I Can’t Believe I’m Doing This

I grew up about 20 miles outside of Washington DC.  I had classmates throughout my years of school that were the children of senators and congressmen, I’ve met multiple lobbyists, political analysts, and commentators.  I have no patience for politics.  I don’t trust the system, I have no faith in politicians and I don’t really believe that anyone in any elected position has any interest in making my life any better.

That being said, I’m going to talk about healthcare.

I’m not going to specifically address the new(ish) healthcare bill for two reasons.  One being that I have no interest in political debate and the other being that I have even less interest in political debate on topics on which I have very little knowledge base and despite the abundance of people complaining about and/or praising the new bill all over the internet, I can find very little that’s actually informative as to what specifically the bill says.

I am going to give you my opinion of government’s involvement in anything (bad) and in something as personal as healthcare (worse).  But first let me lay out for you a few basic facts.

Fact one: Previous to this bill and, I believe, continuing after it, healthcare has been available to everyone.  EVERY- ONE!  No really, it has.  It may not be cheap. It may in fact be prohibitively expensive, but it has been available.  Not-for-profit hospitals (and they’re everywhere) are legally required to give care to any and all comers.  They’ll ask for your insurance info so they know who to bill in the hopes that they’ll get a little cash for the care that they provide, but if you don’t have any they’ll go ahead and treat anyway, they have to, they can not turn anyone away.  Case in point: I work at a childrens’ hospital.  We treat children.  However, when, one new years day, a woman in labor showed up in my OR we sent her down to the ER (because we don’t really have a labor and delivery unit) but we did not send her 100 yards across the sky-bridge to the University hospital (where they do have a labor and delivery unit). Because she had shown up in my hospital, and despite the fact that we were not best equipped to care for her, we were legally obligated to do our best.  So we did, and as far as I know she delivered in the ER and probably lives happily with her child to this day.  What we charged her for that care I have no idea, whether she paid I have no way of knowing, but she did receive care.

Which leads me to fact two: Healthcare is prohibitively expensive.  There’s no two ways about it. I’m not going to try to excuse the cost of healthcare, nor am I going to try to argue that it is an expense that can reasonably be borne by the average family.  It’s expensive, far too expensive.  Healthcare is available to everyone (see fact one) but that doesn’t mean that you won’t be charged a lot more than you can pay and it doesn’t mean that not paying isn’t going to screw up your credit and make it so that you can’t buy a house and have lots of other bad consequences it will, or at least can, do all those things.  I am NOT however going to argue that the natural solution is to get the government involved.  In fact I am going to argue that one of the reasons that healthcare is currently as expensive as it is is government involvement and that if they would just lay off a bit, there’s a chance that the whole thing would figure itself out.

Fact three: There is cost associated with ALL goods and services.  This is the first major fact that our current government system seems to have lost touch with but it is a fact nonetheless.  It may be true that the markup on medical devices is astronomical, it may be true that the cost of 10 minutes in an Operating Room is equal to the price of your first car and that it doesn’t really “cost” that much.  Those things may be true, in fact, I believe that they are, but the fact remains that they do cost something; perhaps not what you were charged but something.

Despite that, in the last 3 years medicare has changed it’s policies.  One of the policies that it changed effected the manner in which it pays for post-op infections.  The new policy doesn’t.  End of story.  Under the new rules medicare does not pay for any care required by the presence of post-operative infections.  That doesn’t mean that we don’t have to treat those infections of course, it just means that the hospital doesn’t get paid for the care that they provide.  The reasoning in the minds of the geniuses at medicare is that if I know that we won’t get paid for post-op infections, I’m going to be more vigilant and careful to make sure that this particular patient does not develop an infection (because usually I don’t care if I give someone an infection).  First of all, I find the whole concept insulting.  I don’t do a good job because of what I’m being paid.  I do a good job because I have been entrusted with the care of another person.  But second, the concept is incorrect.  If a patient develops an infection (which we do our best to prevent but despite our best efforts it happens on occasion) the hospital doesn’t get paid for the follow up care for the infection, the doctors who are billing for the care don’t get paid, but I still get a check.  I’m not paid by medicare, I’m paid by the hospital.  I’m not paid by the case, I’m paid by the hour.  So the hospital may not be paid for the hour that I spend cleaning out that wound but I still do.

Let’s take a moment to review fact three, there is cost associated with the infection.  It’s not nice, it’s not pretty, it may not even be fair but it’s still a fact.  There is a price for having me clean the wound, there is a price for the instruments I use when cleaning out the wound, there is a price for the cleaning and sterilization of those instruments, the gauze, the sterile water, the antibiotic solutions and ointments… All that stuff costs money.  Money that the hospital is not getting back from medicare.  But I still need to be paid and the supplies still need to be bought and the money for that has to come from somewhere.

The money to pay me and to pay for the supplies comes from the other patients.  There’s no other alternative.  For every patient we treat for free (see fact one, we have to treat regardless of ability to pay) we have to charge the other patients a little bit more.  And more.  And more. Until more patients can’t pay, so we have to charge those who can more, so more of them can’t pay, so we have to charge those who can more, so… You do see where this is going don’t you?  It’s great to say that your care wasn’t all that you expected or desired so you’re not going to pay except, well, even the, to your mind, substandard care cost someone something and they’re going to need to get paid one way or another.  Which leads to fact two.

