State of Medicine in the USA

Second Opinion

This is a US discussion, but helpful info from citizens of other countries is more than welcomed.
Do you want the US health care system to change?
If so, how?
What problems have you had getting medical care in the US?
Another other slant on this issue that you have is welcome too.

I have been seeking the right article to start this discussion, and have found it with Bob Herbert's editorial , "A Second Opinion," published today in the New York Times. Bob is reporting on the abysmal state of the health care system in the US, but without blaming either party more than the other. Apparently, in a study done of the health care of 13 developed nations, the US ranks at or near the bottom in every category, and there is no sign of improvement, rather the reverse.

If you are young, chances are your interactions with the health care system are minimal, and limited to yearly visits to the doctor, or occasional visits for the usual array of common illnesses and broken limbs and so on. As you age, and watch your loved ones and yourself fall into the jaws of the system, however, the view changes substantially.

The first view that something is wrong is your first visit to the emergency room. It is crowded with people who have no insurance, who have problems. Even if you have insurance the shear volume of people who are in the emergency room seeking care impairs the care you get, because there are triage delays while the staff tries to figure out who is deathly sick vs. who can wait. (If you really need an emergency room, my advice is "Call the Ambulance First".)

The second view of the problem is when the first person that you love develops signifcant medical problems without actually dying. Private insurers do not insure burning houses, nor are they forced to insure chronically ill people. The coverage your loved one needs will mystically end, either by being unaffordable, or in the worst cases unobtainable.

You may still at this point feel that you are covered. At one point, my husband felt very secure. He had his IBM insurance, my IBM insurance, VA coverage and Medicare. All are now in a struggle to deny coverage one way or another. Be aware, if you are sick, no one wants to sell you insurance. Even Medicare and the VA now use what is euphemistically called, "Demand Control." This is a method of making it harder to obtain care, so that people will avoid getting it, resulting in an imagined saving. The saving is imagined, because often treating a problem late is much more expensive in the long run.

And the way it is in the real world, is that if you don't die immediately of a heart attack, stroke, or accident, you will spend some time in your life sick. When you need it, your insurance will disappear.

This is one reason why the other countries are healthier, and why they were all right--people need Universal Health Care of some sort.

And Herbert is right-here we are with a treatment and coverage problem, and what is going on is the doctors and the lawyers are arguing about tort reform. If you look at the actual source of malpractice insurance rises, there seem to be three to me:

1. Losses due to bad investments by companies when the market crashed
2. Complete lack of regulation of the malpractice insurance industry
3. Too few insurers- (CT has only 2 malpractice insurers. Of course this has the same result as any monopolistic situation in a capitalist economy-runaway price increases.) An example is a local obstetrician with 18 years with no malpractice suits ever filed against him, paying $100,000 a year for his insurance. He is considering leaving the business.

Another issue of course is the fact that America is fat. This changes the age you get sick, but being thin will not keep you from dying. And the most expensive outcome, in terms of medical care, is most likely to get old and spend 5 or 10 years in a nursing home, which is quite typical for people who have cared for their health. After all, nothing could be cheaper to a health insurance system than someone who drops dead of a heart attack while relatively young, for example.

However, the life expectancy items, which are some of the health parameters in the article, are surely affected by the fatness of Americans.

So do weigh in with your opinions! I would prefer if like Bob Herbert, we did not try to blame the problem on one political party or the other, but focussed on the nature and extent of the problem, and how it can be fixed.

agree that medicine is in a bad way.

Yes, the ERs are crowded with people who do not have health insurance. But here's the rub: those with no insurance who are deemed 'indigent' (unable to pay at all) can actually get a more precise diagnosis in the ER because there are no restrictions on tests and procedures. If you are in the ER and your problem can't be immediately pinpointed, your insurance company won't pay for certain tests--the more expensive ones, like CTs and MRIs. If you get the tests done, you will be billed for them, and at an exorbitant rate, because since you have insurance, your charges reflect increments made to support medical care for the indigent.

If you should need a really expensive procedure such as an organ transplant or lengthy chemotherapy, your health care provider is sure to reject payment over and over again. Hospitals typically will not perform transplants unless the health care provider has agreed to pay, or the patient is willing to pay up front. In the case of chemotherapy, the hospital will begin the therapy, but will unceasingly bill you while the health care provider stalls.

