Healthcare Reform for NeoConservatives

Humpty Dumpty sat on a wall,
When he last had medical coverage, he could not recall,


He noticed a small crack,
seemed like nothing at all...


With money or coverage,
he’d have given that doctor a call,
And they might have taped
or glued up that small crack,
so that old Humpty
could get right back on track,
Or better yet prevented it with a good coat of shellack!


But poor old Humpty had neither money
nor coverage to attend to his needs,
So he went about his business and hoped for the best,
Each effort, each movement put that crack to the test,
But feeding his family left him no time to give it a rest.


It started to spread
and some albumin was expressed,
Though he was neither stupid
nor lazy as some might suggest,
Poor Humpty still thought he dare not be seen,
Cause he knew what such a visit might mean,
Some day he might get coverage
and this visit would be eyed with suspicion,
Being an egg, he feared it might be labelled a preexisting condition.


One day it was too late to fix that dread fissure,
He fell off that wall with a loud crack!
And Old Humpty's future faded to black,
Then King’s men and King’s horses rushed him to the emergency room,
Where you’d think there’d be little to do other than get out the mop or that broom.


But modern medicine has come far,
from the time this story was first penned,
So yolk and shell fragments isn’t necessarily the end,
One month then, two in the ICU,
followed by weeks of rehab,
He slowly recovered but ran up a huge tab.



And on that day when the bills finally arrived,
he wondered if it was truly better that he had survived,
He might now be more fit, and certainly more healthy,
but to pay off his debt he had to sell himself off,
as an omelet to one who was wealthy.


Think that this tale is a fantasy with no relevance to you,
That this is but typical left winger skew?
When those bills start piling up, see how each of you reacts,
Cause next time it may be YOUR nest egg that cracks.



Hope this is simple enough for even a judge or legislator to ken,
And they’ll have enough sense this fate for others to allay,
But I hope they do it soon and don’t dare delay,
Cause soon even all the King’s horses and all the King’s men,
won’t be enough to put the healthcare system back together again...

Think of the Healthcare System as a water pipe...

This is a simplified discussion of some of the challenges to real healthcare reform. In this first installment, I'll review some of our problems, and in the next a proposed solution. So, to start, let's imagine the health care system is a length of pipe...

The length of the pipe reflects a number of factors that determine the time it takes to get treated appropriately: time to get an appointment, how long it takes to figure out what's wrong, time to get tests and referrals, time to see if the treatment is working, etc. This pipeline serves a diverse population. As in the figure below, we can roughly divide the population into 4 categories. The first is the really healthy people - I left them off. The other 3 groups are the people trying to get seen (black), those who can’t afford to be seen (the ones in blue) and the ones who SHOULD be seen but don’t know it (the greenies). Generally, more people are trying to get seen that can be accommodated at a given time.


Why should the greenies be seen? Because the greenies may have an occult condition and not know it: hypertension, heart disease, pre-diabetes, undiagnosed cancer, etc. Or they may be at risk for some ailment(s) that could be prevented if they did the right things. The problem is that it’s hard to get people to do anything when they are feeling ok and the clinicians are already so busy taking care of obviously sick people that there is no time to do much prevention.

Why it Matters

It matters because if the condition is serious, it's a race against the clock. Keep in mind that we are already behind the eight ball because of what’s in the diagram below. Currently, a lot of time has passed from when something starts till when we notice it enough to actually call the doctor in the first place. Then it takes time to do all those things we talked about before - and that assumes nobody makes a mistake or takes extra time.


The importance of the time it takes to decide to do something and for the doc to figure out what’s wrong is reflected in next this graph.


On average, the longer it takes to get something fixed, the worse is the outcome and the higher the cost. It’s really that simple.

So if we want to really reform health care we need to shorten this timeline as much as possible. Take a look at the impact of cost and outcome to a shorter timeline.


If we can accomplish this task of compressing clinical timelines over the course of millions of lives the impact is staggering. Estimates of the cost reductions alone range from 25%- 50% of current levels! Or somewhere between $ 500 billion and $1 trillion dollars EACH YEAR! And that is just in the healthcare costs not all the societal costs associated with disease such as lost work, etc.

It makes sense but how do we do this? Well first off, you don’t just play with the payment structure or throw money at the problem (the traditional single payer approach)


Paying people less to do more doesn’t open that pipe up much. You still have people who can’t get in to the clinic and people who don’t know they need any help, still don't. Single payer may be part of the answer but it isn’t THE answer. Plus concentrating just on the costs results in some really dumb ideas - like taxing clinicians to take care of patients.

Nor can you just build a bigger pipe. Training more docs and mid levels for example takes time and costs a lot of money. Which leaves no money left to care for those without coverage. This is one of the approaches that the professional societies advocate - train more experts. The bottom line is that we can’t afford it.

Plus the bigger pipe may reduce some of the time spent waiting for an office visit but does nothing to reduce the length of the pipe itself - how long it takes to correctly get to the bottom of the problem. More doctors does not necessarily result in better decision-making by any of them.

Some compression of the timeline can be achieved using diagnostic support software. By using decision-support tools to aid diagnosis, we can in essence cut out some of the length of the pipe reducing the time it takes to get the right answer. But that alone, cannot increase the size of the pipe and the rate at which patients can be seen to the levels we need to achieve universal access.

Combinations of these approaches still fall short in some key ways. We still are left with a system we can't afford, that can't serve the whole population.


