Think Of It This Way ....

When I arrived at the lab, in this large new clinic building decorated with spectacular art work, it was 6:35 AM. Many of the chairs were filled and those that were empty were soon occupied by people waiting to be called for their tests.  Six or seven people lined-up at the intermittently-staffed lab reception desk.

You might not recognize this as cost-shifting, but in my opinion, it is.  Clinic management has decided that it is more efficient, in terms of their needs, to keep 18 people waiting for more than a half-hour each, rather than bring in phlebotomists to draw blood and instruct patients on how tests are to be performed.  Those patients, waiting for their blood to be drawn and specimens to be taken, were not at work, were not earning wages, and had just used expensive cars and expensive gasoline so that they could sit and wait and wait and wait.

When government and insurance companies calculate the costs of care, rarely are patient transportation costs and lost opportunity costs (not being at work earning a living) added to the equation. Those dollars come out of the patients' pockets, not the government or insurers pockets.  The cost has been shifted and no-one seems to notice or care.

So think of this as a cost shift and as an uncounted tax that each of us pays.

As Much Time As They Needed

A. B., one of my early partners was an experienced Mayo-trained internist who had practiced long enough, in what was then a rural area, to have acquired a clientele of dairy farmers. A.B. loved his work, enjoyed collaborating with new young well-trained doctors, but most of all prided himself on his skill and his commitment to patients.

He had some quirks. When his dairymen called him at 3:30am, just before going to take care of their cows, and complained of minor problems, A.B. called them back at 11:00pm to find out how they were doing. He and they knew the limits of his patience, but he and they knew his competence, dedication and willingness to take care of serious problems at any time.

One day at 6:30pm, when A.B. was unlocking the practice's front door to allow a patient and her difficult husband to leave, the patient thanked him. The husband said, "Doc, I'll bet you will be unhappy when we have socialized medicine." Without any pause, A.B. replied "Oh no, under socialized medicine I would have been out of here an hour ago."

Today, we don't talk about socialized medicine. Our talk of health care reform, health care efficiency, pay-for-performance, economics, triage and universal health insurance has drowned out discussion of health care provider competence, commitment to patients, ethics and integrity. A. B. was certainly aware of the economics of practicing medicine, but he was never financially rich. When his heart gave out, and he retired, he retold the story of opening the door at 6:30pm, with wistfulness because he knew that the relationship between patients and their physicians was changing: the joy of medical practice was being replaced by the increasing burden of health care efficiency, payment for performance, health care economics and guidelines of care.

A.B. spent as much time with his patients as they needed, day or night; does your physician spend 10 minutes of undistracted time with you?

Do You Receive Adequate Quality Health Care?

If you are a young man or woman, and see your doctor infrequently because you know you are in good health, the insurers want you. The young healthy nonuser of health care is what keeps insurers and HMOs not just solvent, but profitable. So there you are, making money for your health care insurer or HMO, going to see your doctor every few years - probably for a bad cold. When you see your doctor, what is the quality of the care you get? Do you know how to assess quality, other than by the time you have to wait to see the doctor and the age of the magazines in the waiting room?

Does anyone check your skin for melanoma? Does anyone check your neck for a thyroid nodule? Does the doctor (or other health care professional) check a young man's testicles for a mass? Does the doctor check the woman's breasts or instruct her on self examination? How about checking lymph nodes? Does the doctor listen to your heart and lungs through three or four layers of fabric because there isn't enough time (or professional interest) to have you take off your garments. Is the doctor (or other health care professional) sufficiently skilled in physical examination to be able to recognize an abnormality or is his or her professional continuing education dictated by the programs which insurers and pharmaceutical companies offer? Or does the doctor or other health care professional ignore the role of history and physical examination and believe that the only way to find disease is by lots of lab tests?

If no one looks, no one finds treatable pathology. If no one finds treatable pathology, the patient will probably change jobs, move to another insurer, and the first insurer or HMO will not be burdened with the costs of diagnosis and treatment. As the insured, you have fulfilled your duty of providing profit for the insurer or HMO and allowed the health care provider to see his or her allotted number of patients.

You may know a lot about football or baseball. In both sports there are rules and umpires. What are the rules governing the care you should be receiving and who is enforcing the rules? If you don't know the rules, you may be the loser.