Malpractice suits are a continuing drain not only on the doctors themselves, but also the hospitals. Somewhere around 80% of malpractice cases fail to result in awards to plaintiffs, meaning that the vast majority of such claims are either frivolous or unsubstantiated. But the doctors and hospitals are represented by insurance companies who employ full-time attorneys to handle the cases, which in turn raises malpractice insurance rates. Of the cases where awards are made, many are the result of settlements forced by the insurance companies, which do not want to risk even larger awards granted by sympathetic juries. So even when a doctor has in fact NOT been negligent, he or she may still have a record of malpractice judgments made against him/her because refusal to settle may result in being dropped by the insurance company.

The specialties which are heavily hit by incredibly high malpractice insurance are obstetrics, neurosurgery and orthopedics. In some states, pregnant women may meet the doctor who will manage their delivery for the first time at the hospital emergency room, because there are either no private obstetricians still in practice, or those still in practice have too heavy a case load to take on another patient. Their prenatal care is handled by a nurse-midwife or nurse-practitioner, or not at all.

The malpractice insurance problem is shared by doctors and patients alike, as doctors are forced to charge more for their services in order to meet their insurance premiums. The lawyers are the only ones who are benefitting from the situation, and they are a powerful lobby who are committed to maintaining the status quo.

Great thread! I agree with what both of you say (including malpractice); however, I would like to keep the focus of this thread on ways of fixing the problem, not renumeration of what's wrong. Unfortunately, we all know the latter. :\

I believe the only way to start fixing the problem is through some sort of a governement insurance, perhaps on state levels rather than federal. This sounds like an anathema to most Americans. However, the private insurance system is no longer working.

For one thing, gone are the days when most people stayed with one employer for decades. As we switch jobs, it becomes bothersome to us and inefficient overall to switch private insurances. Perhaps a doctor is only with one company; forcing patient to switch is never good; neither, BTW, is it efficient. So, I see a solution in an insurance that follows the person through various jobs or unemployment. A governement system is really the only way to achieve this.

Most of the expenses in medicine come from caring for the elderly. However, while private insurance companies earn money from younger insurees, it is the governement that ends up paying most of the expenses for the elderly. Ideally, governement insurance would profit from the person while he/she is young and healthy, and be able to pay for the care later on.

Finally, having universal coverage would (hopefully) push people to take more pro-active steps about their health. I think it is no surprise that where medicine in this country excels is in fixing serious problems, rather than maintaining decent overall health. Perhaps if everyone had insurance it would help get people into that annual check-up.

On the more specific points:
Malpractice. I agree that this is out of countrol. It's hard for juries to not award rewards to those who suffered. It's too tough to side with the doctor who is making so much money.

"Home remedies. It's time to bring the production of health supplements under the FDA roof. Many of them are quite beneficial, and can be used more safely than their chemical counterparts. Unfortunately, in the US today there are NO regulations as to the content of those pills. That's why most doctors won't talk about it at all, and those who do often recomment getting German makes.

Pitchka -- Older people have been paying into insurance for many many decades, and I believe they are entitleed to some benefits now that they are older. I believe that is what insurance is all about. Young one will have the same - We HOPE.

Bush has screwed up Medicare but good. and in the midsts of his War, he is cutting out several benefits for veterans. You figure. Where do you think we get the tax refund?

Joe

Ptichka: "Malpractice. I agree that this is out of countrol. It's hard for juries to not award rewards to those who suffered. It's too tough to side with the doctor who is making so much money."

It's one thing for juries to "reward" people who have suffered because of a doctor's incompetence. That is as it should be. What is not right, and what happens much of the time, is just as you said it: people are being "rewarded" because doctors (supposedly) have so much money, and because the plaintiffs have suffered, even when the doctor was not at fault for the suffering.

