re-implemented really, since this is basically what used to exist in this country up until the mid 20th century) within our human health care system.
Before addressing these problems however, I want to go on an extremely brief tangent and shine a little bit of light on how it used to be in this country and can be again, if we as a society can exhibit a little maturity and common sense. Here is a blog post from the Happy Hospitalist. Please read it. It’s short and should take you less than a minute probably.
Now, as illustrated in that linked blog post, things have been, and can be better in this country. Again however, there are potentially severe problems with a pure free market system and thus safeguards must be in place.
As in part three of this Plan for Intelligent Health Care Reform blog series, where I outlined the problems with our current human health care system, rather than trying to elaborate each and every little detailed problem within the veterinary health care system, I think it will be much more productive to stick to the overwhelming principle behind the problems.
I think this principle can be aptly demonstrated with a little real life example taken from a human health care system overseas, in which the free market apparently prevails, but without the necessary safeguards I allude to.
A few years ago, I worked briefly in the employee health center of a large industrial plant with a nurse practitioner named Mike. Fortunately, the employees in this plant stayed pretty healthy overall, so Mike and I had ample free time to shoot the breeze.
Now prior to coming to work in this facility, Mike had worked in a large hospital in a Middle Eastern country (Now, I don’t want to name names, but let’s just say the name of this country rhymes with Saudi Arabia). Overall, he said he really enjoyed working there. He said it was pretty neat being exposed to a different culture, trying new foods, shopping in the street markets, seeing all the women walking around in large shapeless black bags with eye holes cut in the bottom, having folks try to convert him to the religion of peace, blah, blah, blah, etc.
One thing he wasn’t too crazy about however was the way patients were treated in regards to money. He stated that although the medical care was pretty decent, the hospital was basically run in an purely business like fashion. In other words, money trumped compassion and human decency. Business decision making totally trumped medical decision making.
He stated that if a person showed up in the ER, the hospital demanded payment up front before any diagnosis would be made or any treatment rendered, no matter the acuity of the problem. If the patient stated they didn’t have any money with them, they were directed to an ATM machine in the lobby. Basically, Mike related, the hospital would let a person suffer and/or die before they would give any treatment without payment.
The hospital was purely a business. Businesses do not typically give their products or services away for free. If you look at my last post, you will no doubt come to the conclusion that what this hospital lacked was the influence of medical professionalism in the classic Western European sense. The folks in this nameless Middle Eastern country have apparently not grasped and/or embraced these fundamental concepts of professionalism which we take for granted (or at least should be able to) from professionals in our society.
(This “Medicine-as-a-business” concept, where doctors are looked upon not as professionals, but rather as being no different than any other member of society in any way, and hospitals and clinics are looked upon as being no different than McDonalds and Wal Mart is exactly where we are currently headed in the U.S. Our journey is being hastened by the very folks who claim to be trying to lead us in the other direction. It amazes me how their blatant hypocrisy and contradictions seem to get a totally free pass by the bulk of our “News Media”. It saddens me how easily money seems able to purchase the truth and replace it with a more desirable-from-a-marketing-standpoint truth.)
Now if you listen to the folks calling for universal government controlled single payer health care, they paint the picture that Mike’s observation in the desert is the inevitable consequence in this country if we allow anything resembling the free market to play a part in our health care system.
I don’t think this has to be the case.
As a veterinarian, I observed similar problems to what Mike observed in the desert. I did not however observe the degree of cold-heartedness he described. To be sure, a veterinary clinic is a business, and won’t survive long giving away products and services. That said however, I personally used to do a lot of charity work.
Like the physician of old who might accept a fresh pie as payment for his services from a poor family, I often treated animals for free when a person had no money or if they brought in injured wildlife or stray animals. Often, if a person had limited finances, I’d do everything I could for their animal, and simply provide some of the treatment or medicine for free or at deeply discounted cost. I wouldn’t note it in the record or make a big deal about it. I’d just do what I could to help them out because it was the right thing to do.
Certainly, there were some animals that were just in too severe a condition for me to be able to do this. Sometimes, a person would bring in an animal that was going to require a great deal of money, even to provide the minimally acceptable treatment. If the owner had no way of affording this, I didn’t just tell them “Tough luck, get lost,” and show them the door. I would always at least provide what care I could to relieve animal suffering, which sadly all too often meant providing free euthanasia services. As a professional, I was more than willing to absorb any associated costs if necessary.
Why did I provide this charity work when appropriate? Again, it goes back to that professionalism thing. I felt a professional ethic driven duty to relieve animal suffering. I felt a professional morally driven obligation to help my fellow man as much as possible.
As a physician, I feel the same way (a large part of why this free to the reader website exists). The vast majority of veterinarians and physicians I know do too.
That said, minor charity care and euthanasia for those without adequate financial resources, while arguably acceptable and even noble when it comes to pets and livestock, are obviously far from acceptable solutions within the human health care arena.
