June 09, 2009

Culture of Medicine II

The saga continues.

President Obama made some comments in the news regarding McAllen, Texas, suggesting that he read Dr. Atul Gawande's article on "the Cost Conundrum." Indeed, a recent New York Times article "Health Care Disparities Stirs a Fight" confirms this:
The [Gawande] article became required reading in the White House, with Mr. Obama even citing it at a meeting last week with two dozen Democratic senators.

“He came into the meeting with that article having affected his thinking dramatically,” said Senator Ron Wyden, Democrat of Oregon. “He, in effect, took that article and put it in front of a big group of senators and said, ‘This is what we’ve got to fix.’ ”
There's a fundamental difference in approaches between politicians and doctors. Docs are taught to care for every patient as if they were a member of our own family. Perhaps healthcare spending reflects this attitude. Politicians often abuse their constituents as if they are unwanted members of family. Perhaps they are willing to sacrifice X number of lives to save Y number of dollars in an annual budget. I say this only half-jokingly; it is a political necessity to be separated from the issues since there will always be a passionate dissenting group that protests any sort of stand they make. The difficulty, in politics as well as medicine, lies in controlling our emotions so they do not rule our intellect.

But how do you resolve the most personal and emotional issue of all?
I agree with Obama's eloquent response to the question: "Is healthcare a privilege, right or responsibility?":
I think it should be a right for every American. … for my mother to die of cancer at the age of 53 and have to spend the last months of her life in the hospital room arguing with insurance companies because they’re saying that this may be a pre-existing condition and they don’t have to pay her treatment, there’s something fundamentally wrong about that.

What price do you put on the health and welfare of your family? The New York article mentions data that provides EXACTLY what sort of numbers the government has been willing to spend on each person in 2006:
Nationally, according to the Dartmouth Atlas of Health Care, Medicare spent an average of $8,304 per beneficiary in 2006. Among states, New York was tops, at $9,564, and Hawaii was lowest, at $5,311.

Researchers at Dartmouth Medical School have also found wide variations within states and among cities. Medicare spent $16,351 per beneficiary in Miami in 2006, almost twice the average of $8,331 in San Francisco, they said.
Wow! Hawaii? I wonder if the fact that we also have mandatory healthcare (Pre-Paid Health Care Act of 1974) for full-time workers (>20 hours per week) in the nation has anything to do with these statistics. Massachussetts has a cool system too. Unfortunately, I don't know how well it is working out for them with the confluence of crises.

While it might sound appealing to adapt practices Aloha-style... that really would be doing things just for the love of it. A lot of doctors in Hawaii (regardless if they were Hawaiian doctors or not) are retiring, leaving the state or cutting back on their practice because of low reimbursements for Medicaid/QUEST and Medicare patients. So on the surface, it sounds appealing from a political point of view to slash wasteful spending but this can run antithetical to the goal of improving primary care by chasing doctors away.

Another thing that clogs up the gears of the glimmer of hope for Hawaii's healthcare... recently, the Medicaid/QUEST contract has gone out by two Mainland firms: UnitedHealth Group Inc. and WellCare Health Plans Inc. These companies were under investigation in billing fraud and improper claims scandals. Also, there is concern that the 37,000 enrolled aged, blind and disabled patients may have to change providers and lose continuity of care. Waianae and Waimanalo, the two regions on Oahu with the most Native-Hawaiians ironically are the two areas where the Community Health centers have opted out. (citation DENIED, see below)

I hope that the nation does not look at Hawaii for all the answers. It's much more likely that our docs have just gone uncompensated for a lot longer.

(Disclaimer: My commentary comes from the point of view of a medical student trying to stay informed on health-related news while studying to become a doctor in these changing times. As such, notmysecondopinions are not the best source around on health policy! I wish I could provide better local references... unfortunately the archives for the Honolulu Advertiser are on a pay-per-article access of $2-3! That model is detrimental to quick online Google News Searches for proper content.... gr.)

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