The American healthcare "system" is, of course, not a system at all, but an overfertilized private plot of land, filled with weeds, on which only members of the club are allowed to tread.
Atul Gwande, excellent writer, caught the eye of President Obama with his New Yorker article about McAllen, Texas, which he decries as the locus of iniquity when it comes to medical care, where medical tests are over ordered for the purpose of generating doctors' income with no improvement in medical care. The problem with Dr. Gwande's analysis is he accepts uncritically, the Medicare indices of "quality" as actually being meaningful. He suggests we know what all the good and cost effective practices are and we know what "overuse" means. If we put more pacemakers in, are we over using medical technology.
Of course, this plays to the suspicion that the business aspects of medicine inevitably drive over treatment (read unnecessary treatment with no benefit) and of course, costs.
Arnold Relman, former editor of the New England Journal of Medicine liked Dr. Gwande's article very much because it fit his own concept that when making money becomes a motivator for doctors and for systems, that is inevitably a path down the road to perdition. As Alexandre Yersin (the man who identified plague bacillus) once said: "I could never practice medicine, because it would be like saying to a patient, 'Your money or your life.'"
In this country we argue about whether healthcare is a right or a privilege. Do you have the right to call a doctor at midnight and roust him out of bed, or do you have to pay for that?
If he is a government employee, you have a right.
Of course, 88% of all dcotors in the USA are now employees. But not government employees. They've fled in some way, the business model of medicine and voted with their feet.
Dr. Crile of the Cleveland Clinic, thirty years ago said all doctors ought to be on salary. To which the wags replied, "Would be very happy, Dr. Crile to be on your salary."
Dr. Relman asserts, quite rightly, the insurance companies add nothing of value to American healthcare. If every health insurance company employee disappeared tomorrow, patients could and would still be cared for without so much as a hiccup in the halls of hospitals and clinics.
But there are 15 million health insurance employees pulling in the neighborhood of 300 billion dollars a year. What would President Obama do if he suddenly had 15 million unemployed health insurance people to deal with?
Dr. Gwande found some pretty venal examples of the pursuit of money by doctors who demanded kickbacks for admitting their patients to a particular hospital. But he does not seem to appreciate the difference between that clearly reprehensible act and the doctor who tells his secretary to insist patients with questions about care make appointments to talk about them in the office. For Dr. Gwande's perspective, those doctors are just raping the system, insisting on an office visit because they get paid for a visit but not for a phone call. Is it not possible that telephone medicine is actually poor quality medicine? Is the motivation always so clear?
Years ago Dr. Gwande had another experience with quality of care. He visited a clinic for cystic fibrosis which had been "rated" as one of the best clinics in the country. He did rounds with the head of the clinic who upbraided a patient, put her into tears, because she had acquired a boyfriend, started living life and was not inclined to do her pulmonary toilet on nights she spent with her boyfriend. This doctor put it to the patient: "What are you doing to keep this clinic number one?"
So the "quality of care" was achieved by driving away patients who do not perform. Improves your statistics. All Gwande could see was the rank of the clinic.
Gwande, Relman and others who have never really practiced "In the trenches," love the Mayo Clinic, where physicians actually get together physically to talk about a patient right when the patient is in the clinic. What he misses is the scene at the airport where the Mayo Clinic shuttle picks up loads of patients as if they are hauling Las Vegas tourists, bringing them in to the maw of the institution. Money drives Mayo, too. It's just better disguised.
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