Tuesday, September 1, 2009

Message from a concerned American doctor

Fear and Loathing in America: How to Sell Health Care Reform

I wonder if anyone has considered shifting the focus of the healthcare reform debate? It might seem to those of us who support health care reform that pleading the case of 47 million uninsured Americans and the many millions more who are underinsured or bankrupted by previous illnesses is sufficiently heart wrenching to rally people to the cause. The problem is that the demographic who watches Glen Beck and Rush Limbaugh without recoiling are reflexively persuaded that these uninsured are mostly "ne’er do wells” and “illegals" who are living off of their taxes (even if they, like their spokesman, Joe the Plumber, have failed to actually pay the taxes whose ill use they lament). A much more compelling sales pitch can be made for the other major components of the proposed healthcare reforms, i.e. cost-containment, preventive medicine and improved outcomes. Even the most hardcore conservative can support a reform that aims to find the cheapest, safest way to give granny the best treatment. None would support a system that instead gives granny the treatment which is most lucrative for the doctor, hospital, pharmaceutical company or insurance company. If Bubba realized that this is what we currently have, he could more easily be rallied to the cause.
So why aren't we rousing the granny loving masses with true tales of the endemic dangers in our current healthcare system? Fear and anger are remarkably effective mobilizing tools. Fear based tactics have worked well for Republicans on many occasions, even when used inappropriately -- it is what got us into Iraq without weapons of mass distraction or links to Al Qaeda, allowed too many of us to accept torture and wiretapping as okay sometimes, and it is what has undermined healthcare reform efforts as far back as 1915 when opponents were able to sabotage the establishment of a national health insurance with claims that this was a plot by the German emperor to take over the U.S. Visceral fear invoking rhetoric represents the single greatest threat to health care reform today if those of us who know we must reform don't get our act together and focus Americans fears on genuinely terrifying stuff. It will not avail our cause to simply whimper about the disingenuous fabrications from the likes of Fox News or about certain Republican Congressmen’s refusal to disavow propaganda and entirely untrue rumors. Of course, the Conservatives are attempting to “Swiftboat” the effort. This is what they do, this is their best opportunity to hurt Obama …and it will work if our only response is to cry foul.
The sad truth is that there are many real reasons for Americans to be afraid of our current healthcare system. We are killing grannies every day and we are bankrupting our country doing so. Proponents for reform need not resort to cruel and dangerous misrepresentations such as depicting efforts to encourage end of life counseling via physician remuneration (something every sane and caring physician supports) into death panels which incentivize doctors to suggest that granny snuff herself. The debacle we call US healthcare offers no shortage of real horror tales. Most tragic amongst its shortcomings is that our “healthcare” system infrequently delivers health-- We rank last amongst Western nations on nearly every measure of quality and yet our system costs twice as much to operate and the cost is rising by over 7.7% annually. For all this, our outcomes are deteriorating across nearly every disease category. Rates of diabetes and obesity, the two diseases placing the greatest financial strain on our healthcare system, are rising at alarming rates in both adults and children. Our children are projected to have shorter life spans than we currently enjoy secondary to tripling obesity and diabetes rates over the last 30 years. If nothing changes, the only thing projected to slow this process down is genetics. One analysis reckons that the only reason that the 30% of 6 to 11-year-olds who are obese has not risen further in the last few years is because every six to 11-year-old with the genetic propensity to be obese is obese. This is a disgrace and a true pandemic. Diabetes and obesity are nearly 100% preventable with diet and exercise. Surely in this advanced day and age, there is some way to design a healthcare system that incentivizes all of us from doctors to government and insurance administrators to patients and employers to figure out how to get up off the couch and eat more vegetables? Shouldn't this be the focus of our efforts to improve health rather than idiotic gadgetry driven diagnostics such as correlating expensive pictures of atherosclerotic plaques to risk for heart disease? Would not a an old-fashioned, thorough history about lifestyle habits such as exercise, diet and chill out methods be just as predictive, less dangerous and about 20 times cheaper? Equally illogical is to continue spending enormous funds on pharmaceutical development to treat diseases for which we already have a perfectly adequate arsenal of drugs and for which we know that no drug regimen will be nearly as safe and effective as dancing and eating some beans and broccoli. When the solution is so simple it seems hard to believe that we can all be so sick and getting sicker. The problem is that we have a "healthcare system" that incentivizes sickness care more than health care. The financial rewards for increased medicine (MRIs, procedures, dialysis, surgeries…) are much greater than the financial rewards for performing good medicine such as preventive counseling or adherence to state-of-the-art protocols. It is for this reason that there is an estimated 17 year lag