A Second Opinion on Healthcare

Medical Homelessness

2011-01-05T12:47:00.000-08:00

It has now been 6 months since I returned to the US following my 3 month roving locum in New Zealand. I knew I would need time to process the experience and to reintegrate into my former personal and medical life here, but I was surprised that I was unable to pull some thoughts together for the blog until recently. I’m normally a verbal sort of guy, and this was my first encounter with the dreaded “writer’s block”. I’m sure it was the result of re-entry into the surreal world of US healthcare.

In many ways, the most jarring part of this re-entry occurred in the first few months as I resumed clinical practice here in the US. The differences between Kiwis and Americans in patient attitudes, trust, demands, sense of personal responsibility and perhaps most telling, willingness to take ownership not only of their own health but also for participation in providing health care for fellow citizens all presented a stark contrast.

And as for the US health care system itself, I found it astonishing that the proponents of President Obama’s recently passed but inadequate and compromised “Patient Protection and Affordable Care Act” (PPACA), had more or less declared victory and changed the subject. There had been an enormous amount of activity in the run-up to reform but to me it all seemed to be tantamount once again to rearranging the deck chairs on the Titanic. The fatal design flaws and hubris at the helm remain in place--even as the recession continues to grip the country, unemployment benefits are held hostage to making tax breaks for the wealthy permanent and even the “insured” are being squeezed by higher and higher shares of premiums that provide less and less. And nowhere is there any talk of cost containment, let alone universal access....

In lieu of meaningful systemic change, micro-reforms are being touted as the next new thing. Nothing is literally or figuratively more descriptive of the shortcomings of these “innovations” than the so-called patient centered medical home.

Several months ago, writing in the Journal Health Affairs, a group of colleagues at Group Health Cooperative in Seattle shared their experiences with developing and implementing a new primary health care model termed the “Medical Home” . The concept of the medical home is to improve the primary care delivery experience for both patients and care providers in a number of ways, including:

improved access,
more timely and efficient communications,
application of coordinated--often electronic--record keeping,
quality improvement through implementation and tracking of care standards,
employment of active case management.

Many of these “new” ideas incorporate functions of successful past primary care practice models that unfortunately have become increasingly rare or that were seldom carried out in real world primary care practice due to manpower shortages and to a fundamental incompatibility with fee-for-service reimbursement.

In large health systems such as Group Health’s, every dollar spent on implementing the medical home, $1.50 in savings was reported to be generated. Intangibles such as patient and provider satisfaction were improved. And overall, the quality of care was shown to be better than less organized or proactive methods of organizing care. None of which in and of itself is a bad thing.

But in spite of this, there is the compelling argument that such a model cannot be properly implemented without fundamental reform of the current financing structures presently in place in the US. In fact, reform proposals such as the medical home beg the question. While there are interesting elements contained in these models, this sort of local restructuring fails to address fundamental structural issues surrounding the underlying unfairness of the health care financing system--both from a reimbursement and funding perspective. Without some kind of universal health care financing scheme, as before, only select populations will derive any benefit from these innovations. The vast majority will still be faced with arbitrary, capricious market-based insurance manipulations that will continue to threaten many with inadequate coverage or bankruptcy even as their health care needs are most pressing.

On a personal level, I find it ironic that even as there is more and more talk of things like a patient centered medical home, there is no meaningful structural change taking place that might allow such measures to benefit patients across the board. As a result, I feel increasingly alienated from the unchanging chaos of US healthcare even as I simmer with anger at the ongoing manipulations of the political process by powerful entrenched vested interests in the insurance, pharmaceutical, hospital and medical care industries (which includes doctors) and the politicians who represent them.

I knew it was a risk, experiencing a functioning (even if imperfect) health care system like New Zealand’s, but I didn’t think I’d be left with this feeling of medical homelessness. It’s like returning home to an implacably fractious, dysfunctional, mean-spirited extended family after visiting distant relatives who live in a far more organized, harmonious, compassionate fashion.

I guess in retrospect that I shouldn’t be completely surprised. I met a few US doctors while I was there that had opted to relocate to New Zealand permanently to practice medicine. At the time I didn’t really understand what would compel them to take such committed action.

Now I do.

In fact, in an effort to better understand my initial exposure to the NZ health system, I have decided to return for a 6 month single site engagement--this time with my family--to take a more in-depth look. It’s hard to know what will come of it, but I feel that I have unfinished business there, and frankly, there is no compelling model of care--even in spite of some of the recent microinterventions--to fully engage me here.

2010-05-30T03:50:00.000-07:00

An Open Letter to Tony Ryall, Minister of Health, New Zealand.

Dear Mr. Ryall,

It’s funny, everything here in New Zealand is so informal--up to and including patients and physicians calling each other by first names--that I almost feel like I should begin this letter with “Dear Tony”. After all, we met briefly at the rural general practitioners network conference in Christchurch in March and since then, I have been participating in New Zealand Locum’s “roving locum” program, so that would seem to almost count as the basis for informality in New Zealand. But I don’t feel comfortable with such a salutation. You have an important and honorable position and I would like to formally take a moment to give you some professional feedback and advice based on my 30 years in primary care and on my 3 months here in New Zealand.

Before we get started however, I must weigh in on the above photo. Maybe it “goes”, but I’m not sure all the stripes really work for you. Just a thought from a casual observer. But I don’t really want to go into sartorial issues with you, I think it’s healthcare that occupies us both.

From the very outset, I’d like to thank you and your fellow New Zealanders for affording me with the opportunity to participate in your care and become part of your communities, if only briefly. To say that the experience has been rewarding and reinvigorating would to be an understatement. I had the privilege of practicing in four different locations and I was uniformly impressed with the common sense, intelligence, industriousness, respectfulness, and dignity of the people I met.

In a broad sense, as part of your enormous political responsibility, you are tasked with caring for these people as well.

In recognition of that fact, I thought I’d share a few thoughts with you as to how I think you may better accomplish this lofty mission.

1. Continue to push for more primary care physicians and to generally support primary care, especially in rural settings. GP’s are the base of the health care delivery pyramid and if you look at almost any measure of health outcomes, countries that have a robust primary care network deliver better, more cost effective care. Your ROMPE program (rural origins of medical preference entry) is an innovative and proactive way to address the workforce needs of the country in the future. As is the Voluntary Bonding Scheme whereby students can benefit from debt relief if they practice in rural areas. And finally, your recognition that Integrated Family Health Centers may offer a means to provide more care for rural patients in the community setting is forward thinking. Anything you can do to further support and retain the hardworking GPs of New Zealand will benefit everyone.

2.Think about further modifications to or outright abolition of co-pays in the GP offices. To be frank, I’m not sure how you would do this financially, particularly given the philosophical approach that underpins the recently promulgated National Party budget. But here’s some food for thought: the preponderance of research shows that co-pays or upfront fees, particularly at the primary care portal of access, constitute an impediment to accessing care, especially for those who are most socially vulnerable. In three months, I witnessed several occasions when patients were actually turned away from a primary care practice for inability to pay upfront. Quite aside from the ethical quandary that this poses, it doesn’t make financial sense in the long run as patients are effectively shunted from cost-effective primary care to more expensive portals of entry such as the A&E department (ER).

3. ACC. Now this is a topic everyone loves the warm up to. I must say, that the ACC accident and compensation scheme is a brilliant way to fund and run a no-fault insurance program. It effectively almost eliminates litigation, and circumvents those who have a self-interest in fanning the flames of such. Unfortunately, because of the presence of user fees as discussed above, patients occasionally invoke an injury or accident to justify their physician visit. As with any type of insurance, the gray areas on the margins always seem to become a battleground. If New Zealand had a comprehensive bona fide single-payer system, like, for example, Canada’s, the need for differentiating an accident or injury from a medical problem would be obviated. Just a thought.

4.Procedure Wait Times. So as not to be repetitive I refer you to my recent blog post about this. (http://kwisecondopinion.blogspot.com). I just can’t help but think that a better approach to some of the unacceptable wait times in the public sector is to put more organizational effort, and yes, if necessary, money, into improving that sector of care. “Better, sooner, more convenient”, right? The tacit or surreptitious promotion of private insurance and private sector health care will ultimately prove divisive and uncontrollably problematic. You need look no further than the ongoing chaos in the USA for a harbinger of your future should you continue to promote this misguided approach.

5. Pharmaceutical policy. I would strongly encourage you to abolish direct-to- consumer advertising by the pharmaceutical industry--and for that matter, the health supplements industry as well, with their flagrantly unsubstantiated health claims. There is only one other country in the OECD that allows this sort of thing and again, I suspect that you would not like to be subject to the type or magnitude of political power and economic clout enjoyed by the pharmaceutical industry in the USA. Oh, and while I’m at it, please ask Pharmac to list drugs by their chemical, or generic names, rather than trade names in the published list of approved medicines. (Or has this been some sort of bargaining chip in the price negotiation process?)

I could go on, but those are pretty much the highlights of what I feel could be improved in the New Zealand health system at least from a primary care perspective.. Some of it, I know, it’s politically or economically untenable but that’s always what’s been said in the past about many reform proposals.

Probably most importantly of all, however, is that I simply wanted to ask you to be ever mindful of your responsibility to care for your fellow New Zealanders. Because even in the short time I was here, I was struck again and again by the fact that your fellow countrymen are indeed an extraordinary group of people. As the health minister for these people, you have a solemn obligation to care for them in the best possible way.

I wish you luck in this endeavor and I hope in some small way that this constructive feedback helps you attain that goal.

Best regards,

Ken Fabert, M.D.

2010-05-27T01:12:00.000-07:00

"Better, Sooner, more convenient"..................But for whom?

Welcome to Medtral New Zealand. We are a Medical Tourism company specially set up by New Zealand physicians to provide people living in other countries with access to world-class surgery and aftercare in some of New Zealand’s leading private hospitals.

These high quality non acute medical procedures are available for significantly less than what they would cost in other developed countries such as the USA and Western Europe.

At Medtral New Zealand, we’re committed to ensuring the whole Medical Tourism process is as smooth and stress-free as possible. We handle everything for you, so you can focus all your energy on getting better.

Before your operation and while you are recuperating, you have the opportunity to enjoy some of the many pleasures New Zealand has to offer the international medical tourist

"Better, sooner, more convenient?"

That's the current National Party inspired catch phrase for improvement in the health sector. I heard it from the health minister Tony Ryall when he spoke in March at the rural GP conference in Christchurch. I see it as the title of the annual report of the Pinnacle General Practice Network, a PHO on the North Island. I see it frequently in the newspapers. But I still have to ask myself, why is the well orchestrated drumbeat of the slogan so pervasive? The simple answer is politics, but it probably also strikes a resonant chord with citizens and practitioners alike. The truth is that in New Zealand as with any other health system things are not perfect and the goals identified in the slogan are hard to argue with if they're pursued intelligently, honestly, and equitably.

But as you can see by the small blurb that starts this post, there's competition for health resources in New Zealand. The very first entry to my blog was a half facetious reference to my then upcoming roving locum experience as a new kind of medical tourism. Little did I know that the more questionable form of medical tourism had already taken root right here in New Zealand. Of course, the unapologetic entrepreneur would say "so what?". But I would argue that resources are indeed finite, particularly in a small country. And then there is the previously discussed issue of whether health care can even be regarded as a commodity.

What inspired me to reflect on this was the fact that today I had to write my first patient appeal letter to the departmental review boards who try to assign these scarce resources on a priority basis to patients in the public sector who need "elective surgery". This appeal involved an extremely robust dairy farmer who has now been waiting almost a year for replacement of a hip that has rendered him virtually unable to walk due to severe pain (in spite of attempts to control it medically, I might add). When I see for-profit businesses like Medtral, I'm reminded again that "money talks and nobody walks" (or in this case, you could say money talks or nobody walks...)

It's no coincidence that these sorts of entrepreneurial medical activities are occurring in New Zealand. For the past several years the new government has been quietly pushing its agenda to privatize components of the health sector and to encourage the purchase of private health insurance to gain access to expedited private services. Despite the sensible goals of the slogan, the cynic could be forgiven for pointing out the perverse political incentive to keep the public sector on the ropes. The longer people have to wait, the more attractive the "private option" looks.

All this from a government that just recently embraced a budget based on tax cuts and the increase of the GST, or consumption tax. Aside from being increasingly regressive-- the National Party could not even concede that a consumption tax on food is patently unfair -- this budget resurrects the historically discredited idea that tax cuts for the wealthy will somehow miraculously benefit all. In the words of Bryan Gould, a former vice chancellor of Waikato University, writing in the New Zealand Herald yesterday, "The evidence suggests that if the spending power of the wealthy is increased, it does not "trickle down" to the rest of us through greater investment and a keener eye for new opportunities, but manifests itself instead and more ostentatious and unproductive consumption."

Things like joint replacements for wealthy foreigners, while New Zealand taxpayers languish in pain.