A doctor spends 4 years in college, 4 years in medical school, at least 1 or 2 years in residency, and for some specialties, sometimes an additional 5-10 years of training. During that time, the doctor is working long hours, is not earning much, and is having to pay off steep college and medical school loans.
Training is never really over, because the doctor has to keep up with all the developments in his/her field. The doctor may, after formal training is completed, earn a substantial income, but the same doctor, if he/she is an obstetrician, neurosurgeon or orthopedist, pays an astronomical sum for medical malpractice insurance.

Nearly 80% of all malpractice cases are settled in favor of the doctor, but that doesn't mean no costs were incurred. The malpractice insurance companies still have to pay lawyers to handle these cases. Of the 20% of cases that do involve an award to the plaintiff, many are settlements forced by the insurance company to avoid jury trial and a potential higher payout, even though the doctor has not been guilty of any sort of negligence. Doctors are forced to agree to these settlement out of fear of having their malpractice insurance cancelled.

There does need to be some process for weeding out the truly frivolous malpractice suits, like the ones where a doctor stops to help an injured motorist, saves his life, but leaves him with a non functional finger, and then gets sued because of the finger. A state or county medical commission, similar to the state real estate commission, could do this. They could not make awards, but they could give a summary judgment to the insurance company.

I would have more patience for the doctors if they would clean up their act, as a group. The most obvious problem is that the doctors do a bad job of self policing, leaving the expulsion of bad doctors to the insurance companies by pricing the bad doc out of the insurance. Even then, many states, including FL, do NOT require doctors to carry malpractice insurance. FL requires the doctor to tell you he is not insured. I do not know if that is true in all states. When you hear of doctors with multiple really bad malpractice suits, remember, their fellow doctors did nothing about it.

In fact, many errors in medicine would be avoidable if the doctors' culture were different. The NY Times has reported some good changes mandated by NY this last week or two. But when you think how easy these changes are, it is ridiculous to think that all hospitals were not always doing things this way.

1. There is now mandatory double checking in the operating room that the anesthetized patient you are operating on is the patient you are expecting to operate on.
2. Labels are being put on the portion of the person that are to be operated on. This is to save a common malpractice of cutting off the wrong limb, for example.
While some doctors have been writing on the patient, some have been using water soluble markers that wipe off before the operation. Some have been using no identification at all.

I am not kidding. This is supposed to be an improvement, yet.

Another suggestion would be that absolutely no prescriptions, or discharge instructions should be handwritten. People have been complaining about doctors' handwriting for years, but nothing gets done. These days technology exists for the doctor to dictate the prescription and the machine will type it out. This would save untold mistakes in prescribing.

Newt Gingrich and Ted Kennedy are combining to push an initiative for hospitals and indeed all medical records to go paperless, which will save both money and mistakes. Considering the bipartisan nature of this initiative, and even ignoring the fact that Newt is an a for-profit group expecting to make money out of this, still it is not a bad idea.

Many teaching hospitals have curbed the culture where people are treated by internes and residents who never get adequate sleep. In a country where we will not allow truck drivers to exceed the time limits to drive, we happily allow physicians to try to work 20 hour days. But unfortunately, this still happens.
It contributes to the mistake rate.

At Yale New Haven, each patient who is in a unit for more than a day or two has a nurse assigned as a primary nurse, and another as his/her backup as a primary nurse. These people are responsible for knowing everything about the patient, and for conveying it to nurses on the other shifts, and across the weekends to make sure that the continuity of care is kept. When you are in the hospital for 63 days, as my husband was, the nurse can't just read all the reports. His occupied two full notebooks! This system costs nothing to implement and again saves errors.

If a patient is full of morphine or other mind altering drug, he should have a sticker on his front that makes it clear to doctors and nurses that his answers to serious questions may have factual errors in them. I have experienced problems with this myself.

My personal advice to help you survive the American hospital, which is understaffed, and as seen by the above examples, is often run in mistake prone ways, is that if you don't have a loved one to sit with you day and night, hire a nurse's aide to watch you, especially if you expect to be on morphine or other pain killer.

If there is less malpractice, there will be fewer malpractice suits that really need to be paid.

