More and Less

Let me let you in on one of the basic facts of life, and no, you don’t have to be a doctor to know this one, everybody wants more- more money, more fulfillment from their lives, more love. If you need proof, look in the self-improvement section of any bookstore, or just turn on your television during the day and flip through the channels.
Why do we need more? Well, we need more money so we can get more stuff. Our society and our economy has been based on a simple principle…consume, consume, consume. When we hit a bump and consumer spending dropped the entire world economy stalled.
I hate to admit it, but I’m no different from anybody else. I fell hook, line, and sinker for the lure of “consumermania.” I can even believe that I need the newest two terabyte MP3 player… my crummy eighty gig is way too small, it only holds a thousand or so CDs. Who can put up with that? Unfortunately, as much as I delude myself to believe it is, my need isn’t a real need. I don’t have time to download a hundred CDs, much less a thousand. I have about thirty-seven CDs on my player, and yet I’m gullible enough to believe I need a newer, more technically sophisticated model. With the rapidity of technological evolution in the modern world, this cycle of need and fulfillment is never ending, as soon as I buy the new “two-T”, they’ll begin to advertise a newer model, one that comes with a cell phone in it, and as soon as I get that, there’ll be an even newer model with both a cell phone and a miniature computer in it, and so it goes ad infinitum.
In a lot of ways medicine is the same way, but instead of ego and vanity being the only driving forces, it may truly be that our lives are at stake. We want more and we want better, the heck with better, we want the best. Who doesn’t feel that they deserve the best health care? America is nothing, if not an egalitarian society, in this regard, everybody deserves the best health care, right? I don’t know. Let me pose a hypothetical question, what if there were a drug that was ninety-nine percent effective in preventing osteoporosis in post-menopausal women, and had no identifiable side effects, shouldn’t we give it to everyone that could benefit from it? Sure, that seems like a “no brainer”… but, what if it cost twenty thousand dollars a dose? Ok, well, that does seem a bit steep, but it really would make so many lives better, I guess we still should. The problem is, at that cost, for that many women, most of which will be sixty-five years old, or older, the cost of the drug will bankrupt Medicare in a single year. Now, should we make this wonder drug available to our Medicare beneficiaries? By the way, I hate the term beneficiaries, almost as much as I hate the term, health care provider. These are patients, sweet little grandmothers and mamas, wonderful women, and I am their doctor with this wonder drug that will make their lives so much better. No longer will they have to face the chronic back pain and the debility of nerve root compressions that are associated with the pathologic fractures of osteoporosis. Can I give it to them?
This isn’t a medical decision, medically, the answer is obvious. From a risk-benefit standpoint the drug is amazingly effective, so it’s all benefit with no risk. The only risk is to the solvency of the largest health care provider in the United States. So, this decision becomes not a medical decision but a social decision, a governmental decision, a legal decision, even a moral decision. If the recent financial downturn has shown us anything, it is that consumption has limits, and those limits are imposed by the availability of funds. We are currently in a position that requires that we make a decision on how we will impose limits so that our spending stays in line with the funding available to provide health care.
SGR stands for Sustainable Growth Rate and it's how our federal lawmakers have tried to limit the growth of Medicare costs in the past. They’ve tied the total amount of money that can be expended on Medicare to the United State's GDP or Gross Domestic Product. That means the value of all goods and services produced in the US during the preceding year.
Because our economy is, to say the least, less robust than it was a few years ago and the number of folks becoming Medicare eligible due to baby-boomers pouring in like a damn busted, things don’t work like they did when the law was enacted. The formula stopped working several years ago, and in the current economic environment would be a total disaster. Everybody knows it doesn't work; the lawmakers, the doctors, the hospitals, even the HHS folks who administer Medicare know. Guess who doesn't know? For the most part patients have no idea about the costly, intricate dance that goes on every year, with doctors and hospitals spending millions of dollars to convince the lawmakers to do what they know they are going to have to do anyway.
We need a better system. The nature of the system put in place to make decisions on health care will reverberate through the years, to effect, not just ourselves, but what type of a system our children have to look forward to.
The beginnings of legislation to establish a Federal Coordinating Council for Comparative Effectiveness Research was hidden by our newly elected president in the Economic Stimulus Package. The whole purpose of this council is to slow the development of new medications and treatment technology because they are driving up the cost of health care. This is similar to a board that governs who receives medical care and what care they receive in England and the United Kingdom. Medicare recipients will be judged on the perceived amount of useful life that they have left as to whether or not they will receive treatment for a given condition.
Will the egalitarian system we take as given, grant access to all to every technical step forward, or equally restrict access by all. Will equal access become a quaint naiveté` and give way to a two-tiered, or multi-tiered system of health care delivery, with the latest and best going to those who can afford it, and whatever’s left going to those who can’t? We would never stand for that, as a country, would we? We already do. There are forty-five million Americans without health insurance, the uninsured are now a sub-class, they don’t have access to the same preventative care and routine checks that the insured enjoy. As a matter of fact, even if they can afford health care, they may be afraid to seek it. There’s the big punch-a-roo, if they get diagnosed with a pre-existing condition, they may never get access to health care they can afford.
Do you know which segment of the population is the fastest growing pool of the uninsured? Poor people, right? Perhaps, the unemployed? Nope, on either count. That distinction goes to working males over fifty, that make over seventy-five thousand dollars a year. That can’t be right. That’s what I thought, until it happened to me. When a misrouted bill went unpaid, my insurance was cancelled without notification until sixty days after the action. And once you find out your policy has been cancelled, if you’ve gone more than thirty days without a bridge policy, you have to jump through hoops and throw around a good deal of loot to get any type of coverage. After several rounds of denials, and a total inability to get a private policy to cover either myself or my wife (every company was happy to cover our perfectly healthy children, for the same price we had been paying as a family). Thankfully, I have a good income and the cost of establishing a group policy and hiring my wife wasn’t an undue hardship, but it cost twice what I had been paying. Most families can’t absorb this.
In my opinion, any, health care reform has to deal with both of the issues; cost and access. Until there’s some type of insurance reform that actually reforms the practices of private insurers and provides a means for all Americans to obtain health care coverage in some form, any health-care policy we undertake is a mere band-aid. What is not intuitively obvious is that the elimination of the vast number of uninsured Americans will in and of itself drive down the cost of health care per capita. This is so because the cost of delivering health care to the uninsured is simply passed on to the insured. It is the only way hospitals and health care providers can survive in the current environment. Secondly, coverage of largely healthy younger people whose expenditures on health care do not exceed their premiums will help offset the costs of those individuals with higher costs.
If health care policy is going to be made in secret and obscured in the depths of legislation clearly intended for other purposes, any national dialog on how we as a country feel it’s best to address these issues, is subverted.
What is my message to those in power; the senators, congressmen, and the president? Stand up, be men, do not act in a secretive or cowardly fashion. America deserves the right to be included in deciding where our, and I repeat OUR, health care is going.