I am not as unworldly as someone might conclude by reading the foregoing. I fully understand that the wealthy will demand and create goods and services that are far out of reach of real world people. The Saudi royal family will continue to fly from the Persian Gulf to the Mayo Clinic in MInnesota. Britain with its National Health Service will still have Harley Street, and the elite of Boston will continue to have a Harvard trained subspecialist for every organ system, the cost or practicality be damned. But in countries that are ostensibly democratic, there still needs to be a public conversation about the allocation of health resources and just how these resources are to be put to use.

For instance, Medtral touts the fact that New Zealand is "first world" and "English-speaking". Elsewhere on their website there is even talk about international awards received by New Zealand for being a peaceful place and having very low crime rates.

All these are attributes of a functioning of civil society, not some entrepreneurial endeavor. It is one thing to be proud of these social achievements but it's another to be benefiting from them while the citizens whose taxes and good behavior are the source of this state of affairs--the source of this positive social capital-- receive increasingly rationed care as a result of a politically and ideologically driven push towards increased privatization.

So no, things aren't perfect in New Zealand, but I still think egalitarian cultural traditions, a history of social cohesion, and a robust democratic tradition will allow the people here to address faults and shortcomings in a constructive manner and not be fooled by Reaganesque sabotage of functioning public institutions in favor of market-based illusions that benefit only the elite minority.

2010-05-20T03:24:00.001-07:00

Smoke, Smoke, Smoke that Cigarette

Smoke, smoke, smoke that cigarette
Puff, puff, puff and if you smoke yourself to death
Tell St. Peter at the Golden Gate
That you hate to make him wait
But you just gotta have another cigarette.

by Merle Travis and Tex Williams

As my time winds down here in New Zealand and I prepare for my departure at the end of the month, I’m working hard on a few heavy-issue blog posts about topics like Maori/ Pakeha health disparities and New Zealand’s drift under the new National Party government towards some of the false solutions that resulted in the chaos that is American healthcare today. (Privatization, increased reliance on private health insurance, and judging by today’s new budget proposals and tax overhaul, tax cuts for the wealthy and the fallacy of trickle-down economics.)

But something else caught my eye in today’s Waikato Times, the daily newspaper from Hamilton. For the many of you who no longer read a daily newspaper and kid yourselves that you’re keeping up by grazing web-based content, this is another argument for sticking with print journalism. Today’s paper was full of good, juicy, healthcare related news. The front-page headline was “Patients’ Therapy on Track”, which catalogued the local Waikato DHB’s (District Health Board) progress in improving or attaining numerous health benchmarks ranging from immunization rates, wait times in the emergency room and access to elective surgery, to better diabetes and cardiovascular services. The good news is that the local DHB is doing better and better.

But what really grabbed my attention was one of the benchmark parameters called “better help for smokers to quit”. In NZ, there is real attention being paid to dealing with tobacco as a major driver of death and disability.

Digging even deeper into the newspaper on page 20 was another smoking-related article entitled “Tobacco Ban Rated Life Saver” which highlights a recent public health recommendation from the Otago University School of Medicine and Health Science, Wellington, that all commercial sales of tobacco be phased out by 2020.

I didn’t think that smoking would be one of my New Zealand blog topics, but it’s this kind of forward thinking that gets to the heart of effective public health intervention. After raising the pack price of manufactured cigarettes to over $15 New Zealand ($11 US) last month, a total ban is the natural next step in eliminating this health scourge.

This is a topic that has been near and dear to me ever since the start of my medical career in 1975, because I attended a private medical school in North Carolina called at the time, the Bowman Gray School of Medicine, which was affiliated with Wake Forest University in Winston-Salem, North Carolina, USA. And if you recognize the name of the city as two famous US cigarette brands, you’ll start to understand why I warm up to this topic. In point of fact, not only the medical school but the entire University was underwritten by the Reynolds and Babcock families of Winston-Salem, the owners of the RJ Reynolds Tobacco Co. I’m convinced that it was funded to assuage their collective guilt at profiting so handsomely from a product that so predictably and effectively kills people. It’s no coincidence that the medical school I attended was known for research in atherosclerosis and stroke. There certainly was no shortage of local patients suffering from these conditions as a result of their addiction to the local drug cartel’s product.

In fact, in the spirit of full disclosure, I didn’t escape North Carolina without being addicted myself. But after numerous attempts to quit I finally did and the only thing positive I can glean from the experience has been a credible understanding of what patients are going through who still struggle with smoking cessation. My all too intimate brush with the tobacco industry is also the source of the residual anger I feel at the lies, corruption, and blatant conflicts of interest that provided the institutional backdrop for my medical education.

Interestingly, the medical school has been renamed the Wake Forest University School of Medicine ( more whitewashing?) and to this day, they persist in sending me alumni updates and solicitations for financial contributions. I guess they don’t even read my responses to their solicitations because they keep sending me chirpy newsletters and they simply don’t seem to grasp that the institution is, to my way of thinking, forever ethically tainted.

But I am digressing. Back to the radical proposal: The blunt, get-to-the-point, common sense approach that I’ve come to expect from the Kiwis, comes through in a proposal simply to ban the stuff. In fact the thinking goes further. To limit black market trade, there is an endorsement allowing people to grow their own tobacco if they’re so motivated. It also helps that border control in an island nation is more enforceable than elsewhere.

Why are such measures important? Because young people are still very vulnerable to the glamorization and media manipulation that makes cigarette smoking “cool”. There is also a disproportionate number of Maori citizens here in New Zealand who smoke. Both groups would benefit greatly from significantly curtailed marketing of and access to tobacco. A manufactured tobacco ban would virtually eliminate the 5000 deaths that now occur annually in this country from cigarette smoking. This intervention alone is estimated by Prof.Tony Blakely at Otago University to be “the single most important and feasible action to reduce Maori mortality and ethnic disparities in this country”. Until 2020, additional phase-out strategies could include larger health warnings, a ban on tobacco displays in retail stores, no duty-free imports, and plain packaging (an intervention that Australia is seriously considering implementing in the near future).

It has now been over 15 years since I smoked my last cigarette, but in spite of that my cumulative lung cancer risk is still elevated. (But don’t tell my health insurance carrier, they might cancel me...) For me this issue is personal. Profit-seeking corporations like R.J. Reynolds tobacco sought to kill me with a toxic but “legal’ product. And I was young and stupid enough to think I was immortal or exempt. All the while, they and others like them continue to profit handsomely by peddling their lethal wares. And until now, the corrupt politicians from the killing fields of the Carolinas, Virginia and Kentucky defended the industry. It’s good to know that there’s one place where people are simply saying enough is enough. I truly hope the day will come soon (as I think it is already) when we view cigarette smoking as a bizarre artifact of the past.

Next up, now that we’ve touched on it, the reality of ethnic health disparities in New Zealand.

2010-05-11T03:18:00.000-07:00

Where is the Pain?

Over the past 10 years one of the greatest burdens on US primary care physicians has become pain management. Since the mid-90s there’s been a steady drumbeat of academic opinion that primary care doctors are ignorant of and insensitive to their patients’ pain. It was an easy and seamless transition for the media and the pharmaceutical industry to transform this academic insight into an information and advertising campaign directed at increasing the demand for the prescription of chronic opioid pain medication. By the millennium it was not uncommon to hear from patients that doctors “don’t know anything about pain”-- often followed by demands for opioids,even followed by formal complaints if these demands were resisted.

But just what lay behind the academic assertions that primary doctors were not treating pain and that the drugs were falsely feared and underutilized? Assuming for a moment that there is no conflict of interest in the academic research world (a topic which Barbara Angel, M.D., a former editor of the New England Journal of Medicine has explored in disturbing detail to the contrary), the academicians may be forgiven for being stereotypically ignorant of real-world practice and the problems these recommendations have unleashed. after all they don’t see patients day in and day out in the community setting.

But for the marketing departments of the drug companies it was a very different story. Doctors were told, for example, that long-acting oxycodone formulations, the most heavily marketed of which was the now infamous OxyContin, were less addicting and less euphoria-inducing than once commonly feared. That’s certainly what the marketing team at Purdue Pharmaceuticals was telling physicians during their intensive marketing campaign. The problem was that Purdue had evidence to the contrary which it systematically suppressed. At least that was the verdict of a federal ruling which resulted in a $634 million fine levied against Purdue Pharma’s CEO Michael Friedman and his head Corporate lawyer Howard Udell when they were found guilty of intentionally “mislabeling” the drug. Those who followed this case closely, however, were disappointed that criminal penalties weren’t handed down because not only was OxyContin found to be addictive as result of its euphoria induction, but it was also implicated in a number of deaths stemming from these properties.

The problem is this: between the late 1990s and 2003, accidental poisoning, 90% of which was due to prescription opioid overdosage, became second only to motor vehicle accidents is the leading cause of accidental death in many communities of the United States. Thousands of deaths have been linked to the misuse, abuse, and diversion of prescription opioids, most of it prescribed for subjective non-cancer chronic pain.

There is little discussion about this today but just about any practicing primary care doctor will confirm that as a result of this upsurge in prescribing opioids for the treatment of chronic subjective noncancer pain, medical practice in the US has been fundamentally transformed. Significant time is now required for the monitoring, ongoing pain reassessment, and occasionally, dispute resolution engendered by the upsurge in the use of chronic opioids. When covering for a colleague, the situation becomes even more difficult. And clinically determining the treatment endpoint for a problem that often revolves solely around the patient’s subjective assertion of pain is often frustrating and difficult if not impossible.

The impossibility of the task is highlighted by the extent of the misuse of these drugs. In the Puget Sound region of the US, OxyContin sells for around one dollar per milligram on the street. Recommended chronic pain doses of OxyContin are 20 to 40 mg twice a day with doses of upwards of 60 to 80 mg twice a day for what the prescribing instructions provided by the pharmaceutical company terms “opioid dependent” users. Do the math. There are powerful black market incentives to divert and misuse these drugs. Why? Because someone seeking the euphoria produced by oxycodone can ingest 12 hours worth of oxycodone in seconds by pulverizing and snorting, dissolving and injecting, or crushing and smoking the drug. The abuse potential is enormous.

And how does my experience New Zealand compare with that in the US? In the four communities I’ve practiced in so far, the problem simply does not exist. Patients are more than happy to take a few days of codeine and utilize nondrug management such as immobilization for broken bones. They use ibuprofen or acetaminophen (called paracetamol here) for strains and sprains. And most astonishingly, many are happy to have an accurate diagnosis and prognosis as to the degree and nature of pain, and if it will be mild, they even respond positively to reassurance. And lest you think that I’m callous and uncaring, I have seen a few cases where pain issues were developing and it was addressed after adequate clinical assessment and a care plan was developed.

Are New Zealanders that much tougher than their American counterparts? I doubt it, but there is some recognition that a moment to moment pain-free existence (with euphoria on the side, if possible) is not always necessary or desirable. Could there be an urban versus rural difference? Admittedly, I have spent no time in large urban areas, but some of the highest levels of OxyContin addiction and abuse in the US have occurred in rural states like Kentucky Ohio and West Virginia -- -- so much so that the drug has acquired the moniker “hillbilly heroin”. No, I think it has a lot to do with expectations and, to come full circle, mistaken assertions and unconscionable marketing which has set in motion and continues to perpetuate this serious public-health problem.

And the solution in the US? Meaningful regulation and criminal prosecution of the executives of irresponsible pharmaceutical companies would have a great impact. (The $634 million fine was a fraction of Purdue’s profits and the executive perpetrators vigorously denied any responsibility for Purdue's policies-- blaming the victims, the doctors and the regulators for the problem instead). It also probably comes down to each and every physician taking a hard look at their own prescribing practices. After all, only we can sign the prescription. Helpful too, would be the expansion of detox facilities so that those who are addicted can be properly treated. Additionally,an honest conversation between physicians and patients about the perils of chronic opioids will also be needed. And perhaps most importantly, it will take a concerted education program at both the public health and individual patient level to remind us that pain is a symptom which compels a proper diagnosis as to its source and an exhaustive effort to correct the underlying problem by employing multiple treatment modalities of which chronic opioids are a last, not a first, resort.

2010-05-08T03:41:00.000-07:00

Health Economics 101

In a utopian health system recipients of healthcare would enjoy no limitations on the three corners of the health system resource distribution triangle pictured above. Everyone would be able to get everything ---right away.

But of the three corners of this utopian health system, real world economics only allows you to have two of the three. Different systems make different choices:

In the United States, for example, if you happen to be hyper- compensated corporate CEO, you can get anything you want immediately. But obviously this isn’t available to everyone. In fact the US seems to have consciously and comfortably chosen not to attempt to provide health care for all.

In another system such as New Zealand, just about everyone can get everything, but it’s definitely not available right now.

Developing countries like Vietnam offer everyone a modicum of immediate care but there are significant limitations on what is available.

The final permutation of this health system resource triangle is what’s found in much of the impoverished world where very little is available to anyone ever.