Some say that the solution then is to put the government in charge of healthcare and then everyone gets paid and all procedures get paid for and no one gets charged anything.  It’s a beautiful idea.  The problem is that it just… doesn’t work.  I’ve heard that we’re supposed to look at the VA system to see how great this could be. Well, I’ve worked at a VA hospital and friends, it’s not pretty.  It’s not that the care isn’t good, it is (although, I my opinion it’s not the best).  It’s not that the employees don’t care, they do (as much or more than they do in any hospital).  It’s just that there’s no incentive.  The hospital is going to make what the hospital makes, the doctors are going to make what the doctors make regardless for how much care they give so there’s no reason to hurry and get the case that could take an hour done in an hour, the pay for the day is the same even if it takes two or three.  So guess how long it usually takes.   And if we spend three hours doing a one hour case then we can only do two in an 6 hours, but when we do them in an hour then we can do 6 in 6 hours.  When having one specific patient in the hospital doesn’t cost the hospital money then there’s no pressure on the doctors to get them home, so when a patient needs one more x-ray before they can be discharged, but it’s 5:00 on a Friday, at the VA that patient stays, not for the night but for the whole weekend.  At a hospital that has a bottom line to look at, they pay the x-ray tech for another 15 minutes so that they can open up the bed.  And when you open the bed someone else can fill it.

In talking about healthcare in countries where it’s “free” (one of the most grossly inaccurate uses of the word in history) the issue of wait times always ALWAYS comes up and no wonder.  When you remove the incentive to get people better faster, to get things done faster, then they get done slower and if they get done slower than some of them just don’t get done.

What this means in the current climate, I don’t know.  I see where we are and I see where we ought to be, but getting there, that’s the trick.  And it’s now even more of a trick because we’re moving in the exact opposite direction.  But that doesn’t mean it can’t be done.

It’s possible, probable even that I’m cold and heartless, that I’m discussing healthcare as if it’s all about money and well, I am.  However,  if we’re honest we’ll admit that it was money that sparked the whole “healthcare crisis” in the first place and I believe in calling a spade a spade.  Letting the market equalize and therefore making things in the medical industry cost what they actually cost is not going to magically enable the family that can only just afford food able to afford a heart transplant but it may make it so that the family who has enough to occasionally go on vacation could if they needed to.  It may make it so that that first family, the one who’s just scraping by, can afford to have their kid’s broken arm set and casted on their own, without governmental or any other involvement and to have it done the day that he broke his arm rather than a week later.  And wouldn’t that be better for him? And for all of us?

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8 Comments (+add yours?)

  1. E
    Mar 29, 2010 @ 11:31:32

    I was listening to an NPR story a few months ago about an innovative new procedure that used a tube formed from a blind woman’s tooth and inserted into her cornea to restore her vision.

    All I could think was-this is what drives up the cost of health care; amazingly good (and expensive) medicine. The better care we get, the better we get at saving everyone’s lives and fixing all their problems, the more it is going to cost us.

    Health care was cheap in the 1100’s.

  2. Alison Wonderland
    Mar 29, 2010 @ 11:45:14

    Healthcare will always be expensive, has always been expensive, even in the 1100’s. But the fact is that it should be, it’s important and the things that are the most important should be the things that are the most costly. It should not be unavailable, nor should it be impossible to pay for.

    And you’re right, medical innovation, breakthroughs and new technology are very expensive, but nothing and I do mean nothing is going to prevent their taking place. Hybrid cars initially cost more to produce than they did at the dealership (and they were pretty expensive on the lot) but manufacturers knew that with continued use and experimentation the technology would get cheaper and the demand would increase so they sold those first cars at a loss. And now even I want a hybrid.

    The same thing will happen, does happen, in a free market environment. It happens all the time. if a new development is too expensive, people don’t buy it and so the developers keep working on it until it becomes affordable. Why shouldn’t the same work in this case?

  3. Flipflopmama
    Mar 29, 2010 @ 12:18:13

    Very well written. My husband went on his mission to Canada and he constantly remarks on how long the lines were at the clinics. No incentive. No incentive to be better, to be a specialist or like you said to get people out of the hospitals. I’m scared of the large steps were are taking toward socialism. And the scariest thing is that people don’t seem to notice.

  4. Sara H.
    Mar 29, 2010 @ 13:40:59

    Amen. Anytime a customer (sick people in this case) is separate from the real cost, they will always make inefficient choices. It’s a tough issue to address as a whole, because you hate for people to suffer because they may not have means ($$$$) to pay, but how much money should I have to pay for their inefficient decisions. Not easy.

  5. Chris Jones
    Mar 30, 2010 @ 19:45:04

    You absolutely NAILED this.

  6. LisAway
    Mar 31, 2010 @ 00:20:59

    Looooong lines for public health care here. We go private whenever possible. Also, when I was in the hospital with pre-term labor I literally had to beg to be allowed to come home after 5 days. Maybe the doctor really did think I should stay for medical reasons, but I also know that the hospital gets money for every patient in the hospital (somehow), so they want you there for as long as possible. It’s not good. Also, doctors get paid very little so bribes are a big issue here, too. It’s just bad all around.

  7. Sean
    Apr 03, 2010 @ 09:07:04

    Health Care on the whole is a joke. There are multiple issues that make it ridiculously expensive and those are issues that would have to be resolved as well. One of the culprits in my opinion is medicaid. It’s just another government intrusion that doesn’t help, but, hurts the bottom line. These people frequent any hospital they choose, usually out of network, and know they don’t have to pay, so there’s no initiative to do what’s right because there aren’t any consequences for going to the wrong place.

    Government on the whole isn’t going to make it any better, but they have a really great chance of making things worse, with the one possible exception, if you want to call it that, that they may help people who really have no means to pay at your local hospital that isn’t a not for profit organization.

  8. madhousewife
    Apr 09, 2010 @ 14:38:21

    I wish I were the government and could force everyone to read this or pay a fine.

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