But the solution, may be in the cloud...

Next time - a cloud computing solution to health care reform.

Ode to the Cure (my 200th post)

An insatiable maw consuming 18% of our GNP;
that it cannot go on screams out like a banshee;
and though we spend twice as much as the very next;
we live not as long and lag behind more than 30 in most respects.

Blame for this state is enough to go around the globe a dozen times;
That it is the fault of another, each special interest quickly chimes;
Patients blame the docs who blame the insurers who blame the feds;
and don’t forget the neocons who claim any fix will make us all Reds.

We can blow up the world more than a thousand times;
We can move an army to destroy a regime for both real or imagined crimes;
We can endlessly debate which path or no leads to heaven;
But we can’t vaccinate all kids or provide simple care for at least 1 in 7.

Suggesting that universal coverage might be a fair start;
Has self-serving pols rattling china on their tea cart;
Some moron can try be be coy by suggesting we must all buy a gun;
A family an illness away from bankruptcy may not be ready to join in his fun;

Legislators are quick with a resonating sound byte;
but sadly they don't really have a dog in this fight;
they pass rules all the time that they don't have to employ;
requiring them to abide by what we get might be a sound ploy.

One things for sure, keep this up and a collapse is near;
Then better hope you need no care for one who is dear;
Tea party nay sayers may celebrate what they claim is for freedom a victory;
but to die from neglect, seems to be for a great nation somewhat contradictory.

As one in medicine’s trenches for a quarter century I know what I speak;
wait much longer and harder will it be to find the care that you seek;
Ignore those who believe the phrase health care reform is a kind of profanity;
To avoid the peril that Einstein reminded defined insanity.

Is there any hope, any direction other than over the edge?
any means to avoid the collapse or a means our bets to hedge?
The answer is yes but the cost will be high, though not in dollars;
The only answer is sure to stir a great chorus of hoots and hollers.

No doubt you have already heard the dire rumors;
We can neither afford nor staff to the levels needed to care for the Boomers;
Not if we persist in our national predilection for acute care late in the game;
Only a shift toward prevention, wellness and early detection will these costs contain.

Bricks and mortar systems are impressive with scanners and the latest high tech toy;
But using robots to cure one while others get nothing, any claim to national greatness must destroy;
The cost of one mechanical heart for a former VP;
could vaccinate thousands of kids from many a working family.

The limits are few on the options for those with means;
but nothing is left to provide the poor with the simplest of health screens;
The rich are told, ‘well here of the list of things that might provide some limited good’;
But to offer the most basic care to the poor a doc must don the cloak of Robin Hood.

Test after test is used to define an insured’s problem in detail;
those without means wait outside an ED to be seen at a pace that would bore a snail;
Clinical judgement and communication has fallen by the wayside on the path to a cure;
Why do one test when three can be had for 10 times the price just to be sure.

Oh yes, a doc will claim that they do too much because they are liable;
but as a real excuse that just isn’t viable;
yes lawyers and suits are a nuisance, that much is sure;
but tort reform isn’t where we’ll find the cure.

The real key to reform is a mindset that must be corrected;
if our rendezvous with disaster is to be deflected;
Less the purview of the doc is the change that is required;
More effort than nothing from the patient is needed lest we remain in red ink mired.

Prevention wellness and optimized care lower cost and improve the quality of care;
But for these the individual not the doc is the one who must the responsibility bear;
The Bard was right when he said that the fault resided in ourselves;
Not as some would claim on a pharmacy’s shelves.

Americans have demanded a system that at ‘goal line D’ gets ever stronger;
So that they can smoke, drink, eat, and veg in front of the TV all the longer;
A life of sloth and neglect requires expensive fixes as is our convention;
Ben Franklin, it turned, out was too conservative by far in the value of prevention.

And it’s not just inattention that has its costs as some choose an alternate who claims to cure with water or prefer some Asian needles;
or crystals or prayer or twists to the spine or the ground carcass of some beetle;
that is your right but should not the failure then be your own?;
not shared with those who prefer the direction that the light of science has shown.

But science is but part for the ability to pour money down a hole with greater precision;
Is not what should drive every health care decision;
It’s more than a question of ‘yes we could’;
But can is not now, nor ever, the same as should.

Everyone dies in the end - a sorry fact from which there can be no buffer;
Medicine blurs the edges between preserving life and extending the time one will suffer;
But for every futile act wasted at the end of one’s time on earth;
solace could come from knowing the savings could help hundreds at the time of their birth.

Why a spiritual nation fears the undiscovered country so much;
is a topic of much interest to those who work closely to death's touch;
for we see every day that there can be far more sinister fates;
than to die whether eternal bliss or the void is what awaits.

We must find a balance far different from what we do today;
more attention to staying well than being rescued is really the only way;
and then we can afford to care for all as befits a great nation;
yet still have enough for acute care just not as our sole fixation.

They say that freedom always comes at a cost and it's socialism we should fear;
but our health care freedom currently runs a tab of two trillion each year;
robbing us of jobs and crippling our industries with insurmountable costs;
but opponents to reform offer nothing but rhetoric while our treasury exhausts.

Should we consider our health as an island that to a greater sphere need not connect?
Or in this was Donne once again correct?
The individual must be responsible for their own destiny as this is the answer not another;
and try to get in the habit of remembering that your clinician is not your mother...