I can actually think of no health system that even attempts to attain all three aspects of this triangle. And when you reflect on it, only the goal of providing care for everyone is without pitfalls.

Take for example, the immediate provision of care. I know of a patient in New Zealand who had deteriorating cardiac function due a heart valve problem. For her to obtain even basic diagnostic studies such as an echocardiogram and consultation with a heart surgeon entailed delay. During this time aggressive medical therapy (medicines) was undertaken and the patient was monitored closely. Over time, she responded well to medication and improved significantly, to the extent that surgical heart valve replacement was no longer necessary. In the US I’m certain that this patient would have undergone open-heart surgery and valve replacement sooner than later. It may still come to that in this patient’s case but it can be done in a measured, deliberate fashion. I am also convinced that had the medical therapy failed, there would have been enough elasticity in the system to move forward urgently with surgery. Sometimes immediately, while quite seductive, is not always the best approach. I frequently tell patients that time is a powerful diagnostic tool but for it to have its full impact there must be open lines of communication, a trusting physician -patient relationship, and easy access for repeated reassessment.

Everything can also have hidden costs. CT scanning, for instance, has become the standard in many emergency departments in the United States for assessing a multitude of problems such as abdominal pain and head trauma. There is now a growing awareness, however, that the significant amount of radiation delivered during CT scanning actually has significant carcinogenic potential. Well studied assessment and risk stratification tools such as the physical examination are often very much underutilized because of the clinician’s perceived lack of time and increasingly, a lack of understanding of or training in basic bedside clinical assessment.

The underlying principle behind the inability of any health system to satisfy all three corners of the resource triangle has to do with the fundamental driver of all economic activity: scarcity. Ultimately, resources are scarce and economic and ethical decisions must be made by any society as to how these resources will be allocated.

Just as important in health arena is the fact that demand for health services is what economists would term inelastic. Elastic demand on the other hand, is something that someone can forgo without significant adverse impact as price increases. An example of this would be dinner at a Michelin three-star restaurant or a Mercedes roadster. Inelastic demand would include such items as food and, of course, healthcare. A person with a burst appendix or the parent of a child with meningitis is simply not in a position to be concerned about price or, for that matter, quality comparisons in the way that the proponents of market-based healthcare seem to think.

The reality is that every society makes choices about their health system and the inevitable compromises that must be made. Relying solely on the false analogy of applying market principles to a perfectly inelastic demand curve with human rights and ethical dimensions simply makes no sense---unless you are a shareholder in a for-profit health insurance corporation. Economically rational solutions such as a single payer health plan have been systematically thwarted in the US and this betrays the extent to which the decision-making and implementation process have been a hijacked by a self-interested elite.

The recently enacted Obama “reforms” seem to have been a political necessity in the face of vicious right-wing attempts to destroy not only the health policy reform efforts but his very presidency. I fervently hope in the four years that will elapse before implementation of much of this legislation, there will be a more thorough, intelligent, dispassionate, and successful national dialogue about real changes that will benefit those who are still being left out of the lower right-hand corner of the triangle. We can do with less (maybe even stay healthier) and we don’t need everything right away, but the ethical and economic imperative to cover everyone will be the cornerstone of any meaningful reform.

2010-05-05T12:58:00.000-07:00

The Ultimate Threat to Human Health

One of my chief diversions after putting in a 10 hour day at the Otorohanga Medical Center is reading. At present, I’m sampling a collection of posthumous essays by Bruce Chatwin entitled What Am I Doing Here. Like everything he did and wrote in his all too brief career, these fragments pulsate with creative energy and mischievious unpredictability. When I saw the title of this book, for example, my conventional instincts wanted to place a question mark at the end of it. But of course that’s not how Chatwin operated and just like the way he lived, his book leaves you somehow dangling and unsettled with the grammatical and punctuation tease of its title.

Let’s suppose for a moment, though, that there was a question mark. What am I doing here? What first sparked my interest in this place? I’ll leave the personal and existential aside and talk about the very first time my curiosity about New Zealand was piqued. I can pinpoint the date precisely because New Zealand appeared on my radar when then Prime Minister David Lange had the audacity to stand up to the United States military and forbid the entry of U.S. Navy warships into New Zealand waters if they were powered by nuclear reactors or carrying nuclear weapons. Of course official US reaction and response to this request was to refuse to confirm or deny the nuclear status of any given US warship. There then unfolded a steady deterioration in relations between New Zealand and the US which culminated in New Zealand’s expulsion from the ANZUS alliance in the South Pacific. Shortly afterward, in 1985, French secret agents blew up the Greenpeace ship Rainbow Warrior in the Auckland Harbour because of its stated intention to monitor nuclear testing by France in the South Pacific. This has been, as historian Michael King put it, the first and only act of state-sponsored terrorism against New Zealand.

As a result of this dedicated antinuclear stance in an era characterized by increasing anxiety about the growing possibility of nuclear confrontation occurring between the United States and The Soviet Union, New Zealand was held in high esteem by those of us who refuse to believe that nuclear brinksmanship is a rational way to conduct foreign policy or promote the survival of the species.

A few years later in the early 90s while living in Beaufort South Carolina, I was asked to serve on a CDC citizens advisory committee on the health effects of the Savannah River Site, which is one of the two US Department of Energy /Department of Defense nuclear facilities built to produce plutonium, highly enriched uranium and the hydrogen isotope tritium. (The other is on the Columbia River in Hanford, Washington). I was pleasantly surprised to come to the conclusion that there was no credible evidence of increased cancer incidence in the immediate area surrounding the Savannah River nuclear facility. Based on several tours of the facility, however, I found it chilling to see the sinister artifacts of the Cold War like decommissioned, but still radioactive, reactors and nuclear waste from that time forward that has yet to be dealt with in any remotely definitive manner. Of course, the most logical approach of all to dealing with this deadly residue, often with a half-life calculated in thousands of years, is not to produce any more of it in the first place.The hubris behind the assumption that present levels of containment and monitoring will be feasible over such inconceivably long time frames is mind-boggling and betrays an almost delusional optimism that present political stability will persist ad infinitim.

There doesn’t seem to be much conversation about this issue anymore. But there are still enough nuclear weapons located at the Bangor nuclear submarine base in Keyport Washington, less than 10 miles from my home on Bainbridge Island, to end human history. The macabre local joke is that Kitsap County which encompasses both Bainbridge Island and Keyport, is the world’s third-largest nuclear power. Sometimes it just seems a little surreal to fuss over someone’s blood pressure or sprained ankle virtually in the shadow of weapons whose sole purpose is to vaporize human beings by the millions.

And speaking of millions, the replacement cost of the Ohio class nuclear submarine pictured above (taken from my sailboat this spring in Puget Sound as I was compliantly changing course) is estimated to be upwards of US$4 billion. There are a total of 18 such submarines and service in the U.S.Navy. 14 of which carry a up to 24 Trident submarine launched ballistic missiles each with up to 12 multiply targeted warheads, etc., etc. Quite aside from the sole purpose and mission of these weapons, the financial outlay is staggering. In a perfect world this would purchase a lot of healthcare. Maybe it’s just the burden of empire, but just maybe it’s also a failure of imagination that keeps us from envisioning a future that embraces an alternative to mutually assured destruction and putting our resources to better use to improve the future, not obliterate it.

So good on ya, New Zealand, for barring the grey metal boats from your waters. Maybe this memorable act of courage will inspire other countries to also take a stand against the ultimate cynicism that underlies these weapons of mass destruction---potentially the ultimate epidemic.

2010-05-04T05:05:00.001-07:00

Darryl Sabin, Joe Mullen and Dad

Yesterday on the New Zealand One television channel a brief feature was aired about the tragic injury and astonishing recovery a young man named Darryl Sabin. Darryl sustained a severe dramatic brain injury while playing rugby. For some time his survival and then later, any meaningful recovery was in doubt. But the combination of skilled medical care, intensive physiotherapy, community support, unrelenting family love and involvement and most importantly his sheer will to live, resulted in Darryl’s gradual ability to regain speech and mobility.

Even though his injury occurred during a rugby match, Darrell has turned to that very sport for further inspiration. And that sport has in turn supported him to the extent that the coach and players of the New Zealand national rugby team, the All Blacks, have given him a seat with the team on the sidelines on the injury bench. It turns out that he has been as much an inspiration to his heros and they have been to him. As a physician and a human being I found the story of Darryl’s will to survive to be truly inspiring. Equally inspirational was the extent to which his family, community and society supported him.

I guess I’m always attracted to a story like this because my life too was strongly influenced by an equally tenacious and inspirational person with an equally amazing tale of recovery: my father. In August of 1954 the United States was swept by yet another wave of poliomyelitis, the dreaded summer killer. My father, 33 years old at the time, was unfortunate enough to contract this disease literally months before an effective vaccine was available to the populace. At the time I was 18 months old and my brother was 3 1/2.

At first my father was in a coma. Several days later he awoke in an iron lung with quadriplegia. At this point medical team at Cook County Hospital in Chicago was unsure if there was much hope of progress and they were not optimistic about his long term prognosis. To hear my father talk about it, however, he insisted that he knew even then that paralysis was simply not an option. In the ensuing weeks he regained most of the use of his upper extremities and was able to breathe on his own. But he still remained paraplegic.

He was then selected for a research program which was to incorporate intensive physical therapy in an effort to rehabilitate patients who were considered “older” victims of disease. For the next year we drove back and forth to Illinois Research Hospital (which later became University of Illinois -- Chicago) for daily physical therapy, mosty in the pool. Dad frequently said that Boot Camp in the Army during World War II was a cakewalk compared to the rigors of his rehab. And I don’t think I ever saw him get in a swimming pool in all the years afterward. But within a year he was able to walk again without braces or crutches, his disability betrayed only by a pronounced limp and a markedly atrophic leg.

And how did we fare financially and socially as a family? As it turns out, my father had been hired by a specialty steel company in Chicago Heights, Illinois, as a promising metallurgical engineer who had recently used the G.I. Bill to finish his studies at Case Institute of Technology (now Case Western Reserve) in Cleveland Ohio. As difficult as it is to believe when viewed from a 21st-century US perspective, my father’s employment with that firm was never interrupted and he never missed a paycheck. His boss, a man named Joe Mullen, whose name I’ve heard spoken reverentially but who I never personally met, insisted that our family be supported during this health crisis. There was no disability policy, no social health network. There was only the decision of one man to do something compassionate and vital.

To me, this is a reflection of an entirely different set of corporate ethics and a level of humanitarian engagement that simply would never occur today. Had something like this happened to us in contemporary America, I would have grown up in poverty. The Joe Mullens of that era were part of an entirely different corporate culture. Rather than blindly and obsessively pursuing a so-called fiduciary responsibility to maximize profit for abstract shareholders and investment entities, this corporation still had a human face.

Of course, there are other social entities that can mitigate risk and invest in human outcomes. The story of Darryl Sabin is an example of how societies can be organized to take care of the less fortunate. In New Zealand, the social infrastructure still exists to allow for happy endings. Unlike the America my father knew, it is almost certain that today in the USA, such a positive outcome would be far less likely for many and unimaginable for many more.

This is not a foregone conclusion.It is the logical extension of the misguided policies that relegate caring for people and families to faceless corporate entities. Nothing short of the wholesale reorganization of the health system in the United States will allow us to reliably care for those in such situations, without subjecting them to unbearable social stress and financial hardship or ruin. As I have said before, as a nation we have the treasure, the talent and knowledge. It is ultimately a question of moral courage and political will. Unless we change, there will be fewer and fewer happy endings.

2010-04-30T03:44:00.000-07:00

California Dreaming?

A Case Study in the American Malaise.

So just what is wrong with America? Of course, there are those who think nothing is wrong; who over the past 10 years have been the beneficiaries of the greatest redistribution of wealth--to the already wealthy-- that has ever occurred in the history of the Republic. But there are those whose experience has been different and who have faced the reality of an increasingly elusive and withering American Dream.

What does this have to do with healthcare? The answer is: a lot. One of the fundamental determinants of the health of the country’s population is not the number of physicians or even the money spent (US spends more than 17% of GDP, far more than any other country, and gets at best variable and mediocre results), no, the biggest determinant of overall health is distribution of wealth. Where there are gross disparities in income and wealth, there are predictably gross disparities in health outcomes and health status as well.

Sometimes it takes an artist, a bona fide writer (unlike me) to truly shed light on things as they are. I recently received an essay from a friend and Silicon Valley writer, Gary Garvin, who puts it far better than just about anything I’ve read. The link to his full essay, “Gloriously Pointless”, can be found at http:// rggblog.wordpress.com. Particularly poignant to me is his observation about how much money has flowed through Silicon Valley without leaving any enduring legacy of community improvement for people like Mr.Garvin, his family and the students he teaches in the community college system of California. Here’s an excerpt from Mr. Garvin’s essay:

‘One of the factors that has shaped my life and which has gotten progressively worse is the hassle of going from A to B, the stalls, the noise, the urgent, massive crowding. The freeway was rough everywhere, with cracks and patches and asphalt warps, reminders we might be living on borrowed time. Still, the scenery was pleasant once we put the Silicon Valley sprawl behind us, the bare, softly rolling hills, fully green from winter rain, soothing and sensual. Yet the hills would turn dead brown in the coming rainless summer, as they always do, and it was hard not to think of grass fires, the Oakland fire, mud slides, and earthquakes, the faults beneath the smooth veneer of the California landscape.

