Tuesday, June 14, 2016

Why we hate the U.S. medical "system"


Writing at Vox, Sarah Kliff recently laid out one of the major reasons why even those people who have good affordable health insurance hate the U.S. medical system:

Patients are the health care system's free labor
... ... The American medical system is expensive; that's no surprise. That medicine can be costly is no shock to pretty much anyone who has visited a doctor.

But American medicine demands another scarce resource from patients, and that is their time. The time it takes to check in on the status of a prescription, to wait for a doctor, to take time away from work to sit on hold and hope that, at some point, someone will pick up the phone. ...

... [This is] the burden patients face in managing the health care system: a massive web of doctors, insurers, pharmacies, and other siloed actors that seem intent on not talking with one another. That unenviable task gets left to the patient, the secret glue that holds the system together.

For me, this feels like a part-time job where the pay is lousy, the hours inconvenient, and the stakes incredibly high. It's up to me to ferry medical records between different providers, to track down a pharmacy that can fill my prescription, and to talk to my insurance when a treatment gets denied to find out why.

She has nailed the common patient experience. Read the whole thing.

Too many medical providers seem oblivious to the demands placed on sick people by the incoherent "system" within which they work. And the sick people are seldom in a position to explode about what they are being put through.

Obamacare has increased access to health insurance for 12.7 million people; reduced medical debt, a common cause of bankruptcy; and freed millions from "job lock," being forced to keep a hated job to maintain insurance coverage. But it has scarcely become more popular for all that; a majority still disapprove of "Obamacare."

Might this resistance to the health law be rooted in the reality that it does little to reduce the "patient labor" that Kliff describes? If accessing the services of the doctor remains painfully demanding, not perhaps of so much cash, but still of unavailable time and attention, no wonder people don't feel that their burdens have been eased.

Kliff's article (and a large part of an installment of the Vox podcast "the Weeds") discusses a possible remedy to this mess, what Obamacare calls "accountable care organizations." But these seem few, far between, and at best unproven alternatives to the existing tangle of medical providers.

Times medical commentator Austin Frakt also reports on the medical tangle:

Considering how much we already pay for health care, you have to wonder why doctors, hospitals and insurance providers so often fail to coordinate their patients’ care.

Your primary care doctor, the hospital you visit and the various specialists you are sent to are typically part of different organizations that do not communicate effectively with one another. Balls get dropped and care suffers. In part, it’s a consequence of siloed medical practice.

That’s why the standard advice for patients who are hospitalized or have complex medical conditions is to monitor their own care. This means tracking what each specialist advises and prescribes, ensuring it gets done and informing other doctors about it. Failure to monitor, communicate and coordinate care increases the chance of errors and omissions that can harm health. ... Complicating matters, you may have to coordinate your own care while you are sick, unless you have help from a loved one.

Yet Frakt goes on to question whether the push for accountable care organizations is really working.

To anyone not embedded in the "system," it would be flat out obvious that what we have is crazy. And it is cruel to those who lack the resources or community support that would enable them to work their way through the maze. That's probably most of us. No wonder Obamacare has never earned a great bump in approval: these were the problems as we experience them -- to this the ACA has not provided relief.
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It's easy for me to write this because, through sheer luck, for the last 20 years I've been a patient of what is probably the largest, most successful integrated care organization in the country, Kaiser Permanente. If I get sick, I email my doc. If she thinks I should come in, she indicates my choice of appointments based on the severity of the complaint. She has electronic access to all my medical records. If she thinks I need a test, she (or a support staff member) can schedule it right away. She'll get the electronic test results as soon as they emerge from whatever machine took the measurement. If I need a specialist, I get the appointment on the same visit. If she gives me a prescription, I can pick it up in the same building. Should I be passed on to a hospital, I'm put in a Kaiser facility where my records and meds go with me. If it is October or November, I'm offered my free flu shot in the lobby of the building with no waiting! I am freed from all that work Sarah Kliff describes.

Kaiser is not perfect. Nothing is. But for sheer escape from aggravation when afflicted by ordinary ailments, I doubt of it can be beat. This is the standard that would increase general approval of U.S. healthcare. While patients are expected to do all the coordination work, nothing is going to raise satisfaction.

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