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
No comments:
Post a Comment