Traffic, of course, is not a big deal and it is much worse elsewhere. We get used to it and put this irritation aside. It would be madness not to do so. Earthquakes seldom are a big deal either, and most who have lived here long enough don’t pay much attention. We learn to roll with the punches—this is what defines the California character—yet after thirty years I still haven’t settled in, and each time I feel a tremor, something inside me slips a bit.

I wonder what else we have inured ourselves to, with what effects.

I am worn out and dispirited, for personal reasons I won’t bore anyone with. I will, however, look outside. Part of the problem, mine and ours, as with freeways, is the size and complexity of the facilities and institutions that determine the course of our day-to-day lives, the distance, separation, and simplifications—and chaos—these can cause. But I haven’t heard much discussion about issues of scale, and our solutions tend to larger schemes.

An enormous amount of money has poured through Silicon Valley the last decades without beneficial effect on its environment or the quality of its life and culture. Now many of us are scrambling, and if we took the time to leave the freeways, we would find more of us are doing much worse. Yet all these years, prosperous and lean, the state has gone through a series of budget crises, the current one the worst. Services have been cut, the infrastructure left in varying states of disrepair. Public schools have endured perpetual hiring freezes and layoffs, and program cancellations and increases in teacher loads. Like earthquakes, budget shocks have become a permanent part of our economic climate. But that cannot be a problem of size, but of priorities, or of something else we have not looked at and factored in.

I have taught at seven schools, three of them with some reputation, and the experience has not been wholly rewarding. Faculty at all are competitive and contentious, the departments specialized and divided. Not only is there no mechanism in place to give support and recognize basic needs, the language does not exist to express them. The humanities can be less than human, and sometimes inhumane.

I am not alone. Many I know of my age, in teaching and in other professions, here and throughout the country, are in the same shape and they voice similar concerns. Like me, they didn’t see it coming.’

So why doesn’t the money “stick”, or the culture cohere? Is it because taxes and cooperation are for suckers? Is it because the era and legacy of Ronald Reagan so thoroughly legitimized greed and the obsessive pursuit of self-interest that there is simply no thought paid to giving back or belonging to something larger than our own reflections? And the corollary question is: as a result of this spiral of social disintegration, have we totally lost our bearings and connection to any physical place or community? I fear that, ultimately, when this happens it is only one more small step to losing even more fundamental human qualities such as compassion and caring. How often in the past three decades have we heard those who are less fortunate callously dismissed as mere “losers”? Are we becoming a nation of a few haves and many losers?

So ask yourself: Is this the America I’ve always believed in? If not, where do we go from here? I think many of us would agree that the current path is not one we would care to continue on to its logical terminus. Not only our health but our very survival as a civil society depends on changing course. Are we up to it? Do we have the moral strength and political courage? In many ways, a health care system is an indicator of so much more. It is really nothing less than a reflection of how we chose to live and what we hold dear.

2010-04-29T04:55:00.000-07:00

The Tall Poppy Syndrome

You can’t spend much time in New Zealand before you hear about the infamous “tall poppy syndrome”. It seems to be part of the psychological fabric of this country and most would agree it has a meaningful influence on the national psyche here. The problem is that people differ, often vociferously, on just whether this a good or bad thing.

What is the tall poppy syndrome? It’s the widespread feeling that individuals who are, quite literally, outstanding, or persons that have distinguished themselves in some way, have somehow violated the social contract to remain part of the group. There is a deep mistrust of success with the implicit suspicion that it is attained through tainted means involving varied degrees of self-promotion, aggressive behavior, manipulating connections, or bending the rules. Unlike the United States with it’s myth of the ‘rugged individual’ and the self-sufficient pioneers, New Zealand has a long history of a significantly more social and egalitarian ethos. In his definitive history of New Zealand, historian Michael King quotes the late 19th century New Zealand politician and later High Commissioner to the British government,William Pember Reeves, who stated in his 19th century history of New Zealand entitled, The Long White Cloud, the following regarding the liberal reforms of the late 19th century that resulted in New Zealand being the first country in the world to grant universal suffrage not only to women but to indigenous people:

‘They were the outcome of a belief that a young democratic country, still almost free from extremes of wealth and poverty, from class hatreds and fears and the barriers these create, supplies an unequaled field for safe and rational experiment in the hope of preventing and shutting out some of the worst social evils and miseries which afflict great nations alike in the old world in the new’.

This in a nutshell summarizes the political and social underpinnings of a centralized governmental system that influences the character of New Zealand society even to this day. Of course, this was the Anglophilic, Pakeha (European) perspective in New Zealand. From the standpoint of the systematically displaced and neglected indigenous population, the Maori, this sort of egalitarianism was simply not a reality in late 19th century New Zealand-- less than 40 years after the Europeans perpetrated systematic treaty violations and widespread land grabs, often by military force.

But ironically, even in traditional Maori culture there have been values that contribute to a more communitarian and cooperative ethic than is found in more competition-based societies. The Maori concept of utu, the practice of achieving balance and reciprocity in social and political affairs, is, oddly enough, in alignment with the more egalitarian aspects of Pakeha culture and governmental institutions. Utu was often translated during the era of Maori/Pakeha conflict as “revenge”. But, to quote Michael King again:

‘it more properly means reciprocity or balanced exchange. Utu determined that relations among individuals, and between families, communities and tribes were governed by mutual obligation and an implicit keeping of social accounts: a favor bestowed which increased the mana (prestige) of the donor, required eventual favor in return from the recipient; and an insult by one, real or imagined, also activated an obligation to respond in kind’

As warfare between the Pahkea and Maori abated and violent intertribal conflicts diminished, the concept of utu became ritualized with cooperative and competitive endeavors between Maori communities throughout the country becoming the norm.

As can be seen, there are powerful traditions in New Zealand among both the Europeans and Maori that oppose the emergence of “tall poppies”. Whether this is a good or bad thing depends on who you’re talking to. There are those who argue passionately that New Zealand has low standards for excellence and simply cannot compete economically and academically with more individualistic, competetive and aggressive values found in places like the United States. For others, the vast wealth disparities and lack of social cohesion-- and even dysfunction-- that frequently afflicts community and political life in the US (like with health care!) are seen as examples of why the tall poppies are undesirable.

Of course, both sides are right. As in all things, the trick is finding a critical balance between individuality and community cohesion. In the arena of healthcare, the system in New Zealand certainly is more coperative and socially based than that of the US and has, I believe, much to teach us. On the other hand, the innovation and pockets of excellence that can be found in the US offer models for change and improvement that could benefit the delivery of healthcare here.

To me it really comes down to just what sort of tall poppies are cultivated or tolerated. If it has to do with granting someone the intellectual or artistic freedom to innovate and excel, I’m all for it. But if, as is so often the case in the US, the tall poppies are merely self-important, arrogant egomaniacs from, for example, the corporate CEO caste or the entertainment world, who actually believe that their day-to-day activities are worth millions of dollars per month to society, then I truly hope New Zealanders continue to prune those plants in the community garden quite carefully.

Every individual is unique and has talents and dreams that should be allowed to flourish, but we must also understand that we are fundamentally social beings and that we are deeply rooted in the soil of social cooperation. Indeed, without that cooperation, we would not have achieved the things we have, nor in all probability, would we be here at all.

2010-04-23T02:02:00.000-07:00

You’re Dead Wrong, Jay Inslee (D -WA, 1st)

Last summer as the infamous town hall meetings played out across the country, I experienced my initiation into the world of health care reform and public politics. In the gymnasium of the North Kitsap High School in Poulsbo, Washington, I was one of

thousands of concerned citizens who turned out to hear our congressman, Jay Inslee, Democrat, 1st Congressional District, Washington referee a public meeting on health care reform. From the outset it was clear that there was a well orchestrated contingent that was bent on disrupting the proceedings and propagating well scripted lies and disinformation about the issues. As my name was called to comment half-way through the proceedings, I experienced my political debut and transcended my normal reluctance to address public audiences. After I got the microphone and in the brief time allotted to me, I tried to refute as much of the disinformation as possible and to frame the case for meaningful single payer reform. It was clear, however, that even the “liberal” Democrat Congressman was not really invested in medically meaningful reform.

I must commend Mr. Inslee on the way he handled the fractious and potentially disruptive crowd. However, I was disappointed but not entirely surprised when he concluded his summation by reaffirming his belief that litigation is a means by which the quality and the integrity of healthcare can be assured. The right to sue, according to Mr. Inslee, is to be preserved to achieve this goal.

This philosophically blinkered and transparently self-interested perspective (he is a lawyer, after all) is among the greatest reasons that the US health care system is so completely dysfunctional. (Aside of course, from the predatory practices of the health insurance industry--but that’s a topic for another time). Alternatives such as universal health insurance which obviates the need to sue for expenses, or socially regulated, truly mutual, no-fault, non-profit insurance schemes were just not on his radar.

Of course, to listen to the academic discourse on health care costs might lead one to conclude that he is right. Frequently stated in the press, in think tank statements, and amongst the policy wonks is the notion that the cost of litigation contributes very little if anything to the runaway costs of health care in the United States. Author Tom Baker, a lawyer, in his book, The Medical Malpractice Myth, published by the University of Chicago (no less) states blithely that “the real problem was too much medical malpractice, not too much litigation”. He dismisses the impact of manifest and hidden costs of malpractice litigation as an “urban myth”. Aside from the obvious failure to transcend professional bias, Mr. Baker is part of a wider academic failure to comprehend the very real day-to-day impact of what has frequently become nothing less than a system based on adversarial patient care.

He is not alone. Academicians such as Greg Bloch from Yale, are quoted as maintaining that at most 2% to 3% of the multi-trillion dollar health-care expenditures in the US are attributable to litigation and defensive medicine. That translates to “only” $55 B per year. How much care would that provide in underserved areas of the US? Such analysts even tout their dual law and medicine degrees, but it is a safe bet that such people have never once had to deal with the ethical and financial dilemmas that are a daily routine in real-world medical practice in the US.

The reality is that the toxic influence of adversarial patient relationships and the spiraling mutual distrust that characterizes many patient-physician encounters in the US has utterly poisoned the formerly advocacy-based and sacred physician-patient relationship. Any lawyer or academic apologist for this adversarial, litigation-based system that is rampant in the US has never walked a centimeter in a clinician’s shoes. If they had, they would understand that the implicit threat and the mutual wariness that characterizes most clinical encounters in the US are destructive to the very foundation of any sort of rational, humanistic, population-based, not to mention effective, healthcare delivery.

This also results in the paralysis of clinical judgment, the undermining of collaborative treatment and results, at its very heart, in the destruction of the very power to heal. And it is yet another example of the cynical reduction of health care to a commodity that can be manipulated for personal financial gain as a part of the self-perpetuating and ultimately self-defeating cycle of self interest that is slowly destroying American healthcare. And this is not just a 2% or 3% proposition.

Of course, if you ask a lawyer like Jay Inslee, they see themselves as a last bastion of hope in the defense of hapless consumers who are subjected to the routine callousness and arrogance of the medical profession. Life is just one continuous John Grisham novel where self sacrificing lawyers are the only ones who truly care. In fact, the health care policy literature is rife with statements by legal academicians to the effect that litigation is the last best hope for quality assurance and high standards in healthcare. It simply does not occur to them that there are other far less self-interested, costly, and destructive means to the same ends. How on earth can a 30% contingency fee be a tool of health care quality assurance or reform? In fact, a truly dispassionate observer might rationally conclude that the role of litigation and its manifestly adverse impact on the very foundations of health care are not only misguided but ultimately constitute nothing less than a parasitic extortion racket with no concern whatsoever for improving the health or wellbeing of the nation’s citizens.

If there are any lawyers reading this blog who made it this far, I make no apologies, because the effect of this perverse worldview is enormous on clinicians. Perhaps there is fertile ground for researchers less encumbered by conflict of interest or legal indoctrination to explore just to what extent quantitatively this perverse arrangement actually has on healthcare delivery and cost. However, as a physician who in almost 30 years of practice has never been sued, (probably a combination of competence, common sense and luck) but who has witnessed conscientious, compassionate, humane colleagues utterly destroyed by capricious law suits served up on a whim by self-interested lawyers, I can tell you again that it’s a far more more than 2% to 3% impact. Qualitatively, the day-to-day impact on physicins is enormous. And that’s not an “urban myth”.....

