A Country Doctor Writes:

The problem with healthcare, and drug prices, in America isn’t that we spend too much money. The real problem is that we believe we are spending “other people’s money”.

Yes, I was raised in Sweden, but no, I’m not a Socialist. But the irony is that “free” healthcare there is more clearly understood to be directly financed by local(!) taxes that can go up if people in that region consume more healthcare. Here, nobody really knows what anything healthcare related actually costs, or who pays how much, so how can we really care about the cost of healthcare?

Here, most health insurance is financed by employers, and I don’t believe the average American worker is lying awake at night worrying that his family’s medical bills will eat into the corporate profits of his employer. And even if American workers bear some of the costs of their health insurance, the relationship between how much healthcare they consume and how much their portion of the insurance premium will go up is less than obvious, depending on who else is insured in the same risk pool as each particular worker’s employer sponsored insurance.

The Swedes have, in spite of their minimal churchgoing, a set of ethics that relates their personal choices to the impact they have on society as a whole. They recycle batteries instead of throwing them away, they worry about air pollution – so much that it is illegal to idle your car for more than 60 seconds, for example when the bridge over the canal in my home town opens to let a tall ship through. My former countrymen also care deeply about how waste in the healthcare system can affect the availability of healthcare for vulnerable people.

Another thing they are more sensitive about than we are over here is corporate greed. The examples on this side of the Atlantic are so many, and occur so frequently that we soon forget each individual case. What we do retain is the regrettable sense that healthcare is a dirty business where someone is always taking advantage of someone; providers cheat Medicare, insurers cheat patients, drug companies cheat them all.

What we need in this country is a moral wake up call, whether that comes as a crisis or a disruptive innovation. It is obvious that Government regulation and oversight has done relatively little to reduce the “Wild West” behavior and mentality of the big players in our “industry”.

The first thing we need to do is scrap the concept of health insurance, because insurance is when something expensive but unusual and infrequent is paid from a pool of money that a lot more people pay into than withdraw from. In America today, everybody draws from that pool of money, even for things that are completely predictable, like having a baby or even an annual physical (except if you have Medicare, and then you get a Wellness Visit, but that’s another story). That means every single transaction of healthcare in this country becomes a profit center for one or more types of middleman, who most of the time adds little value but draws handsome revenue from what they do.

If we are trying to cover everybody for everything, let’s call it what it is, Socialized medicine. But are we ready, today, for a society where we all stop and consider the common good before we ask for that MRI, “just to know what’s going on”, or where drug prices are negotiated between a “single payer” like CMS or each State Health Department and the drug companies?
I believe the citizens of my adopted homeland prefer to have more freedom of choice than a Socialist system usually offers, and I believe that by having both the ability to choose and the responsibility to pay for services, we can make the healthcare value equation come out more even.

And, I’m sorry, but if we reign in the excesses of insurers and drug companies, American patients may act more responsibly, but as long as the gauging, fraud and abuse continue to be rampant in the industry, there will be no loyalty between patients and “the system”.

Then, our only hope will be a post-apocalyptic Direct Primary Caree model, which is just as American as the corporate model. Come to think of it, maybe even more so…

As a physician with a strong sense of calling, I always see myself working for each patient, regardless of who pays the bill. Following in the footsteps of role models like Hippocrates and Osler, how could I do anything else?

Ted Ross has been my patient for decades. He can’t seem to lose weight.

John Jackson has admitted he doesn’t know how long he can keep doing the kind of work that has supported his family until now.

Ted is a long distance truck driver. He needs a DOT physical. Because of the new requirements, he will probably need a sleep study to rule out sleep apnea. If he fails, he could lose his job, because we all want to feel safe on our highways.

John came in with back pain the other day. As I filled out the Workers Comp M-1 form, he sighed “this may be it for me”.

John told me his back started hurting when he lifted a washing machine at work. As long as his employer’s Workers Comp carrier doesn’t challenge the claim, he’s covered for medical costs, rehabilitation and disability income, possibly even for life. If it had happened at home, on his own time, he would not be entitled to anywhere near the same benefits.

Medicine is a very personal business. A trusted provider hears more than a stranger and his or her words have more impact. Our patients assume we are there to help them. But sometimes we are put in a position of working for someone else, against our own patients.

In Ted’s case, I won’t be the one to tell him that his job is on the line because of his obesity. When the new requirements and certifications for performing physicals for the Department of Transportation went into effect, I simply didn’t pursue them.

In John’s case, as the treating physician, I have to file regular reports with his employer’s insurance company, and every test or referral I want to make has to be approved by them. If I keep him out of work longer than they expect or prescribe more pain medication than the average situation requires, I get a call from an insurance company nurse whose job it is to bring my treatment in line with their expectations.

It is impossible to overlook the fact that his employers Comp carrier is trying to direct John’s care; they are the ones who pay me for each one of his visits.

If other life circumstances come into being while I am treating him for his back injury, I have to be very careful not to spend too much time talking about them, and I certainly can’t put any of it in his record, since every Comp visit goes to the insurance company for review. I have to constantly remind patients that a Comp visit is a legal document, to be used in what amounts to a case of litigation.

If I could help it, I wouldn’t treat Workers Compensation cases for the same reason I don’t do DOT physicals: I never want to represent an authority or institution that can be seen as the opponent of patients I need to have a therapeutic relationship with.

If John’s Comp carrier were to claim that since he went to the Cityside Hospital emergency room with low back pain after a minor car accident ten years ago, he had a preexisting back problem, his medical expenses could bankrupt him. He has a high deductible health insurance. If he can’t go back to work, he will have 26 weeks of reduced-pay short term disability benefits. After that, he’d have to apply for Social Security Disability, which could take several years.

If Ted loses his DOT certificate, how can I be effective as his personal physician with my signature on the document that cost him his career? And if he were to commit suicide, as some middle aged men who lose their jobs do, could I counsel and care for his wife and daughter?

I often think about my native Sweden in cases like these. I saw many things that frustrated me when I worked there after graduating from medical school, but they didn’t have one level of health and disability benefits for injured workers and little or no help for people who got hurt on their own time. That is a pretty arbitrary and inhumane way of stratifying health care.

If you’re hurt, you’re hurt, regardless of whose fault it is. (I’ll tell you about Sweden’s no-fault medical malpractice payments some other time.) And if you seek help from a doctor, you expect the doctor to be working with your best interest in mind. And if the society you live in doesn’t take good care of people who are sick or injured, you may have trouble accepting that your doctor is putting the good of “society” or “the system” before your most urgent needs to put food on your family’s table.