Tuesday, September 15, 2009

Health Care Delivery

I have a patient's perspective. Not being a medical professional, my comments are based on personal observations over my lifetime. Having experienced heath care change over the last fifty plus years I have some insights into health care delivery that others may not have.

In my earliest recollections of health care delivery there were single doctor offices and doctors made house calls. When you went to an ER the first question asked was do you have Blue Cross Blue Shield. ER's had yet to be ruled by the government as unfunded free clinics to the poor and illegal aliens.

Location determines what health care is available. When in the USAF I was overseas at a small base. When I had a small cavity they pulled the tooth instead of filling it. They also misdiagnosed allergies as a sinus condition and gave me pills to treat the symptoms. After discharge from the USAF I went to work for a large company that had a nurse's office which dealt with basic care not requiring a doctor. For example, the company nurse gave me weekly injections prescribed by my allergist. The allergies the military doctor in Germany said I didn't have. In some cases health insurance was fully covered by employers but less so over time.

As doctors trended from general practice to specialties small groups banded together to share an office and administrative costs. More medical services were offered on site and health care delivery was clinic run. They naturally delivered services they were trained for even if not necessarily well practiced in. Referrals were after all lost revenue. You might say they rationed care according to what they could deliver. One of these clinics performed out patient surgery to remove a fatty tumor from the back of my head. They didn't get it all so it grew back over time and another clinic operated. Like the first, they didn't remove it all and again it grew back.

I changed jobs after my wife became pregnant and learned about preexisting condition coverage. My new insurer wouldn't cover prenatal care, the delivery or my wifes hospital stay. Needless to say I had to come up with thousands of dollars which I didn't have. The hospital refused to release my wife and new son until I paid. I called their bluff, while at the desk of the collection person that was threatening me, I called the FBI to report an abduction. I was so angry I refused to make a specific payment arrangement just to make their life difficult. Unknown to them was my plan to pay as much as I could every payday until the bill was paid.

With a new job and this time a state residence change came a forced change of health insurance provider. Government regulations dictate you must purchase insurance in the state you live which limits competitive choices and punishes you with preexisting condition limits. I had a preexisting condition and the company offered insurance plans wouldn't cover me until after a long waiting period. I had little choice but to enroll in an HMO that had no preexisting condition limitations. This large HMO had a statewide network of clinics and hospitals which gave me better access to specialists and lab facilities, all of their choice. Remember the fatty tumor, this time it was removed by a very experienced surgeon and never grew back. Waits for getting an appointment were much longer and always resulted in long lines and waiting when you came for your scheduled appointment. In my 50's my Aortic heart value started to malfunction and only worked at 50% efficiency. Less than a month after diagnosis my valve was replaced with a mechanical one. Over time my blood pressure became more difficult to control and I ended up on four different blood pressure medications at the same time. I became potassium deficient and saw an HMO specialist that diagnosed me with hyperaldosteronism. Aldosterone is a hormone secreted by the adrenal glands. They put me on huge potassium pills. What I didn't realize at the time was that my care had been rationed for the HMO to save cost. Drugs were the only option offered and the link to high blood pressure was never explained.

As a war time veteran I'm eligible for VA health care. In my case a co-payment is required for delivered services. After retiring I decided to sign up with the VA -- the HMO wanted a thousand dollars a month for my wife and I. They effectively price the insured out of coverage when they get older. I then relocated to be near the VA hospital in Fresno CA. The VA also diagnosed my Aldosterone problem but instead of medicating the symptoms they fixed it. The cause was a tumor in an adrenal gland and the VA performed the surgery to remove it at the San Francisco VA Hospital. My potassium level and blood pressure returned to normal. Clearly the cure that was best for my long term health. Routine appointments can take thirty days to get, there is waiting at the blood draw lab and waiting at the pharmacy. However if I feel I need faster attention there is always the VA's ER. I should note that the VA ER is only available to veterans. I went to the VA ER after I passed out and awoke on the bathroom floor. The ER did a CT scan of my head and found I had bleeding on the brain. They arranged for a neurosurgeon and sent me via ambulance 170 miles to his location at the Palo Alto VA hospital. The next morning my surgery was performed -- no waiting involved.

Many of the health care providers at the VA are veterans themselves. We share a common bond and a military sense of duty. Like the HMO, the VA prescribes from an approved formulary of drugs. You will get generics when available which lowers the cost to the VA or HMO. I can say that the VA prescribed more modern drugs for my type 2 Diabetes than the HMO did. One of the VA's prescriptions was even for a non-generic. The VA also has what may be the only nationwide 100% electronic health care records system and provides Internet based health information, personal record keeping and prescription renewal. I found the VA superior to the HMO in every way. They have always provided me with the most effective heath care -- not the cheap way out. Northern CA is said to have the best regional VA system in the country. No doubt the level of care and number of facilities varies in other parts of the country depending on population density and closeness to top medical schools.

There are many factors that have increased the cost of health insurance. I've already mentioned the prohibition on purchasing health insurance across state lines. The government also mandates what is covered so the customer can't choose and balance cost based on their own needs and ability to pay. Did you know that a drug developed by a US pharmaceutical company costs more in the US than let's say Canada. Our government makes sure we can't buy our drugs from Canada where they are cheaper. I for example wouldn't purchase mental health coverage. Tax treatment has made employers the default source of health insurance further limiting your choice of insurer to those selected by your employer. Individuals pay at higher rates for insurance and sometimes higher rates to hospitals if they have no insurance. It would be much better if individuals directly purchased their insurance from any of the 3,000 plus insurers in the US. There is plenty of competition if only the government allowed it to take place. Forced loss of coverage for preexisting conditions would be under the individuals control where it belongs.

I've never participated in a Socialized Public Option and hope I never have to. When examining socialized medicine in other countries I find they provide a much lower level of service and care than even the HMO I belonged to does. Months of waiting to see a specialist can be a death sentence. For example in the UK the death rate from breast cancer is much greater than in the US. Government does a poor job of running business and health care is one business we can't afford to let them mismanage. The farther away from the patients and doctors the rationing rules are made the more disconnected from the patient they will be. Formula's that devalue older individuals and ration care to them aren't my idea of health care. Health care decisions/rules in a socialized medicine system will be made primarily on cost and all health care decisions will be made according to those rules. The patient and their doctor won't be part of the decision process. In the government decisions are made totally by rules and not by a careful analysis of all factors for an individual situation.

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