I have no personal animosity towards Jay Inslee. In fact, during the brief conversations I’ve had with him, I like the guy. However, the legal profession and the lawyers who become politicians in disproportionate numbers have imposed an antagonistic worldview on our society that simply doesn’t mesh with our better instincts to cooperate and to care for one another. I am convinced this is one of the many reasons that the healthcare “system” in the USA is so irretrievably broken and so impervious to meaningful reform.

Perhaps we need more teachers and plumbers and farmers and poets in Congress. (As well as the sweeping campaign finance reform needed to bring this about.) Perhaps we need to work conscientiously to recapture the communication skills and trust and caring that are central to effective health care delivery. But clearly the present way is not satisfying or satisfactory for doctors or for patients. There will probably always be doctors who are arrogant, incompetent or uncaring. And there will probably always be patients who simply cannot establish a relationship based on trust. But for us to build our entire health system on the cynical premise that is the basis for the misguided adversarial approach we are now taking, is a prescription for therapeutic failure and financial ruin.

Local Politics in Paradise

2010-04-19T04:45:00.000-07:00

The late great Tip O’Neill, the former speaker of the US House of Representatives from the US state of Massachusetts once famously observed that "all politics is local". Confirmation of that pearl of wisdom was provided once again last week during my locum stint in the small town of Takaka, which is idyllically situated on Golden Bay in the northwest corner of the South Island of New Zealand. Nestled between Able Tasman National Park and Kahurangi National Park (home of the famous Heaphy Track) and isolated from the nearest city of Nelson by a long tortuously twisting two-lane road reputed to make for the worst driving New Zealand, Takaka has developed a superb and somewhat unique model for health care delivery to its community. The Golden Bay way of doing things has also seen the winds of change that have affected numerous practices and communities throughout New Zealand. Specifically, with the establishment of district health boards (DHBs) and primary health organizations (PHOs)discussed in one of my previous posts, there has been a trend towards standardization, centralization, and in the eyes of not a few, loss of local and professional control. To complicate things further, these two entities, the DHBs and the PHOs are thought by some to be engaged in a power struggle to define their roles and dominance, while the oversight boards of both tend to consist of political appointees, who are often felt not to be entirely dedicated to transparency or democratically responsive or accountable to those their decisions most immediately affect.

One week before I arrived in Takaka, a tentative agreement was reached between various stakeholders in the region, community, and the physicians that will change the delivery of care in this small somewhat isolated place. Specifically, the doctors of the Golden Bay Medical Centre (GBMC ) became employees of Nelson Bays Primary Health, the local PHO. But there was also dissent in the practice and ongoing concerns about professional control, community input, and transparency of management have continued to be a source of controversy and concern.

At issue is the attempt to consolidate the freestanding medical practice, ambulance services, local senior center, and small community-based chronic care hospital. A decision has been reached to move ahead with construction of an integrated health facility at the site of the old hospital 2 km out of town that would encompass all of the services. Unfortunately, this will involve relocating the senior rest home and moving the medical practice from its present downtown site. The primary driver of the choice of location is that it represents the least expensive real estate option for the DHB.

These decisions were reached by a group called the Interim Management Group (IMG)which is made up of representatives from the Nelson Marlborough District Health Board, the trust in charge of the rest home, the GBMC community trust and professional members of the Golden Bay Medical Center. In seven days there will be a community meeting in Takaka presenting the final proposals to the community. There is also another community meeting, organized by a group of dissident citizens, scheduled for April 20. High on the list of concerns is loss of community control and transparency of the process.

In response to those in the US who think that a single-payer plan such as New Zealand’s represents monolithic socialism I would only point to the community engagement so evident in Takaka. What I saw there goes to the very heart of participatory democracy. There is a real struggle afoot to try to reconcile uniquely tailored local solutions with the greater integration, standardization and economies of scale that large organizations can offer.

In a perfect world every community would be able to strike a delicate balance between these countervailing forces and come to a consensus about the best way to proceed. Despite some of the heated opinions and passionate arguments I heard from various sides of the issue, I’m actually quite impressed that the commitment of the community will translate into further expansion and enhancement of the high-quality institutions that already exist.

The integration project’s IMG in their public summary that appeared in the April 16, 2010 Golden Bay Weekly, states that they are happy that the proposal meets the future health “needs’ of the Bay. They also believe that it meets the “wants’ as well. Or as three of the physicians from the GBMC said in their public announcement of their change in employer to the Nelson Bays Primary Health (PHO), “We anticipate that this will be a challenging journey but feel it’s an excellent opportunity to further the provision of health care in our community into the future”.

After the dust has settled I’m confident that Golden Bay will continue to build on its tradition of excellence in healthcare. I hope the community can also look back with pride on its active participation in the process and on the degree to which it demonstrates that, quite simply, they care for one another. Tip O’Neill would be proud of this place.

Stress and Health

2010-04-12T03:45:00.000-07:00

Twenty years ago in Japan, cardiologists first described a unique form of heart failure called Takotsubo cardiomyopathy. Cardiomyopathy is a weakening of heart muscle and can be caused by a number of pathological processes including viral infections, diabetes, and most commonly, coronary artery disease. But in the case of Takotsubo cardiomyopathy, the only causal factor that could be consistently found was extreme emotional stress such as the loss of a spouse or loved one. As a result, the base, or apex, of the heart balloons out and causes pain and reduced pumping capacity. And as a result of it's only apparent cause, this cardiomyopathy has also been referred to as "the broken heart syndrome". It has been estimated that up to 1 to 2% of admissions to US coronary care units can be attributed to this pathologically enigmatic disease. http://www.mayoclinic.com/health/broken-heart-syndrome/DS01135

But how can stress alone cause acute cardiac decompensation? It appears that there is a substantial decrease in microvascular circulation as well as an associated increase inflammation-- both of which have been associated with such problems in other cardiomyopathies. In my own clinical practice I've seen patients with no risk factors whatsoever develop sudden heart attacks when informed of catastrophic loss. As I tell patients, we are not simply biomechanical entities. Our emotions and our responses to the environment around us have an enormous impact not only on how we feel, but also how we respond physiologically or pathophysiologically to external stressors.

If acute emotional stress can precipitate a cardiomyopathy, what impact can long-standing stress have on overall health of individuals? Or more specifically, in the context of the stressful unpredictability of healthcare in the United States, what impact might this have on the overall health of our population?

These sorts of questions have been on my mind recently as it has become apparent to me that not only are the New Zealand patients I am seeing less stressed about their healthcare, I too, am feeling less stressed in this place. Maybe it all has to do with a less adversarial and more cooperative society, or maybe it's simply due to a far lower population density than I'm used to, but I have the distinct impression that overall levels of stress here are lower. When you think about it, how could that not be? Patients here don't have to worry on a week-to-week month-to-month basis about their employment status and its impact on their ability to provide healthcare for their families or themselves. Nor do they have to worry about the impact of healthcare on a proposed job change, geographical move, or, for that matter, an entrepreneurial or creative endeavor. Ironically, a comprehensive socially-based health plan such as that found here in New Zealand affords its citizens far greater social mobility than that found in the United States. There is no "job lock" due to pre-existing conditions, no impact of health insurance on career choices. So much for Tea Baggers' concerns about "freedom". As with so many other things, they've got it backwards.

When I think about stress and its impact on the health of specific populations, I can't help but reflect on the seven years I spent in Beaufort County South Carolina caring for a significantly African-American population. Over and above the contributions of diabetes,obesity, and smoking, I saw a disproportionate number of people who had remarkably high blood pressure that was often treatment resistant, despite progress in treating the other associated problems. At the time, an occasional patient would tell me that it was all due to stress, to which I often gave less credence than the presumed physiological causes. But now I'm less sure that those patients weren't right. Generations of poverty, lack of access to healthcare, and yes, racial oppression may well have had a far greater contributing role than I was willing to admit or address.

I now wonder whether the same can't be said for the entire USA. Certainly we spend more money per capita on healthcare than any other country on earth, but in spite of that we have significantly worse outcomes. This can be broken down ethnically, geographically, and socioeconomically but I still wonder whether the stress of life in a country where many people are, to use Barbara Ehrenreich's term, "nickeled and dimed", (or worse...) doesn't play a far greater role than is appreciated by the purely biomechanical research paradigm most often utilized to investigate such medical problems.

Just maybe, if we were to embrace a more comprehensive, universal, humane health system such an overarching adverse risk factor for collective bad health could well be reduced or eliminated. Studies clearly show that one of the greatest predictors of the health status of a population is distribution of wealth. Perhaps the corrollary, collective stress, is equally important.

As for me personally, I will be monitoring my borderline elevated blood pressure to see if my personal perception of reduced stress translates into something physiologically demonstrable. I think it might....I'll keep you posted.

The New Zealand Way

2010-03-31T19:02:00.000-07:00

It seems that patient dissatisfaction is not unique to the US. Last week in New Zealand’s third- largest city, Christchurch, a middle-aged family man named Neville Toohey, decided to go on protest-mode after a long simmering feud regarding a claim with New Zealand’s ACC (Accident Compensation Corporation) for back problems. His public demonstration consisted of climbing the Christchurch Cathedral steeple, barricading himself inside, and unfurling a banner stating how he felt he had been mistreated by ACC (he used a less genteel word) and then directing further inquiries to his website. Probably more germane to my previous blog posts is not so much the detail of the disagreement, but how the New Zealand authorities dealt with this act of civil disobedience. The predictable appeals to Mr. Toohey to abandon his protest were made both by church authorities and the police. He declined to obey. Eventually, it was negotiated that Mr. Toohey would descend the cathedral tower at noon on the following day. He complied with this, was arrested for trespass and bail was immediately posted pending a hearing. He was released to go home. Mr. Toohey expressed remorse at lost revenues for the Cathedral (the tower climb is a fee-based tourist activity ) and made a contribution to the church to offset these losses. Most notable was what didn’t happen: there were no SWAT teams, teargas, snipers, or any of the other increasingly militarized tactics employed by police in the US in lieu of rational discussion. This outcome, to me, seems to mirror the reasonable civility and rational approaches to problem solving I’ve seen here so far--even in the face of substantive disagreements.

But just what is the ACC?

The ACC is one of several pillars on which the New Zealand health care system is based. It is a no-fault national insurance program funded directly by the government to cover medical expenses stemming from any accident that occurs in New Zealand. In addition, the rules of the ACC preclude further litigation because both medical expenses and subsequent compensation are provided for. Thus, the absurdities and excesses of an adversarial litigation-driven system of compensation such as that found in United States are simply rendered irrelevant. And even though health policy academicians--frequently law school professors and economists rather than medical clinicians-- downplay the impact of litigation on costs to the US health care system, the corrosive effect of this lawyer-driven adversarial system is pervasive. Just ask any clinician. In a future blog I will address this issue more comprehensively, but for now let’s continue to look at what else makes the New Zealand health care system tick.

As we discussed earlier,a well-organized and well trained primary care base is vital to the rational utilization of healthcare resources. Surprisingly, at the initial point of access, which is often a physician-owned practice, the patient is expected to pay some or even most of the cost of the encounter. Many patients, however, are able to obtain a community health services card so that the co-pays are on a sliding scale based on income. There are also further subsidies available for patients with chronic illness who have more than 12 visits per year.They are granted a high user health card, or HUHC. Despite these subsidies, I was rather surprised to see computer prompts linked to patient accounts which commented on bad debts and previous payment status, but this seems to be generally accepted as a necessary evil to maintain financial viability and overall fairness in the system.This is the only part of the system that requires out-of-pocket payment. And despite the potential barrier to access posed by these copays, my experience thus far is that it doesn’t seem to be a problem--at least in the sites I saw so far. I do want to continue to observe the potential effects of this system. But that’s where the potential financial barriers end.

After being seen by a primary care doctor, all laboratory investigations, radiology tests, emergency hospital evaluations, hospitalizations and surgery are paid for. No deductibles, no co-pays, no maximums.

Recent changes in subsidies have further included “free care under six”, full prenatal and obstetrical care, and recently a nationwide capitation scheme for the state’s share of primary fees. These costs are administered through primary health organizations, or PHOs. PHO’s are one of the primary conduits of the annual national health budget which directly pay GPs and other primary providers.

Another recipient of government funding is the District Health Board, or DHB, which pays for hospital and laboratory services. (This is a simple mandate on paper, but as with hospital systems everywhere, efficient, fair allocation of these funds is an enormous and politically charged task. In fact, the Health Minister Mr. Ryall, recently announced significant budget cuts to the DHBs, stating that more funds are to be devoted to clinical care.)

A third entity that makes up the foundation of the health system is PHARMAC, the Pharmacy Management Corporation. PHARMAC is the national formulary and pharmaceutical supplier. It negotiates directly with pharmaceutical manufacturers for supply and pricing of essential pharmaceuticals. All covered drugs are $3.00 NZ ($2.10 USD) per prescription.This includes at least one, if not more, representative drugs from virtually every modern therapeutic class of medications utilized in modern medical practice. In my three weeks of prescribing in New Zealand, I have yet to feel constrained by the PHARMAC formulary. Labeled on-patent drugs are still available, but at substantially more cost to the patient--just like the situation virtually every patient faces in the US who does not benefit from the advantage of collective bargaining.

