In March of 2013 I wrote Healing the Health Care Cost Conundrum. Four years later, in March of 2017, I have retired from the US Army and am practicing medicine in Memphis, TN. My practice is in the inner city, and our focus is serving the Medicaid population. Our patients are impoverished and often very sick, with chronic diseases frequently showing up 20 years earlier than in their more affluent counterparts. Many live in dangerous communities, have no reliable transportation, and have unhealthy food. Obesity is the norm, violence is taken for granted, and serious mental illness is widespread. It comes as no surprise that many patients abuse drugs, citing chronic pain that may or may not be real. Some come to the clinic for no other reason than to feed their drug habit, and try to get narcotics to generate a little extra income. It is the toughest medical environment I have encountered since my combat tour in Iraq.
Meanwhile at the policy level, Obamacare is proving too expensive to sustain, and just yesterday Republicans in the House of Representatives failed to pass a bill with their plan to reform health care. While the survival of Obamacare causes rejoicing in some and consternation in others, the simple truth is that neither the Patient Protection and Affordable Care Art (Obamacare) nor the American Health Care Act (Republican bill) are health care reform, they are health insurance reform. Both pieces of legislation regulate how health care is paid for, not how it is delivered. With all due respect to our legislative leaders, they cannot improve health care delivery. Only health care professionals can make health care all that it needs to be. This is what those in my practice are trying to do – build a system that can provide quality, affordable, medical care to the poorest Americans. If we can do that, in conjunction with others around the nation striving for the same goal, American health care will be transformed.
Revolutionizing medical care, rather than merely medical insurance, may be a noble goal, but achieving it is like walking from Cairo to New Delhi; long, arduous, and dangerous. One reason for this difficulty is that no matter the education, resources, or social support, humans will be humans.
My Personal Tale
This past week I developed an eyelid infection. I ignored it for a few days, and one evening after a long day at work I decided to do something. Since most medical facilities were closed, and we had no other antibiotics in the house, I took some long-expired antibiotics that had been prescribed for someone else. Taking expired medications can be dangerous, or at least ineffective, and expired antibiotics can increase resistance. I regularly tell patients not to use expired meds or those given to someone else. In this case, I opted for short term convenience, and hypocrisy.
After unsuccessfully trying home care, I went to the Emergency Department at a local hospital. This infection could have been treated more effectively, and far more cheaply, at a local primary care practice. But it was only 6:30 in the morning, too early to call for an appointment. Most practices that we found opened at 8 or even 9, while I had to be at work at 8, and I could not be guaranteed to be seen. So again, I violated my own standards and took a my eyelid infection to an emergency department, costing my insurance about $1,000 instead of about $50.
I tried to be a patient instead of a doctor in this setting, but my secret came out when the nurse asked my occupation. It would have leaked anyway, because medical people talk differently about medical conditions than lay people do. My description of my eyelid as red, swollen, and tender but not painful, was a dead give-away. When the physician’s assistant (PA) came in to examine me, he suggested that Vigamox eye drops would be the best to cure this infection. Even though I thought an oral antibiotic would be a better choice, I was still trying hard to be a patient and not a doctor, so I agreed.
My wife later called from the pharmacy. Vigamox, with a generic name of moxi-floxacin, cost $200 for three milliliters. I was more than a little annoyed; a similar ophthalmic solution of ciprofloxacin would cost $15. Why had the PA prescribed as his first choice something so ridiculously expensive? Word of mouth? Pharmaceutical company marketing? Ignorance of the cost? All of the above? How would this affect others such as the uninsured or the underinsured?
A day later, my eyelid got worse. The Vigamox was not controlling the infection, because it was more widespread than the PA realized. We made an appointment with optometry, and I worked from home. The optometrist prescribed oral Bactrim, which cost $2 at the pharmacy. The infection gradually improved.
The Lessons Learned
This tale of minor misjudgment, multiplied hundreds of thousands of times, is much of the story of health care in America, and around the world. Patients do things that they should not, even when they know better, and do not do things that they should. We opt for convenient care instead of cost-effective care. Had I been faced with the whole bill, I never would have gone to the ED instead of a clinic; I simply would have called in late to work.
Well-meaning but hurried providers make poor diagnoses and prescribe dauntingly overpriced treatments. Because of mistakes in primary care, specialists get involved unnecessarily. Drug companies tout their latest miracle cures, but make no mention of comparative pricing. In fact, no one knows the real price of anything in health care. The ED did not provide a clear statement of the total cost, nor did the optometrist. Further, the prices for me, someone with commercial health insurance, are different than the prices for a Medicare patient, a Medicaid patient, or an uninsured patient.
Quality is an issue. Was the ED that I visited a high-quality ED or not? How did they measure quality? How would I know what the scores were? The PA was a pleasant chap, but the quality of care that I received was lacking. In the absence of metrics, word of mouth rather than clinical outcomes becomes the main quality measure. I went to the optometrist that my mother had recommended because when she saw him, “he was nice”.
An eyelid infection is a relatively minor medical problem. Imagine how much mischief the same combination of human laziness, misjudgment, opacity, and inconvenience causes for more serious diagnoses. Imagine how much these factors contribute to unnecessary expense, and to human suffering.
When I told my daughter, a student in Public Health, my story, she was disgusted. She called it “a personal problem”, but unfortunately the effects are more than just personal. Rather than getting an inexpensive prescription at a primary care office, spending less than $100, I got ED care, an expensive prescription, and specialty care, likely costing well over $1,500. Rather than taking two days to get better, it took five, including time off work and lost productivity.
My foibles are obvious, but they are not unique. I have met few doctors who have never used higher priced care when a cheaper care would do. I have met even fewer doctors who have never taken someone else’ medicine or used expired medicines. Nurses and other health care professionals do the same, and we all know better. Little wonder that patients, who often don’t know better, follow our example.
How then do we revolutionize health care, my stated goal at the beginning of this article?
- By engineering hazards out, including mistakes, misjudgments, and misunderstandings.
- By transparency in quality and pricing.
- By better rewarding good behavior.
- By practicing evidence-based medicine.
- By intentionally using low cost medications and other interventions when the outcomes are similar.
- By making the patient more responsible for costs and outcomes, having “more skin in the game”.
Please also see Healing the Health Care Cost Conundrum for more ideas.
Republicans and Democrats at all levels, local, state, and federal, will continue to fiddle with American health care. Their work is important, but can only address a small part of the problem. We as health care professionals must figure out how to provide quality, affordable, and accessible care to everyone. Using lessons learned from stories like this, we can do it.