Dr. Rangel’s piece, Lowered Expectations
, makes a lot of hops, skips, and jumps of logic that I’m scratching my head at, as well as illustrates the issues that many physicians face in understanding
and appreciating the health illiteracy of many of our patients. (
Plug for my recent Op-Ed on health literacy!
)
He starts out being upset with Medicare/Medicaid for requiring letters about denials for procedures or tests to be written at a 5th grade level–but I’d
argue that’s not really too far off or inappropriate. A 1993 study (I know, almost 15 years old) showed 21-23% of adults functionally illiterate, and another
25-28% only marginally literate (equivalent to reading at or below a 5th grade reading level). I’d imagine this is why CMS uses the 5th grade
standard–about half of the adult population cannot easily understand language beyond this (scary!). Adults with low literacy are also more likely to be poor as
well (43% in poverty vs 4% in povery at the highest levels of literacy).
See Kirsch IS, Jungeblut A, Jenkins L, Kolstad A. Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey. Washington, DC:
National Center for Education Statistics, US Department of Education;1993
Add on to this fact that
health literacy
is one step more complex than just reading basic information (you have to understand basic things about the body and drugs) and this can add to confusion. We also
know that the elderly, immigrants, and the poor are more likely to have poor health literacy, and since those groups are often the people that Medicare and Medicaid
serve, I don’t think this requirement is all that outlandish. (In fact,
immigrants are more likely to be on Medicaid
than their non-immigrant American counterparts.)
If we’re writing things or saying things to our patients that they don’t understand, what good is it to them or to us? How many times does Dr.
Rangel–or myself, or any physician for that matter–say something that is so obvious to us that we don’t even realize our patients don’t
understand it? It doesn’t even have to be “medical-ese;” just last month I overheard a patient asking about his heart arteries, wondering if they
were blocked, and someone answered, “It appears to us that your plaque is stable.” Now, if you don’t know that a “clog” or a
“blockage” in your coronary arteries is thought to be due to an unstable cholesterol plaque that ruptures and causes a clot of platelets, you won’t
really know how the doctor answered the question.
He then goes on to talk about Medicare Part D (which I’m in agreement with–the implementation was and continues to be incredibly confusing, mostly because
it was lobbied to death and one Representative called it “The Ugliest Night I Have Ever Seen”).
Next is the ultimate link to how terrible the world will be and how quickly the sky will fall when “socialized universal health care” takes over. The 5th
grade reading level requirement is clearly unfair, since I’m sure he explains sensitivity, specificity, and positive and negative predictive value to all his
asymptomatic patients who ask for whole body CT scans. And he’s never seen a patient who doesn’t know what his or her medications are for, or call their
hydrochlorothiazide (a diuretic used mainly for blood pressure) a “water pill?” Or just refer to their pills as “the blue one,” or “the
red one?” I’m all for encouraging and begging patients to take initiative and learn about the drugs they’re on and the diseases that they have, but
you’ve got to meet them where they’re at. If they think they’re taking their diabetes drugs for “high sugars,” does it make sense to go
way over their head with the pathophysiology of diabetes and insulin resistance?
I understand where he’s coming from–I really do–but I think it’s more a function of physicians being so entrenched in the medical world that
we have no idea what it’s like to
not
understand medicine or drugs or disease. I think it’s actually almost impossible for us to truly understand the patient’s perspective sometimes, given all
our background knowledge that we use and possess without even realizing it. Is it often overly simplified, especially at a 5th grade level? Sure, and this can cause
problems, too. I guess I’d rather have all my patients have a basic understanding than some of them have no understanding at all.
He then jumps to this final conclusion, which I’m still trying to figure out:
If you think that you have it bad now with your private insurance company, just wait until the Federal government takes over and must severely limit health care
consumption in order to be able to pay for the care of over 300 million Americans. At least your insurance company doesn’t automatically assume that you are
10 years old.
Quick bullet points, because there’s just a lack of understanding of health policy going on here:
- The federal government already pays for about 60% of health care costs.
-
Under most “socialized universal health care” plans, money currently spent for private plans would be diverted to a centralized payer (ooh, scary!). All
the money in the system would still be in the health care system.
- You’d also gain tens of billions of dollars by simplifying administrative overhead and waste ($80 billion toward patient care would go a long way).
-
Economic predictions generally show an increase in health care expenditures over the first few years of a universal coverage plan, as folks that are uninsured or
under-insured try to go get their health optimized, but this would then settle soon after.
I’d like to hear where your data for the “severely limited” health care consumption is, Dr. Rangel. I’m just not seeing it. Changes? Yes.
Problems with the transition? Of course. Severe limitations? I’m just not buying it.
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