Finally, there is a private sector. Occasionally, patients feel that wait times are excessive for elective surgery such as joint replacements. They can then opt to be treated through the private sector, and frequently the wait times are indeed shorter for such elective procedures. The general perception is that there is no quality difference between the private and public sectors, just differences in timing. The spector of a two tiered health system doesn’t seem to have arisen. Not surprisingly, there is a growing health insurance industry for those who seek their care in the private sector. In general, the insurance industry is better regulated here than in the US, but I have heard stories of the usual limitations, asterisks, exclusions, fine print, etc., etc. that have become the stock in trade and major source of profitability of the Health Insurance Industry in the US.

So to summarize, a medical patient in New Zealand can expect the following:

some amount of copayment, if not full payment to access the GP.
If lab tests, investigations, emergency treatment, hospitalization, or surgery are required it is free.
If the patient is pregnant, prenatal care and delivery are free.
If the patient is injured in an accident, the care is free (and subsequent compensation is provided for).
if medications are required, each prescription covered by the formulary is $3.00.

Is everyone in New Zealand happy with this scheme? Obviously not ---at least Neville Toohey isn’t--- but by and large people seem to be satisfied with the basic provisions available to them. There is occasional grumbling, but when I ask New Zealanders if they would rather have a system like that in the United States, the response is a unanimous and unequivocal “NO”.

The New Zealand health system is not socialism. This is an example of an intelligent educated population and leadership understanding that one of the cornerstones of a human rights-based society, as well as, incidentally, a healthy productive creative society, is the social provision of healthcare.

I see words like “landmark” and “historic” used to describe the recent health care legislation signed by Pres. Obama. Compared to the NZ system these legislative reforms are functionally inadequate and morally lacking.

I hope to gain deeper insight into this system as I continue to work here for the next two months. As I do I’ll share them with you. This includes problems and shortcomings, but also the kind of problem-solving that is taking place to keep the citizens of this country healthy and productive.

2010-03-26T03:20:00.000-07:00

The Political Thuggery Of Health Care Reform Opponents Continues

I know I said I would foreswear political commentary and get on with describing the New Zealand Health Care system after having experienced it first hand for 2 weeks, but I am increasingly incredulous as I continue to read the news from home. The sorts of political intolerance I described in my last post have apparently increased and the role of the Republican Party in tacitly approving this outrageous behavior (and even perpetrating some of it themselves) appears to be escalating. First, the latest:

Louise Slaughter, D-NY Had a brick thrown through her district office window in upstate New York. She also received telephone threats of a future sniper attack.

Gabrielle Giffords, D-Arizona. A window was smashed in her office.

Bart Stupak, D-Michigan. Telephone death threats. (And since he pushed through anti-abortion language included in the bill’s final version, we should assume it couldn’t be the “pro life” activists, even though in the past they seem to have had no qualms about supporting the murder of doctors they disagree with).

James Clyburn, D-South Carolina. Sent a faxed picture of a noose, a time-honored Southern symbol of racial intimidation...and more. (Clyburn is black).

And the GOP response? House minority leader John Boehner from Ohio tepidly stated that “ I know many Americans are angry over this health care bill and that Washington Democrats just aren’t listening”. Apparently, in the eyes of the GOP, this militant behavior is the Democrats’ fault. Not much of a condemnation of political violence, is it?

Or are the Republicans conniving to foment civil unrest through further manipulation of public opinion by distorting the size and impact of their fringe elements? Even the Republican National Committee have resorted to loaded imagery and veiled threats when, in a recent appeal to their supporters, they show Nancy Pelosi engulfed in flames as they urge voters to “fire” her. And of course, there’s the Republican Presidential darling Sarah Palin, who tips her hand in very revealing ways, when on her Facebook page, she singles out Democrats for defeat by showing their districts in the crosshairs of a weapon. Nice touch, Sara.

Add all this to the brain-dead obstructionism shown once again by the Republicans in Congress who could come up with nothing better than to attempt to derail the reconciliation process with a number of trivial amendments to the law-- such as banning erectile dysfunction drugs to convicted sex offenders. Now that’s creatively looking out after the vital health interests of the American people.

And finally, there is the Republican effort now underway in at least 13 states to challenge the constitutionality of the new health care legislation as an infringement of “states rights”. Clearly, the Republicans have no historical sensitivity or for that matter, sense of decency, because if they did, they would know that this phrase was the major rallying cry of the racist Jim Crow southern state governments as they doggedly enforced the systematic denial of civil rights to blacks--and then combated Federal efforts to enforce the US Constitution. It is no coincidence that this ugly phrase is once again trotted out by right wing human rights opponents--this time to try to obstruct health reform (even the compromised bill that was eventually passed). This is the sort of politically irresponsible behavior we have come to expect from the increasingly reactionary and irresponsible GOP. It is the kind of political behavior that can rip societies apart. And because of that, it is the kind of behavior that must be challenged in the courts, protested in the streets, shamed in the press and unequivocally punished at the polls.

From this distance, I’m not even sure I recognize the USA anymore. And I can confirm that to outsiders, the country looks increasingly erratic and disturbingly unbalanced. Maybe balance will be restored and maybe the vaunted American resilience will reassert itself, but it’s high time we all speak out for progress and civility and repudiate the tactics of division, fear, intolerance, and inhumanity.

2010-03-25T02:54:00.000-07:00

Party Politics

By now it should be abundantly clear to anyone reading this blog that I’m deeply disillusioned with both the process and result of health-care legislation passed by Congress. For all the reasons I’ve enumerated I do not think this legislation will address the fundamentally unjust way we are attempting to provide coverage for sick people. As I’ve indicated before, the process itself has been tainted by problems ranging from overt corruption to a deplorable Faustian bargain made by the Obama administration with the pharmaceutical industry not to seek a negotiated national formulary, to cite just a few examples.

I need to be very clear, however, that at least I find the rhetoric behind the legislation to be laudable even if it is politically shortsighted and perhaps somewhat disingenuous. At least the Democrats still attempt to appeal to our more illustrious past, our better instincts and our hope for a brighter future (that hope thing again). This stands in stark contrast to the cynical self-serving demagoguery that characterizes the opposition Republican party. The consistent response of the GOP during the healthcare debate has been one of obstruction, disinformation, fear-mongering and in general, an appeal to its adherents basest instincts.

In past weeks, healthcare reform opponents have gone so far as to humiliate and harass a demonstrator in Ohio, who had severe Parkinsonism; they have indulged liberally in racial epithets; and they even spit on John Lewis and Barney Frank, esteemed members of Congress who happened to be black and gay respectively. This kind of rabid intolerance has been not only been tacitly accepted by political opponents of health care reform, it has been actively encouraged.

Bob Herbert writing in the New York Times on March 22 put it like this:

“At some point, we have to decide as a country that we just can’t have this: We can’t allow ourselves to remain silent as foaming-at-the-mouth protesters scream the vilest of epithets at members of Congress — epithets that The Times will not allow me to repeat here.

It is 2010, which means it is way past time for decent Americans to rise up against this kind of garbage, to fight it aggressively wherever it appears. And it is time for every American of good will to hold the Republican Party accountable for its role in tolerating, shielding and encouraging foul, mean-spirited and bigoted behavior in its ranks and among its strongest supporters.

For decades the G.O.P. has been the party of fear, ignorance and divisiveness. All you have to do is look around to see what it has done to the country. The greatest economic inequality since the Gilded Age was followed by a near-total collapse of the overall economy. As a country, we have a monumental mess on our hands and still the Republicans have nothing to offer in the way of a remedy except more tax cuts for the rich.

This is the party of trickle down and weapons of mass destruction, the party of birthers and death-panel lunatics. This is the party that genuflects at the altar of right-wing talk radio, with its insane, nauseating, nonstop commitment to hatred and bigotry.”

Perhaps it is this last phenomenon of right wing talk radio that best highlights how extreme both the rhetoric and the tactics have become. The ‘tea bagger movement’ is really an artificial and highly structured result of a conscious decision to attempt to foment disruption and discord in the run-up to the healthcare debate in Congress. There was nothing spontaneous or ‘grassroots’ about it. (Incidentally, I would like to retract whatever attempts I made in one of my previous posts to be understanding towards these people. Understanding and empathy are values that are completely lost on them.) It has been radio-- with its enormous potential to disseminate falsehoods and foment emotional unrest--that has played a pivotal role in all this. Radio can, of course, be a highly beneficial element of a free and well-informed society, but it also can be and has been horribly abused. Think of the chilling role of radio in unleashing the genocide in Rwanda. And most frightening of all is the way Nazi Germany so skillfully exploited the powerful propaganda potential of the then new medium.

In fact, I can’t help but draw parallels between the kind of rabid intolerance increasingly found in the United States and the slow terrible slide of Germany into its nightmare of genocidal insanity. If you think I’m exaggerating, read Richard Evans’ masterful and highly acclaimed historical analysis, The Coming of the Third Reich. Change the names, the dates and the places and he could be describing some of what is happening in the US right now. And as Bob Herbert points out, all it took was for good people to remain silent. It is indeed way past time that we,a s a nation, repudiate the politics of ignorance and intolerance.

I somehow needed to get that off my chest. But after rereading this, it’s clear and I need to change gears and leave US politics behind. I’m in New Zealand-- with a highly refreshing level of civility, incidentally--and I still haven’t reported on how things work here. (Hint: Kiwis occasionally grumble but they really don’t know how good they’ve got it). Next, the nuts and bolts of the New Zealand health system.

2010-03-20T19:43:00.000-07:00

Half A Loaf

Looking back at yesterday's post written in reaction to my growing realization that meaningful health care reform simply is not going to happen this time around, I became aware that in the process of writing this entry, I violated one of the first maxims of blogging: keep it short and conversational.

All the necessary detail was contained in Jane Hamsher's comparison chart. Added commentary on my part may have been a bit redundant. A pithier summary of the overall state of affairs comes from my PNHPWW (Physicians for a National Health Program Western Washington) colleague and fellow primary care doc, Jim Squire of Seattle:

"I have always said that if you bake up some horse shit to look like

half a loaf of bread, then all you get is horse shit. It all depends on

what your definition of 'loaf' is."

And no matter how you slice it, this half-loaf just isn't made of the right stuff.

2010-03-20T03:32:00.001-07:00

I Read the News Today, Oh Boy.....

I must confess that I’ve been out of the loop. Until just now I missed the latest flurry of legislative activity surrounding the most recent efforts of President Obama and the Democratic Party leadership to move forward with a House reconciliation bill that would allow the previously passed the Senate health care reform package to become law. Unfortunately, despite over three weeks of a virtual news blackout, clearly nothing has changed. The previously passed Senate bill and the last-minute legalistic tinkering being undertaken by the House will do nothing to provide the people of the United States with any meaningful protection from predatory insurance practices, employer health insurance abuses, exorbitantly priced pharmaceuticals, and the very real ongoing risk of adding bankruptcy to the stress and misfortune of serious illness.

Max Baucus's early and vigorous exclusion of meaningful reform proposals like single payer have stuck.

The Senate bill which was really written by Liz Fowler, the former VP for public policy and external affairs for Wellpoint, the nation’s largest for-profit insurance company, is in reality a windfall for the health insurers through direct Federal subsidies and lack of regulatory oversight. In addition to not being held accountable for flogging a fatally flawed product and shamelessly profiteering on the backs of the sick and unfortunate, now the power of the State through the IRS will be employed to compel more people than ever to participate in the insurance industry’s extortion. Rather than providing health insurance itself (or heavily regulating it a la Germany), the Government is compelling it's citizens to buy an intrinsically flawed, market-based product. Rather than building a safer ship or even installing better navigation equipment or improving watch procedures, the Senate bill packs even more passengers onto the Titanic. This ship of fools, too, will come to grief and seal the fate of even more potential victims of the US healthcare system than the estimated 45,000 excess annual deaths already caused by lack of health insurance. The only really good news is that this travesty of “reform” won’t even take effect until 2014. But it’s highly unlikely that this 4 year hiatus will allow for the replacement of this legislation with something like single-payer which could actually save the government $400 billion a year or improve the dismal health outcomes so often found in the US. No, even if the bill passes, I fear the Democratic “leadership” will declare “mission accomplished” (maybe they could stage it on a cruise ship instead of an aircraft carrier) and we’ll be saddled with yet another crazy quilt “system” that reinforces the rest of the developed world’s accurate impression that US healthcare is immoral, corrupt inhumane and just plain bizarre.

