Wednesday, April 5, 2017

Boy, That's Some Good Medicine!

So we really spend too much on health care? Do we, really? Of course we do – just ask anyone, just read anything anywhere, it's up to 18% or 19% of GDP, it's the main employer in lots of communities. If spending on health care dropped the unemployment rate would rise, so it must be wasteful, very wasteful. Our prices are higher by far than other OECD countries, our prescription prices are far higher and protected from competition, that is unassailably true.

And we get less for our money, don't we? All our measures of health and well being are below scores of those of other countries – infant mortality rates, and lots of other measures cooked up by the public health people. And much of what we do is needless, in the ICUs for dying patients, operating on backs that won't improve with the operations, and selling once a day vitamins for that matter – this is true, too. The health of communities is affected by nutrition, sanitation, levels of education and employment, health habits. Medical care hardly matters, by the telling of the public health numbers.

And yet, we keep spending, we keep sending money down that rat hole of delivering health care to people and wealth to hospitals and doctors (except pediatricians and other primary care doctors, of course – we make half of what the specialists make.) We keep spending because the system won't be reformed, because the “silos of greed” won't let us reform. One way to keep the costs down would be to make people more responsible, which in the opinion of some means that we need to keep more than we do off the rolls of the insured, or make them work if they qualify for Medicaid and want to keep that support. Anything to bring down the total cost.

It's true, of course, that nobody wants waste, and nobody wants profiteering. Yet it's also true that all systems have waste of one sort or another. And what else should we be spending our money on, in a prosperous (far too unequally distributed, but prosperous) economy? Football stadiums in Las Vegas?

The night before last Ann and I had dinner with friends on our ship the Silver Wind, headed from Fort Lauderdale to Madeira and thence to Monte Carlo, currently in mid-Atlantic just past the large swells of a northern storm. Ed and Elizabeth had recognized us from a trip three years ago on Seabourne from Barcelona to London, and I recognized them, too, so we made a dinner date which we kept after a few days of rough seas when we ate in our stateroom instead of the dining room. They looked great, fit, alert, active, happy. We had known each other only slightly on that past trip, so we got to know more now. It came as a surprise when Ed said he was 81 because he looked about 69, which happened to be Elizabeth's age. Now living near San Diego, they had gotten together in the 80's when they were both working on the LA Olympics and were married to other people. We agreed that things can get messy, especially with the kids, some of whom forgive and some of whom don't. We wondered how things had been going since we last saw each other, figuring that it had been pretty steady since they looked so good.

Well, not as good as they looked, is the answer. Ed said, “We've had cancer.” Elizabeth had come up with ovarian cancer and had been opened up and eviscerated stem to stern, taken back losing blood quickly a few weeks later when her transverse colon fell apart, and had a big metastatic brain tumor which was excised. And last June non-smoker Ed came up with lung cancer and has been on radiation and chemo and an experimental drug. He just gained back 10 of the pounds he lost during the process.

I told them about my own pituitary tumor. “Oh,” said Elizabeth, “That's a hard place to get to! Mine, they just had to saw off the bone and there it was.”

“His was benign, though,” said Ed. Big difference.

They still travel extensively – they have it down. Ed scouts out the cruises and negotiates for good economy, and Elizabeth deals with the details of the cruises and excursions after Ed sets them up. They live positively, supporting each other and getting closer to one another all the time, taking the time they have. They are frank with the world and very engaging, and look pretty much as I remembered them, but seem perhaps a bit deeper.

So naturally we talked about the care they had gotten. “Scripps?” I asked. “Nope,” they said, “UCSD.” That's the University of California San Diego. Scripps had turned down Elizabeth's surgery at tumor board, but not UCSD. It helped that her brother was an oncologist at Johns Hopkins before he turned to running a clinic, so he could make some calls and connections for both of them, but aside from this inside connection, they are essentially just regular people. Regular people, but they are dealt with like kings. Close teamwork and warm relationships with the doctors at UCSD. For instance, an MRI showed two little shadows in Elizabeth's brain about six or seven weeks ago. They knew that Ed and Elizabeth were coming on this cruise. So they said, let's wait about three weeks and see what's happening. They rescanned then and saw a little, not much, but a little growth. OK, they said, we'll zap them, we'll get our team together and do it a week before you go away, then we'll check you when you get back. Elizabeth remembered at her last operation there were about six doctors in the OR, cooperating. She said that with a little wonder in her voice and eyes.

Cancer has become a chronic disease that is managed. “Yup,” they said, “that's it. So far, anyway.” I told them about Andrea up at the end of our street, who had a bad knee that turned out to be cancerous with a lung primary and brain mets, and who is two years down the pike and looks great and is very active. Chronic disease management, who'd a thunk it.

So, I listen to this, and what dissipates is my concern about the percentage of GDP that health care consumes. I just don't give a shit. Too old to treat? I don't think so. Gotta line up our priorities and wait three years for a new knee? I don't think so. What a wonder! These ordinary people are getting just what they need by people and an institution that cares, cares for them, bends to them, treats them like family. Cut somewhere else, not this!

It reminds me of my friend Bob who almost died twice of heart attacks, had to be cooled down a few days in the ICU the last time a few years ago – quiet a few years now, come to think of it – and who is cared for personally by a young cardiologist whom he loves and who loves him, and who directed him away from the in-house arrogant cardiac surgeon who was going to do valve surgery “now,” but was deflected to another place and another time, just looking out for Bob. (And, by the way, to make a medical care organization wonkish point, she had the freedom to choose where he went, they weren't tied down to one system. Free choice really has a meaning, it's not just a luxury and a delusion.) What's more precious than his life? I can't think of anything.

Or of the less positive story of my brother-in-law Jim, another ordinary guy, who thought he was being treated like a king at Cedars-Sinai although he finally succumbed. My sister Kathy and Jim didn't think their first oncologist was very caring, so they switched and were very happy that they did. Yes, Jim died, but there's a big difference between being cared for and being YOYO – You're On Your Own. Not one of these people feels uncared for, not one has been treated too aggressively (I think), not one has been asked to give something up for the team.

This is what medicine should be doing. I don't want to hear about those goddamn statistics, which I distrust. It is so difficult to make a one to one connection between medical care and the health of a population. The statistics stink – they don't measure everything that takes place with patients like these. The public health people will always produce statistics that show that they should be getting more money, because public health is more important than medical care, no? Economists always want statistics and use what they get – ever hear of one saying that they can't make any judgements because the measurements aren't good? Not often. They'd be out of business. Or maybe I'm wrong and just swayed by the personal stories. I know, I know, the plural of anecdote is not data. But still, there is person after person being cared for, some over-treated, but mostly people working hard to deliver the best.

Is there waste? Yes, you bet. Look at the number of administrators and the salaries, look at excessive fees for equipment and drugs, look at some fat and happy orthopedists who own their own MRI and CAT scan machines. They make too much, and they should be cut down. Are surgeons paid to much and the thinking specialties too little? Yes, I think so, there is an imbalance.

But, we have to appreciate what we have. The system is not all bad, to be junked and rebuilt. “Baby and bathwater” applies here. Lots of what we have is good, and with research is getting better and better. If there's a weakness, it's in implementation and administration, and some profiteering, especially by pharma. That should be attacked aggressively. And we need lots more emphasis on primary care.

But I don't want to see Elizabeth, Ed, Bob, or Jim get anything less than the very best. We're a rich country. We have doctors and others who want to help, who get off on helping others, on doing their best for them, who kvell when something good happens to their patients. Repair, but don't replace. Just strengthen and rationalize some.

Why should they get anything but the best? Hey – these are friends of mine!

Budd Shenkin

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