health care…

Posted on Tuesday 21 July 2009

I started Medical School in 1963, but because of a lot of training, obligatory military service, and years in academic medicine, I didn’t become a private practitioner until 1985 [at the age of 43]. By then, the world of [so-called] Managed Care was in full swing. I guess I was fortunate, the thing I did [long term Psychotherapy and Psychoanalysis] was not covered by any insurance of any kind, so I didn’t have to deal with the madness of trying to practice in the modern world of Insurance and Prescription Plans. I’m sure that I wouldn’t have done it. I would either taken a salaried job or found something else to do with Medicaide programs that cover the indigent patients I see. I count myself lucky to have made it through my career in a way that skirted the intrusion of big pharmacy and big medicine into my personal practice, though it wasn’t possible to avoid it entirely. An example…
A friend had a severe chest pain that developed over several days. It sounded like Shingles, but there was no rash. I was stumped. She went to the emergency room with a complaint of "chest pain." Before being examined, she had a Chest X-Ray, an EKG, and Lab Work. By the time she was examined, the rash had finally appeared. Yep. It was Shingles. I guess "chest pain" = "possible heart attack" = "X-Ray, EKG, Lab."
That’s absurd, simply absurd. Fortunately, she had Medicaire. Medicaire doesn’t pay for that kind of fee churning, so it was a loss for the hospital. But some Insurance might have. And some "uninsured" people might have paid. Such practices happen hourly, daily. The result is outrageous fees as medical systems try to maximize charges to increase the revenue stream.

Even someone as "business avoidant" as I am can’t hide, even in a log cabin in the woods. I’m on the Board of an after school program for druggie adolescents that have gotten in trouble with the law. Drugs are ubiquitous in rural America. In our area, the heart of the "moonshiners" of yore, it’s meth labs and pills from Mexico. It’s a really good program. The kids choose it over incarceration. They are drug tested frequently; they have to be in school and pass; and they come to our program three afternoons a week. They call it "drug court" [I’m in drug court], and bitch and moan about having to do it. But they’re dealt with by some very dedicated recovering adults who really make a difference, playing strict but beloved "aunt" and "uncle" roles to kids from homes that are beyond "broken." The results are impressive.

But funding such a thing is very difficult. State money comes and goes. Medicaide Providers come and go, change the rules, are slower than turtles paying. The guy that runs the program started it up by mortgaging his house, and we eke along week by week with payroll. They drive 70 miles to the food bank in Chattanooga to get drinks and snacks for the kids. We borrow empty buildings to have a space for the program. The Counsellors carry the records in their cars, because there’s no permanent storage. So the program is a clinical success but a fiscal nightmare.

Which brings me to yesterday. There’s another bigger, better funded, facility owning, non-profit that has remained financially viable over time. But in the process, they shut down needed services, delivered less than what they promised, and alienated the judges who make these referrals. They had actually bailed out on a previous incarnation of the very "drug court" program I’m involved with. So, yesterday, I’m in a meeting. The other non-profit needs "clients." We need funding. We were trying to broker a deal that was win-win, something like their assuming our debt and taking over the finances, and we continue the clinical part. I don’t know what the outcome is going to be, but it got me thinking about what’s going on in Washington. All we talked about was money, coverage, billing, and I left with a headache.

 

There’s a delicate balance between cost containment and the delivery of services in Medicine. I’ve rarely seen it. It was present in the VAH system I worked in. It was present in the Military. But I never saw it anywhere else: Public systems, University systems, Private systems, nowhere. Occasionally, the pendulum swung through something sensible, but it just kept on swinging. So, based on my career, in the world of Medicine, there is at least one Physician [me] who is a genuine Socialist. I think the whole thing has to be controlled from top to bottom for it to work – from Medical Education to service delivery. When the profit  motive enters, rational medical thinking leaves by the back door and the bean counters start warring over money. Medicine doesn’t fit Capitalism since there’s really only one product. My final specialty, psychoanalysis was outside the world of medicine and shouldn’t be covered. There are other such things, cosmetic surgery comes to mind. Those are choices, not rights. In a civilized world, I believe there is a basic medical care that is a right. And as much as I personally was not born to be a soldier, the military system as I knew it in the 1970’s stands out as the best health care system I’ve personally ever seen…
Major 1boringoldman MD
USAFE, retired      
  1.  
    July 21, 2009 | 11:50 PM
     

    You’re not the first person to praise drug courts, but I’m glad you brought it up. A former meth addict and meth lab cook wrote to me and credits drug court with helping him to kick the strangle hold that methamphetamine had on his life. He can’t say enough good things about the drug court program that he was involved in. In fact, he’s joined a meth coalition to help address the problem of meth addiction and meth manufacturing in his area.

    It’s sad to hear that programs that “work” continue to struggle to get funding. Actually, it’s distressing to hear it. Good luck to you! My son lives in TN as do my grandchildren, who are 3 and 6. The youngest one has autism and my son and his wife have to forego needed treatments for him because their insurance co-pay cost would be about $600 a month. They just can’t afford that, so he misses getting therapies and treatments that would help him. My grandson’s potential is now limited, because of insurance. By making co-pays high, they discourage people from getting the services they need. Is it intentional? I’d say it is. Insurance companies don’t have to pay out a dime, if you opt out of services because you can’t afford the co-pays.

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