Perhaps saddest is the sense of resignation that has resulted in the capitulation of even some of the most passionate advocates of meaningful reform like single-payer. I’m referring specifically to the disappointing announcement by Dennis Kucinich that he would vote for this bill in an effort to get something, anything, passed. I really don’t fault him since he has had no support whatsoever from the Democratic Party. The complete failure of leadership on the part of Barack Obama, Harry Reid, and Nancy Pelosi is simply breathtaking -- and in my most cynical moments I think is simply indicative of the crying need for campaign finance reform and reclaiming our democracy from the power of corporate lobbyists and influence.

I have contemplated trying to enumerate all the problems with the latest legislative effort but it’s clear to me that I will never be able to write anything nearly as comprehensive and succinct as the comparison below that appeared in Jane Hamsher’s blog FireDogLake: http://fdlaction.firedoglake.com/ Ms. Hamsher is perhaps the one political writer I know of who best articulates the compelling case for rejecting the current “reform” legislation.

Here amidst all the propaganda, disinformation, misunderstanding, and willful lies is the naked truth about the woeful inadequacy of the proposed “reforms”. (Thanks again, Jane Hamsher!)

Myth

Truth

1. This is a universal health care bill.

The bill is neither universal health care nor universal health insurance.

Per the CBO:

Total uninsured in 2019 with no bill: 54 million
Total uninsured in 2019 with Senate bill: 24 million (44%)

2. Insurance companies hate this bill

This bill is almost identical to the plan written by AHIP, the insurance company trade association, in 2009.

The original Senate Finance Committee bill was authored by a former Wellpoint VP. Since Congress released the first of its health care bills on October 30, 2009, health care stocks have risen 28.35%.

3. The bill will significantly bring down insurance premiums for most Americans.

The bill will not bring down premiums significantly, and certainly not the $2,500/year that the President promised.

Annual premiums in 2016, status quo / with bill:

Small group market, single: $7,800 / $7,800

Small group market, family: $19,300 / $19,200

Large Group market, single: $7,400 / $7,300

Large group market, family: $21,100 / $21,300

Individual market, single:$5,500 / $5,800^*

Individual market, family: $13,100 / $15,200^*

4. The bill will make health care affordable for middle class Americans.

The bill will impose a financial hardship on middle class Americans who will be forced to buy a product that they can’t afford to use.

A family of four making $66,370 will be forced to pay $5,243 per year for insurance. After basic necessities, this leaves them with $8,307 in discretionary income — out of which they would have to cover clothing, credit card and other debt, child care and education costs, in addition to $5,882 in annual out-of-pocket medical expenses for which families will be responsible.

5. This plan is similar to the Massachusetts plan, which makes health care affordable.

Many Massachusetts residents forgo health care because they can’t afford it.

A 2009 study by the state of Massachusetts found that:

21% of residents forgo medical treatment because they can’t afford it, including 12% of children
18% have health insurance but can’t afford to use it

6. This bill provide health care to 31 million people who are currently uninsured.

This bill will mandate that millions of people who are currently uninsured must purchase insurance from private companies, or the IRS will collect up to 2% of their annual income in penalties. Some will be assisted with government subsidies.

7. You can keep the insurance you have if you like it.

The excise tax will result in employers switching to plans with higher co-pays and fewer covered services.

Older, less healthy employees with employer-based health care will be forced to pay much more in out-of-pocket expenses than they do now.

8. The “excise tax” will encourage employers to reduce the scope of health care benefits, and they will pass the savings on to employees in the form of higher wages.

There is insufficient evidence that employers pass savings from reduced benefits on to employees.

9. This bill employs nearly every cost control idea available to bring down costs.

This bill does not bring down costs and leaves out nearly every key cost control measure, including:

Public Option ($25-$110 billion)
Medicare buy-in
Drug reimportation ($19 billion)
Medicare drug price negotiation ($300 billion)
Shorter pathway to generic biologics ($71 billion)

10. The bill will require big companies like WalMart to provide insurance for their employees

The bill was written so that most WalMart employees will qualify for subsidies, and taxpayers will pick up a large portion of the cost of their coverage

11. The bill “bends the cost curve” on health care.

The bill ignored proven ways to cut health care costs and still leaves 24 million people uninsured, all while slightly raising total annual costs by $234 million in 2019.

“Bends the cost curve” is a misleading and trivial claim, as the US would still spend far more for care than other advanced countries.

In 2009, health care costs were 17.3% of GDP.

Annual cost of health care in 2019, status quo: $4,670.6 billion (20.8% of GDP)

Annual cost of health care in 2019, Senate bill: $4,693.5 billion (20.9% of GDP)

12. The bill will provide immediate access to insurance for Americans who are uninsured because of a pre-existing condition.

Access to the “high risk pool” is limited and the pool is underfunded. It will cover few people, and will run out of money in 2011 or 2012

Only those who have been uninsured for more than six months will qualify for the high risk pool. Only 0.7% of those without insurance now will get coverage, and the CMS report estimates it will run out of funding by 2011 or 2012.

13. The bill prohibits dropping people in individual plans from coverage when they get sick.

The bill does not empower a regulatory body to keep people from being dropped when they’re sick.

There are already many states that have laws on the books prohibiting people from being dropped when they’re sick, but without an enforcement mechanism, there is little to hold the insurance companies in check.

14. The bill ensures consumers have access to an effective internal and external appeals process to challenge new insurance plan decisions.

The “internal appeals process” is in the hands of the insurance companies themselves, and the “external” one is up to each state.

Ensuring that consumers have access to “internal appeals” simply means the insurance companies have to review their own decisions. And it is the responsibility of each state to provide an “external appeals process,” as there is neither funding nor a regulatory mechanism for enforcement at the federal level.

15. This bill will stop insurance companies from hiking rates 30%-40% per year.

This bill does not limit insurance company rate hikes. Private insurers continue to be exempt from anti-trust laws, and are free to raise rates without fear of competition in many areas of the country.

16. When the bill passes, people will begin receiving benefits under this bill immediately

Most provisions in this bill, such as an end to the ban on pre-existing conditions for adults, do not take effect until 2014.

Six months from the date of passage, children could not be excluded from coverage due to pre-existing conditions, though insurance companies could charge more to cover them. Children would also be allowed to stay on their parents’ plans until age 26. There will be an elimination of lifetime coverage limits, a high risk pool for those who have been uninsured for more than 6 months, and community health centers will start receiving money.

17. The bill creates a pathway for single payer.

Bernie Sanders’ provision in the Senate bill does not start until 2017, and does not cover the Department of Labor, so no, it doesn’t create a pathway for single payer.

Obama told Dennis Kucinich that the Ohio Representative’s amendment is similar to Bernie Sanders’ provision in the Senate bill, and creates a pathway to single payer. Since the waiver does not start until 2017, and does not cover the Department of Labor, it is nearly impossible to see how it gets around the ERISA laws that stand in the way of any practical state single payer system.

18 The bill will end medical bankruptcy and provide all Americans with peace of mind.

Most people with medical bankruptcies already have insurance, and out-of-pocket expenses will continue to be a burden on the middle class.

In 2009, 1.5 million Americans declared bankruptcy
Of those, 62% were medically related
Three-quarters of those had health insurance
The Obama bill leaves 24 million without insurance
The maximum yearly out-of-pocket limit for a family will be $11,900 (PDF) on top of premiums
A family with serious medical problems that last for a few years could easily be financially crushed by medical costs

*Cost of premiums goes up somewhat due to subsidies and mandates of better coverage. CBO assumes that cost of individual policies goes down 7-10%, and that people will buy more generous policies.

Documentation:

March 11, Letter from Doug Elmendorf to Harry Reid (PDF)

The AHIP Plan in Context, Igor Volsky; The Max Baucus WellPoint/Liz Fowler Plan, Marcy Wheeler
CBO Score, 11-30-2009
“Affordable” Health Care, Marcy Wheeler
Gruber Doesn’t Reveal That 21% of Massachusetts Residents Can’t Afford Health Care, Marcy Wheeler; Massachusetts Survey (PDF)
Health Care on the Road to Neo-Feudalism, Marcy Wheeler
CMS: Excise Tax on Insurance Will Make Your Insurane Coverage Worse and Cause Almost No Reduction in NHE, Jon Walker
Employer Health Costs Do Not Drive Wage Trends, Lawrence Mishel
CBO Estimates Show Public Plan With Higher Savings Rate, Congress Daily; Drug Importation Amendment Likely This Week, Politico; Medicare Part D IAF; A Monopoloy on Biologics Will Drain Health Care Resources, Lancet Student
MaxTax Is a Plan to Use Our Taxes to Reward Wal-Mart for Keeping Its Workers in Poverty, Marcy Wheeler

Estimated Financial Effects of the “Patient Protection and Affordable Care Act of 2009,” as Proposed by the Senate Majority Leader on November 18, 2009, CMS (PDF)
ibid
ibid
ibid
Health insurance companies hang onto their antitrust exemption, Protect Consumer Justice.org

What passage of health care reform would mean for the average American, DC Examiner
How to get a State Single Payer Opt-Out as Part of Reconciliation, Jon Walker

Medical bills prompt more than 60 percent of U.S. bankruptcies, CNN.com; The Patient Protection and Affordable Care Act Section‐by‐Section Analysis (PDF)

So, if you still think the proposed legislation is better than nothing, you’ll still have four years to wait to see how bad it really will be. In the interim, an additional 180,000 people will die for lack of health insurance; the insurance industry will continue to raise premiums unchecked; big Pharma will continue to gouge consumers and systematically lobby to deprive them of any meaningful collective bargaining arrangements to reduce costs; personal bankruptcies -- often among the insured -- will continue to accelerate; and globally, US healthcare will become even more synonymous with institutionalized human rights abuse through market-based denial of health care. In fact, it will probably be far more than just four more years of this wretched status quo. Through this colossal failure of leadership we may have squandered our very best chance to implement reform for a long time to come. That is, of course, unless we manage to elect a new generation of political vertebrates who will do the right thing. Got hope?

I really regret that I am so comprehensively pessimistic, but I see nothing in this health reform process to convince me that our politicians have anyone’s best interests at heart other than their own. If this were not the case we would see something more meaningful. As hard as it is to say this, I think I understand the anger, frustration and mistrust of the rank and file Tea Baggers.(But far less so their leaders.) Unfortunately, they simply don’t realize the depth of their ignorance and the degree to which they been manipulated by and played into the hands of the very political forces they profess to reject. As I said in a previous post, the solution is ethical, responsive government -- of the We-The-People sort-- that reflects the values and compassion of our communities that really do care for one another. That is really the only way we can join the ranks of all the other developed countries who employ democratic processes to carry out this most vital of democratic functions.

Next, we’ll see how things are set up in New Zealand, with a dose of reality based on a busy week in the trenches in Darfield on the South Island. Not surprisingly, it’s not perfect and there have been a few surprises, but ultimately everyone gets cared for without bankrupting individuals or the government.We'll see how they do it.

2010-03-15T02:55:00.000-07:00

What Chief Inspector Wallander Knew

Although I read a lot, I’ve never been particularly enamored of the police/detective genre. Other than an odd Tony Hillerman or Sarah Paretsky when I’ve been sick or have been looking for diversion on a long flight, I’ve usually put my reading energies elsewhere. Recently though, I stumbled upon the Swedish author Henning Mankell and his acclaimed Kurt Wallander series. I just finished his book entitled The Man Who Smiled. In addition to a riveting plot and well-crafted atmospherics, it unexpectedly contained some moral philosophy from the lips of Inspector Wallander himself.

The story revolves around an extremely wealthy international business tycoon, Dr. Alfred Harderberg (the non-MD type, incidentally) with all the trappings of international Uberwealth: the biz jet, the beautiful-people staff, the architectural splendor, the sartorial perfection, the radiant smile and the intimidating aura and implicit threat of seemingly untouchable power. The problem was that behind the façade of all this wealth and power lay the frozen heart of an inhumane criminal who, as it turns out, was trafficking in human organs. And as he learned about this horrific underworld from a journalist he was interviewing, Wallander felt that he had taken

“a journey into an unimagined world where human beings

and body parts have been reduced to market commodities,

with no sign of any moral consideration.”

The parallels with the United States health care system are inescapable. And it is not an “unimagined world”. Beautiful, perfectly turned out business elites of for-profit insurance health insurance companies are paid tens of millions of dollars annually to issue ever more claims denials, rescisions, exclusions and otherwise come up with mechanisms to exclude the very people who need health care the most. And it is all while carrying out their “fudiciary responsibilites” to shareholders and the non-human legal entity otherwise known as the corporation. As individuals these elites are so insulated from the suffering their corporate power unleashes that they truly appear to have no moral compass whatsoever. Like Harderberg, they too have reduced human beings and human illness to a mere market commodity. This to me is the greatest injustice in an exclusively market-driven healthcare system that knowingly applies a false economic analogy, somehow equating human health with a refrigerator or an iPod. Most remarkable of all, in a political system populated by politicians who are so tainted with corrupt corporate money, it is all perfectly legal--- with little threat to the corporate benefactors of seeing any political effort by their representatives in Congress to regulate or change this fundamentally immoral system.