I shouldn't be jumping in on this since I am a doctor, but the sad thing is while it is true that we as physicians haven't done our best to clean up our own house, it's also true that you can't watch daytime TV without an ad for personal injury lawyers telling you that "it must be somebody's fault". There is a difference between an unavoidable outcome (e.g. someone dying of cancer) and not having the cancer diagnosed in time. I remember patients acting as if they had won the lottery because they had to wait several hours in the ER for a "penile drip" while we took care of patients with chest pain instead. I remember arguing with insurance clerks with no medical training who were denying my patients care. I remember watching medicine start to become shift work as residents said to me as the consulting attending that "night float would take care of it" Wrong answer. I remember the day that I chose to leave a career I loved because of all of the above. I'm starting to miss patient care again, and I may start to do some volunteer work if I can (most VA hospitals need an extra ID doc in AIDS clinic), but the health care system in the country is in worse shape than the politicians in Washington care to admit.

Here's a lovely little story that has it all, malpractice, the profession protecting it's own, and the joy's of tort reform.......worth reading to the end. It's sad that patients and lawyers trying to make a quick buck have now made it impossible for those who have truly been the victims of malpractice to receive the compensation they deserve.

http://www.sundaygazettemail.com/section/News/2004062620

HANDWASHING........one of the easiest ways to prevent the spread of germs. Every sink in the hospital has signs reminding and showing how. Here is what is really happening. Prior to the threat of HIV infection gloves were worn to protect the patient during sterile procedures and to protect the care giver in really messy situations. Believe it or not when I a started practicing nursing it was considered insulting to the patient for the caregiver to wear gloves when bathing a patient and I am talking a COMPLETE bath here, when giving enemas, and when cleaning patients afterwards unless there was the risk of hepatitis or something that the patient needed isolated for. Now it is just the opposite caregivers wear gloves whenever there is any contact with a patient or even their linens. So caregivers put on a pair of gloves and THEY are protected BUT they go from patient to patient wearing THE SAME PAIR OF GLOVES. This is mostly with nursing assistants but they have the most physical contact with a patient. Doris, ITA with what you said and would even suggest that anytime one is in the hospital to have someone there as your advocate. This is a job of the nurse but with staffing problems and with inpatients being much sicker it's impossible for nurses to do it all. Also if possible read your chart this will probably require an order from your doctor. I once found the result of my prostate biopsy on mine....while I was admitted for a hysterectomy. Don't be afraid to question anyone, anything and everything. i would much rathe be referred to as the b&#*$ than the late.

The glove issue and failure to ditch the gloves each time the nurse, or nurse's assistant, or doctor leaves a patient's room is checked when nursing homes are recertified, and is a frequent cause of failures and gigs against the home. This inspections of nursing homes are done courtesy of the State of CT, and also the Social Security Administration.

I wish to heck they would do the same for hospitals.

Bronxgirl, There is a VA clinic at the Coast Guard Academy in New London, which is really close to Mystic. There is a good quality VA hospital in New Haven. That would be two good places to try to volunteer. The NL VA has a view of the Thames River, so it's even a nice location.

Don't feel shy to comment on this topic because you're a doctor. Or a nurse. Your input is what is most needed.

Piel, That was a truly dreadful story, and just what disturbs me about the way the medical profession is currently organized. An unqualified guy performing horrible surgery on everyone walking by in him the ER in multiple states, without any state to state traceability. Have the certifying boards heard of fingerprints, for Chrissakes???? BTW, I think I did hear this case on 60 minutes. At that time, the doctor was in TX, doing those titanium implants in people's backs. The cost of this guy is borne by every hard working doctor, and every patient in consequence. This is the sort of guy that triple damages was invented to curb.

In criminal terms, he is a predator, and a serial criminal. And no one is doing anything about it in the medical profession. He just coughs up his license in the state he is in and then goes on to a new state and sets up shop at a hospital and no one investigates whether he is qualified to operate on peoples' backs.

Another sad commentary is that there will be more of an outcry against Andy Hansroth receiving narcotics long term than there will be about the doctors wrongdoing.

Piel, I'm sure you're right. I am hoping that Rush Limbaugh's sad story will instigate a more productive discussion of treating chronic pain.

I've also noticed that they have those little aerosol cans of foam that are antiseptic and see the Dr's. use those instead of washing their hands between patients. I really doubt they are as good as handwashing but don't really know.