I am often asked why I made the switch from veterinary to human medicine. This fundamental problem of finances was the main cause of my switch (though certainly not my only reason).
As a veterinarian, I had the pleasure of helping lots of wonderful people and their animals. By and large, most of the animal owners I interacted with were kindhearted folks who cared a lot about their pets. They wanted the best for them and I always did my utmost to deliver that.
That said, virtually everyone has a limit as to what they were able and/or willing to spend on their pet. In my practice, just outside of Mobile, Alabama in the mid 1990’s, this limit typically fell somewhere in the range of between $200-$1000. To be sure, I had the occasional pet owner who I felt confident would take a second mortgage on the house if necessary to help their sick pet. For most folks however, once the estimated cost started getting above their personal threshold, they started saying things like “Well gosh doc, I think I’ll just take Ole Roy on home and see how he does,” or “Well gosh doc, I don’t want him to suffer. How much would it cost to just put him to sleep?”
Of course, the real classic was “Money is no object. Do everything you can for him Doc!”
This could typically be translated with great reliability to “Money is no object, because I don’t intend to part with any Doc!”
These folks would typically drop their dying pet off at the clinic, and I’d do all I could for that pet, and at the risk of sounding like a braggart, I felt like I pulled many of these animals literally out of the very hands of death. Amazingly however, the “Money is no object” owners would usually vanish quicker and more thoroughly than Grand Duchess Anastasia Nikolaevna of Russia, leaving me with a now medically expensive abandoned pet to find a home for.
I studied long and hard to become a veterinarian. I learned all sorts of wonderful ways to prevent illness in animals and to diagnose and treat sick animals when illnesses did occur. I gained tremendous experience in orthopedic, neurologic, and soft tissue surgery. I felt truly blessed to witness and be a part of all the advances of modern veterinary medicine. Once I left academia however, and entered the “Real World” of private veterinary practice, it was a different story.
There used to be a saying amongst veterinarians when I was in practice (I imagine it is still a saying amongst vets, but I don’t run in those circles very much anymore). The saying was something along the lines of “When the toilet is broke, and the dog is sick, and the economy is in the tank, the plumber gets a call. The veterinarian starts contemplating becoming a plumber.”
After all my education and training, it used to break my heart to euthanize a dog with a shattered femur because the owner wasn’t willing to part with more than 50 bucks, when I knew that for a couple hundred, I could do surgery on that dog and have it walking on that leg the next day. It used to break my heart watching some poor dog die of distemper or parvo virus, because the owner was to too cheap to get the dog vaccinated as a puppy. I could go on here, but I think you get the picture.
I reasoned to myself that even the cheapest jerk won’t typically tell their pediatrician to just put their kid to sleep if he gets meningitis or say “Sorry Grandma, you’re just gonna have to live with that broken hip, cause it’s gonna cost too much to fix it.”
I’ve certainly run into more than my fair share of jerks who I think in fact would just as soon have Grandma or their child put to sleep, rather than having to delay the purchase of that plasma television or spinners, but for the most part, most people still do put more value on human life than that.
(Now before I get a bunch of hate mail, I want to be perfectly clear on one thing.
If you happen to own a plasma television or have spinners on your car, I do not in any way think that makes you a self centered jerk who would euthanize your kid or grandma. I think plasma televisions and spinners are amazing wonders of modern technology and if you are a lucky owner of these wonders, well then kudos to you. I think that’s just ducky.
If however, you own any of this crap at the expense of a loved one’s health care…and yes, I include in this category anyone who is receiving any form of taxpayer-funded public assistance for health care…or taxpayer-funded public assistance for anything else for that matter…then yes, you are in fact a jerk. I am one of the taxpayers funding your public assistance. I do not own a plasma television or spinners. Quit wasting my money. Get a job and pay your own way. Jus’ sayin’.)
So, I think I’ve mostly made my intended point with this post. While overall, I think veterinary health care in this country is about a million times better both in quality and value than our human health care, it is not all a bed of Utopian roses.
If we are going to make changes in our health care system aimed at rolling things back toward the nearly free-market fee-for-service laissez-faire type of system that largely existed in the U.S. prior to the second-world-war, it is absolutely imperative that these changes also include some safeguards to prevent fiscal decisions taking priority over medical decisions. Ultimately, doctors must have the freedom to conduct themselves as professionals whose primary motivation is serving the patient’s best interests.
I am convinced that a workable solution can be implemented. I am equally convinced that what is currently being proposed by the single-payer crowd will simply make things much worse than they currently are.
I am convinced that a system can be put in place that largely mimics the environment in which veterinarians practice, while at the same time safeguards against the unacceptable problems within the veterinary health care system.
I think these four initial posts have done a fairly good job of laying out the necessary ground work.
Starting with post number five, I will begin outlining some actual solutions that I think would make a positive difference and constitute a plan for intelligent health care reform.
Cheers till then,
…Sam
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