By 1834 the British Empire had banned the slave trade as morally unacceptable. They finally reached the conclusion that human life could never be bought or sold. In the United States the abolition of slavery was a more difficult process, only to finally be settled through devastating civil war. Why is it that moving in the direction of respecting fundamental human rights is always so contentious in the USA?

It is my fervent hope that my country will finally come to the same conclusion that chief inspector Wallander arrived at in the pages of a detective novel: that human beings ,their bodies and their health can never be reduced to mere commodities to be subjected to the whims of the markets and the elites who control them.

2010-03-14T00:18:00.000-08:00

US Health Care: The Problem.

So just what is the problem with US healthcare? Let me give you an example that is very close to home. It occurred right in my community, a place of education and affluence and also a place where people silently suffer.

The woman who cuts my daughter’s hair immigrated to the US from South Africa a number of years ago. She has always worked as a hairstylist. Her current work situation is structured such that she is a “contractor” who leases her workspace from the salon she ostensibly works for. She is technically not an employee of the salon and as a result, she receives no benefits and no health insurance. She is one of the 45 million Americans whose only health plan, as Alan Grayson, US Congressman from Ocala, Florida, so boldly stated on the floor of the US House of Representatives last summer, is, quite simply: “don’t get sick”.

Unfortunately, she did get sick. It turned out to be nothing serious from a medical standpoint, but she did have an episode of acute asthma triggered by an unanticipated exposure to a neighbor’s cat. Her bronchodilator inhaler was empty and because she had no doctor and no health insurance,she had no choice but to seek assessment and treatment in the emergency room of a major regional hospital. The assessment and treatment of this relatively straightforward clinical situation took a total of seven hours, and resulted in being subjected to numerous blood tests, EKGs, chest x-rays, and other unnecessary tests before finally receiving the simple nebulizer treatment that made her better. Afterward, she was billed nearly $2000 for her medical “treatment”. In a primary care setting, this would have been a relatively routine office visit and would have cost a fraction of the bill she was sent. Worse yet, since she was unable to pay this bill, she was turned over to a collection agency who harassed her and significantly damaged her credit rating. The bill was eventually negotiated down and settled but not without significant stress, aggravation and financial hardship. This scenario plays itself out thousands of times each day in the USA and is the leading cause of personal bankruptcy in the USA. And the majority of those who go bankrupt, DO have health insurance, albeit woefully inadequate.

But this person was lucky. She did not have a life-threatening, chronic illness. For a truly heartbreaking account of what’s in store for people who don’t have health insurance and are unfortunate enough to have a life-threatening chronic illness, I would refer you to the prologue of T.R.Reid’s book,The Healing of America. There he tells the story of a 32-year-old woman who had severe systemic lupus erythematosis (SLE) who died because she was unable to get the treatment she needed due to lack of health insurance.

As Mr. Reid states in his book:

“those Americans who die or go broke because they happened to get sick represents

a fundamental moral decision our country has made. Despite all the rights and privileges

and entitlements thatAmericans enjoy today, we have never decided to provide

medical care for everybody who needs it. In the world’s richest nation, we tolerate a

healthcare system that leads to large numbers of avoidable deaths and bankruptcies

among our fellow citizens. Efforts to change the system tend to be derailed by arguments

about big government or free enterprise or socialism--and the essential moral question

gets lost in the shouting.... All the other developed countries on earth have made a

different moral decision”

It’s time we stop shouting and start caring about our fellow citizens. It is ironic indeed, and not just a little hypocritical, that in a country that still has political arguments about whether it is a “Christian nation”, caring and compassion are so absent from the discussion. T.R. Reid is right: It is, in the final analysis, a moral issue.We have the wealth, the know-how and the technology, but do we have the will to change what is so obviously unjust?

Next, I’ll share a few thoughts on human rights and health care from author Henning Mankell’s fictitious Swedish police detective, Kurt Wallander.

2010-03-13T01:58:00.000-08:00

The Making of a Roving Locum

Like almost all developed nations, New Zealand has a shortage of qualified primary care physicians. Why is this important? It’s because the efficiency, cost -effectiveness, and overall success of a delivery system measured in health outcomes are all directly related to the successful delivery of primary care. Without organized universal access and rational implementation of effective primary care strategies, costs soar and outcomes worsen. And in real terms, it is patients who suffer in proportion to the unavailability of this vital building block of any health system.

Why the worldwide shortage? The reasons that are as varied as the health systems themselves, but it has a lot to do with the hard work, long hours, low prestige, lower pay, socially disadvantaged patient populations, and non-urban settings that are often part and parcel of the practice of primary care.

As with many aspects of healthcare in the United States, issues surrounding primary care are complicated. On one hand, the United States represents the world’s single largest net recipient of primary care physicians trained overseas, often in countries that can ill afford to lose these physicians. On the other hand, there persists in the United States perhaps the greatest maldistribution of primary care vis-a-vis specialty physicians in any healthcare system in the developed world. The World Health Organization recommends that approximate 70% of the physician workforce be represented by primary care. In the US it’s almost the opposite, with the predictable excess expenditures, discontinuity, and general lack of access that all too often characterizes US healthcare.

In New Zealand there are far fewer organizational and systemic impediments to the provision of adequate primary care. With the legislative establishment of primary care organizations (PHOs) in 2001, which provided the organizational basis for the entire country, the philosophical, political, and to some degree economic commitment to primary care was made. Unfortunately, there is still a significant net loss of primary care physicians to countries with higher pay scales, most notably Australia and Canada. In an attempt to provide short-term (and ultimately long-term) coverage, the use of temporary physicians known as locum tenens is common.

There are several for-profit and nonprofit agencies that seek to facilitate the placement of both New Zealand and foreign physicians in such positions. I opted to utilize an agency known as NZ Locums, a nonprofit affiliated with The New Zealand Rural General Practice Network, NZRGPN. NZ Locums was my initial point of contact in the process and I’ve been working closely with them for a number of months to deal with the numerous credentialing, visa, and logistical requirements required to make such a placement occur smoothly. I would like to say publicly that NZ Locums did a great job and was a pleasure to work with.

The final component of my placement entailed a three day orientation during which time I was briefed by representatives of various agencies and organizations that a practicing physician must deal with here. The sessions included presentations by Pharmac, the New Zealand national formulary; ACC, the New Zealand accident compensation scheme;WINZ, the national income and disability program; the Medical Protection Society, a physician advocacy organization in the event of disciplinary action (it should be noted that in the event of malpractice, patient compensation and physician liability are separate and not subject to the contingency-based litigation).

Needless to say, these sessions were invaluable. Equally important was a talk on the day-to-day realities and demands of primary care practice. The orientation ended with an excellent discussion of the growing movement in New Zealand toward biculturalism. This took place in the National Museum,Te Papa, in Wellington. The two-hour tour was led by two extremely articulate and knowledgeable young Maori women who covered topics ranging from cultural issues in medical encounters to the often troubled history of interaction between the indigenous Maori and the European colonialists. I came away from the session with a much better appreciation for and understanding of the past and the new bicultural future being forged here in this country.

Finally, to round out my medical immersion in the New Zealand primary care world I had the opportunity to attend the annual New Zealand Rural General Practice Network conference for 2 days in Christchurch. It began with a traditional Maori Mihi Whakatau, an invocation ceremony of welcome and thanks that includes Waita (song) and the performance of Hongi, the pressing of the nose, a symbolic sharing of the breath of life which brings all together for the event. I was able to meet numerous doctors and even have conversations with a few colleagues from the US who have made longer-term commitments to practice here. Indicative of the personal scale of this country, there was a two-hour session during which the NZ minister of health,Tony Ryall, addressed the conferees and detailed concrete political measures being taken by the New Zealand government to address primary care shortages. (Imagine Kathleen Sibelius speaking to a convention of rural primary care physicians with actual policies to address actual needs!). Most inspirational was the chance to meet New Zealand medical students and registrars (what we call residents) whose intelligence and enthusiasm were really quite inspirational and cannot help but bode well for the future primary care here.

Today I arrived at my first rural placement where I begin on Monday morning. I plan to use my Sunday to practice left-sided driving on the quiet country roads and to gear up for day one.

Walking in Wellington

2010-03-07T01:51:00.000-08:00

Although this blog is not intended to be a travelogue, it inescapably involves physical travel as well as a changing healthcare environment. I had heard that the flight from the US West Coast to New Zealand is almost interminable. I’m here to report that it seemed slightly longer than that. (There is a reason that studies on immobilization and deep vein thrombosis have been performed on passengers flying this route!). Fortunately, I was able to do lots of stretching en route and I did not arrive with any coagulation problems, only some serious jetlag. Even that resolved relatively quickly, however, and when I finally was able to get outside and stretch my legs in earnest, I was greeted by an extraordinarily attractive cityscape bathed in glorious sunshine with temperatures in the 70s. I’ve heard it said before that travelers from the US find Wellington reminiscent of San Francisco with its clear maritime light, hilly bayside waterfront setting and--at least to this Midwestern hick--exotic flora such as palm trees. Wellington has all that and more. Add to this natural beauty a compact density imposed by its location and it’s clear that it’s a place that simply invites exploration on foot.

With a weekend to recover from my jet lag, I opted to do just that. While I was walking past a city hard at play, and enjoying intimate neighborhood street streetscapes I couldn’t help but reflect on the process of walking and its relation to health care. ( You knew I’d work back to this!) Walking is indicative of something vital that we’ve lost and is a potential solution to some of the ravages of the chronic diseases that are increasingly straining our ability to care for our fellow citizens. As with so many things in medicine, it’s really pretty simple: we don’t have wings; we don’t have fins; we are bipedal creatures designed to ambulate. Our entire physiology and structure have evolved for this purpose. And yet, like the obese skeletally atrophic humans many centuries in the future depicted in the recent movie Wally, we seem to be developing infrastructure that makes the exercise of this fundamental physiological skill set almost impossible. Of course the most conspicuous enemy of all is the automobile and the seductive convenience that it allows.In this new environment of left-handed driving an additional threat to life and limb is posed by the fact that every intersection and pedestrian crossing is a hazardous exercise in relearning some very basic pedestrian skills--like looking to the right, not the left when crossing. And as much as I have been telling myself to be very careful, I almost had an incident today that would have allowed me to get an intimate unwanted first-hand exposure to the New Zealand health system.

So even walking has its hazards in my current setting. But I do hope to not only walk as much as possible as a means of everyday transportation, I also hope to experience at least some of the legendary system of “tracks” (trails) that supports the popular NZ activity known as “tramping” (hiking to us).So I hope not only to meditate on walking as a simple preventative health intervention and as a metaphor for more rational health interventions overall, I hope also, if you’ll pardon the cliché, to simply walk the walk.

I may even get a little healthier myself.

Tomorrow starts my 3 day orientation into the NZ health system. We’ll see how it looks.

2010-02-26T17:05:00.000-08:00

Medical Tourism of a Different Sort

No, I'm not traveling to Mexico for a lap band, or to Bangkok for cosmetic collegen injections, or to India for a knee replacement--I'm going to New Zealand to spend three months taking part in a "roving locums" program sponsored by the New Zealand Rural General Practice Network (NZRGPN) to provide rural general practices and practioners with short term coverage to allow them to beef up staffing or take a break.

Why New Zealand? Well, aside from the renowned natural beauty of the place, they have a functioning single payer health system and I have a strong desire to experience, first-hand, how such a system really works. That's the Kiwi part of the blog title.

The second opinion portion of the heading reflects my need to reassess my career professionally and politically. In medicine, it is a time-honored tactic to obtain a second opinion if the diagnosis is unclear or if the therapy isn't working. Fresh thinking and ongoing collaboration often offer new insights and better outcomes. And for health care in the USA, a second opinion is desperately needed. While politicians argue and posture, patients are dying for lack of access to even the most basic care. Last year alone there were over 45,000 excess deaths in the US due to lack of health insurance. If over 1,000 wide-body airliners had crashed last year, we would be seeing more than political wrangling and corporate manipulation.

What will I find in New Zealand's health care system? Utopia? Bureaucratic dysfunction? Probably neither. But I do hope to see another approach to any number of questions such as:

How do New Zealanders themselves feel about their health system?
What do they love or hate about it?
How would they change it?
How is access to procedures and specialists?
What is the approach to end-of-life care?
Is there a problem with abuse of prescription pain killers?
Are there class or ethnicity-based health disparities?

The specific questions are limitless, but I think a general picture will emerge. I hope to learn from these experiences, both clinically and as an advocate for reform at home.

One final note on the blogging process.Those of you who know me personally, are probably astonished to see me embracing this 21st century technology. After all, my data entry skills are notoriously 6th decade. But I can't think of a better way to communicate my experiences to my family,friends and colleagues who have already shown so much interest in what I find.

Bear with me as my skills evolve and I'll try my best both to explore this alternative health care delivery world and to come to a deeper understanding of the past and future of US healthcare.

Welcome!