between a new medical discovery and implementation unless this discovery is a lucrative procedure or medication. Keep in mind that this implementation lag results not only in failure to utilize helpful treatments but failure to cease utilizing harmful treatments. This distorted system results in too many situations in which granny receives treatments that are neither the cheapest, the most effective nor the safest. For instance, if granny goes to the hospital following a heart attack, even if she is one of the patients for whom evidence-based protocols recommend a relatively cheap and safe regimen of medications followed by cardiac rehab rather than an angioplasty; in many parts of this country, she is likely to undergo the angioplasty with its related risks, because this procedure will pay the hospital on average 40% of $20,000. By contrast, opting for the evidence validated safer protocol of medicines and rehab will cost the hospital approximately 11% of its expenditure on granny. It is this reality about which people should be enraged and afraid --not Sarah Palin’s imagined death panels.
As physicians and other concerned citizens who genuinely care about granny it is our responsibility to join the effort to pass meaningful health care reform. This means reform that achieves better health with minimal harm along the way. Since this route usually also involves the lowest tech, most lifestyle based interventions it is also the cheapest. Our current healthcare system is terminally ill—it has become so distorted as to lose track of the only truly relevant outcomes. Number one --do the patients undergoing the intervention feel and function better without a pharmacopeia so obtunding that motor vehicle operation ought not be allowed. Number two -- are the patients who underwent the intervention less dead than those who got no treatment or other treatments. Reform can be accomplished in a highly sustainable fashion. Furthermore I believe that making these changes will reinvigorate physician’s commitment to their craft. Few of us would object to working in a system which supported good medicine and thereby, happier, healthier patients-- even if this meant slightly less pay. Believe it or not, most of us love medicine more that money and lament the formers demise.
Virtually no other business model would tolerate the lack of quality or quality controls seen in our healthcare care system. If a widget making company was spending more and more on R&D and its widgets were becoming increasingly wonky, somebody would look into the data to figure out what was working and what wasn't and thus produce less wonky widgets. The only thing that would interfere with such a logical course of action would be a situation in which multiple powerful industries had grown up in the capacity of maintaining wonky widgets beyond their wonkily shortened life spans. If the various spring makers, ball bearing re-surfacers, lubricant specialists and so on stood to lose significant revenue on less wonky widgets which required less maintenance for longevity, then they would do everything in their power to sabotage the creation of high endurance, low maintenance widgets. This is, unfortunately, where we are in medicine. A few very powerful players—Big Pharma, some procedurally oriented physicians and hospitals, surgical instrument and other gadgetry makers –have a very strong interest in keeping us wonky. The studies of treatment efficacy proposed in the reforms are not in their best interests. In the meantime, the rest of us are literally dying to know what works.
Our current disaster management model of medicine is the least effective, least kind and most expensive way to do things by every assessment. Without reform, the economic viability of our nation and the viability of our people are imminently threatened. Americans should be afraid, but their fears should be of real bogeymen not socialist rationing, death panels or fascist takeovers. To paraphrase my hero, Jon Stewart-- while the language in the health care proposal may be complicated and open for interpretation; is it the least bit realistic to believe that the interpretation which would be chosen at the impetus of the government, would be the one in which doctors are compelled to push euthanasia on elderly folks?! Perhaps under a Cheney administration, but otherwise this is absurd!
So let’s get our troops in order and make sure that healthcare reform passes and that that the reforms transform our sickness care system into a healthcare system. Let’s stop whining about the misuse of fear and anger and appropriately focus these emotions. Fear and anger mobilize people whether aptly or illegitimately used. We have legitimacy on our side. So let’s all collect factual anecdotes and data illustrating the dangers, costs and glaring inefficiencies in our current system and inundate the people with this information. Let’s rally influential, well respected celebrities from all walks of like to the cause. Healthcare reform is arguably the most important issue facing this country. The system must change. We have the technology. So let’s go and scare the hell out of folk’s in the name of good medicine, good living and good healing. In a properly reformed health care system granny would get the colonoscopy she needs, be spared the colonoscopy that's more likely to harm than help, and if she is diabetic she would be treated early with diet and exercise counseling. That way, if she likes them, she'll get to keep her kidneys and feet. Oh, and for the gazillionth time, if she likes the current insurance administrator that stands between her and her doctor she can keep him too. And we'll all live healthily and happily ever after.

Lisha Barré, M.D.

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