Doris:

I would say, one of the best things about life in Canada is our health care insurance. Sure we grumble about having to pay our monthly premiums - I pay 54.00/mo - some pay as little as $7.00 per month - it's based on ones yearly income. We have Tommy Douglas (Kiefer Sutherlands grandfather) to thank for establishing our wonderful medical servics plan. Of course, over the years our government has eroded much of what we had away from the original plan, such as coverage for yearly eye tests - we all have to pay a basic fee for that now ($50.00). In spite of some changes the plan is still an excellent one. However, with the high influx of immigrants to our country it has taken a toll on our health system. One of our biggest concerns right now is our medical services plan and protecting it. Some politicians are trying to introduce a "two tiered" system which means rich folks can "jump the que" for operations while the rest of us have to wait up to one year or longer for needed surgery. Anyway, we are trying to keep the plan in tack as it is. While some coverage, such as eye exams, as I mentioned have pretty much disappeared the main coverages - Drs. appointments, specialist (for medically proven conditions) and hospital stays are still covered. Let's hope our new Prime Minister - Paul Martin - can hang on to our great medical program!

Sorry, if I diversed from your original question - Yes, I think the US needs a better medcial coverage system - I can't even imagine life without ours - it would be terrible.

Joesitz said:

Pitchka -- Older people have been paying into insurance for many many decades, and I believe they are entitleed to some benefits now that they are older. I believe that is what insurance is all about. Young one will have the same - We HOPE.

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Joe, that's my point. People have been paying all their lives to a private insurer, while it's the governement that ends up paying for them when they're old. With a governement insurance, people would essentially be paying the same insurer when they are young and healthy as the one that will be paying for them when they are old and sick.

DORISPULASKI said:

If there is less malpractice, there will be fewer malpractice suits that really need to be paid.

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Right now, whenever a patient in a hospital dies, for many people the immediate response is "Whom do we sue?" I work on hospital software, and hospitals often try to pass the blame on to us -- believe me, it's nothing but "passing the blame".

dorispulaski said:

Another suggestion would be that absolutely no prescriptions, or discharge instructions should be handwritten. People have been complaining about doctors' handwriting for years, but nothing gets done

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Great suggestion. We had a hospital presentation where doctors talked about what could go wrong. I was quite shocked! Not only are prescriptions hand-written, they are then often faxed to the pharmacy, making it even more legible. A computerized system not only helps minimize human error, it also contains extra checks for drug interaction. Of course, it doesn't hurt that the company I work for would certainly profit from such a bill

I don't know much about the technicalities about healthcare in the US, but my aunt is a pretty well-known OB-GYN in Tallahassee. She delivers 60% of all babies there. She almost had to quit her job because the insurance, which would cover cases against her for past and future issues, would've cost a million dollars. She's a pretty wealthy lady, but that was crazy! She ended up finding a less-expensive insurance company that would cover her for future cases, but not for any cases that regarded past events. That means if someone who had a delivery complication 20 years ago won a case against her for millions of dollars for it, she would be in deep trouble. To prevent the chance of her family (including 9 children) from losing everything, she put all of her assets under her husband's name, so technically she has nothing to lose... but still. How did they think they would deliver their babies if there was no doctor to do it?

brinababy, The issue of past deliveries is really interesting. Isn't there any statute of limitations on how long ago the damage can have occurred?
If there isn't, there should be. That would be a logical limitation that would help lower malpractice insurance.

I think there is a limit, 25 years. Maybe making it less would help though!

As I've mentioned before, I work for a company making hospital equipment. One thing we sell is a machine that measure contructions. What it then does is stores the read-out "forever". Why? To protect doctor/hospital from being sued some time in the future.

I am surprised at what you are saying, though -- wouldn't your aunt's insurance cover it?

BTW, here is another example of malpractice fears effecting medicine. We sell a device that is used to measure the baby's vitals signs during delivery. Basically, the idea is that even if some things are not going quite right, you can still proceed with vaginal birth if you know the baby is OK. We sell this all over the world, but not in the US. Because of malpractice concerns, doctors would rather perform a C-section even when it could have been avoided.