Item 1: Medicare is paying employers to maintain their retirement plan health care benefits, to the tune of $4 billion. These health benefits compete with Medicare Part D benefits.

Item 2: We already subsidize health care insurance, primarily through making business expenses for health insurance tax-deductible.

Item 3: Medicare isn’t allowed to negotiate on drug costs, although another federal agency, the VA, can. Medicare pharmaceuticals cost sometimes double what VA drugs cost .

Item 4: Our President’s plan to fix the health care system, Health Savings Accounts, is primarily targetted toward the middle- and upper-classes , those who already have health insurance. It also ignores the fact that approximately 80% of health care costs come from approximately 20% of patients (the really sick ones).

What’s next? The government subsidizing the drug companies for taking part in the Medicare D benefit?

Is it just me, or does it seem like our leaders are just setting up the government to fail?

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The hospital I’m at has been on divert status multiple times this month ( this is not uncommon ). That basically means that the ED is full, and can’t accept any more patients. For us, it’s also worked out to mean that our entire hospital is full, including the ICU. There are no open spots. Anywhere.

This prevents surgeries from happening (because there’s no place to put the patients for monitoring after the surgery), and it prevents truly sick people that walk into the ED from getting hospitalized, too. Our schedulers and case workers and discharge planners knock on our doors daily, desperately seeking patients who might be going home. And with our aging population , I really can’t see this getting any better. Nursing shortages make this worse, because of staffing, especially on the weekend, open beds can’t always be turned into patient beds, because of nurse to patient ratios.

This obviously brings up something of an ethical dilemma, where the lofty goals and aspirations of perfect medicine hit the limited resources pavement. There are several people in the ICU who have been there for as much as 8 months or even a year–in comas, on respirators–with little hope of improvement. Yet their living wills insist that they remain on a ventilator, or their family members insist–even despite the patient’s own declared wishes. And so they remain. Then there are others who come back time after time with the same serious problem, sometimes self-induced.

I could easily argue this point either way, and where you stand probably boils down to where you sit on issues of individual or group mentality. Should we do what’s best for any one individual, at the possible cost to the group, or should we sacrifice an individual for the good of the group? (I myself am a total hypocrite, preferring the group mentality in theory, but the individual mentality when it comes to my own health.)

I guess I mainly worry that this problem won’t just go away, and that whatever solution we come to will be one decided either at the last minute, or will be decided based on the most unethical of deciding factors: money. There’s of course an alternative I haven’t discussed here: just build more hospitals, more nursing homes, more clinics, and try to squeeze everyone in, but that will probably just lead to worse nursing and doctor shortages, and lead us deeper into the red.

Any of my answers turn my stomach, so I guess it’s up to choosing between the lesser of two evils.

1. First-come first-serve doesn’t really seem appropriate; just because you got sick when there was an available hospital bed shouldn’t decide whether you get care.
2. There’s a “he who contributes most deserves most” idea, but it’s rotten, too–just because subjectively one person “contributes” more to society than another shouldn’t necessarily buy them more or better care than someone else.
3. You can also go by age alone–that children should get more extensive and intensive care than the elderly, because in someone’s words, “children haven’t been able to live their lives yet,” but some elderly folks may still have better prognoses than some very sick children.
4. There’s a functional cutoff–if you’re “high-functioning” and you get sick, you should get extensive treatment, but if you’re low-functioning (again, the definition is a problem), you’re out of luck.
5. Or how about an formula based on your chances of recovery, partial recovery, or no recovery, based on all the data we have available?

I don’t particuarly like any of these for many reasons. You can’t arbitrarily sign a death sentence for a person, and you can’t take away a person’s hope so quickly. I don’t know what’s going to happen, but it really, really frightens me.

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Read’em and weep , common logic. If you drop co-pays for the sickest and most at-risk people, you save tens of thousands of hospitalizations and thousands of ED visits. A RAND study.

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I follow single-payer news by following an RSS feed of a Google News search for single-payer , and I think it’s a pretty decent way to track how popular a term is over time. And I’ve noticed, over the past 6-8 months, there’s been a quantitative rise in the number of news articles that include the word single-payer–from a low of 4s when the program started out, to now about 25 a day. Keep it up, single-payer!

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I honestly wonder how much the American Health Insurance Plans association paid United Press International for this total fluff piece supporting Medicare Part D .

“I’m hearing shock from (state) Medicaid directors that we’re getting better prices than they are,” she told UPI. “I don’t know of any other government program where the real costs are less than the estimates,” she said, arguing that the plans are offering “affordable products” with low premiums and low deductibles. -Karen Ignagni, president of the health insurance association

Actually, Karen (can I call you Karen?), the administration has been charged with trying to supress the real cost of the plan, getting the program passed with a much lower estimate . The administration told Congress the plan would cost $534B over 10 years, when it’ll probably actually cost more than double that. Whoops.

And, uh, by the way, UPI, your headline is absolutely wrong. The “Fed”–that’s the VA, right?– actually gets better prices than Medicare Part D .

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Call me crazy (“Hi, Crazy!”), but I think we need to start changing the medical school curriculum a bit.

One of the main focuses of the pre-clinical and clinical curricula is teaching the medical student the art of the differential diagnosis. You basically take someone’s symptoms, and try to figure out what’s causing their disease–any number of body systems can cause similar systems. And as the saying goes, “You can’t treat what’s not on your differential.” That is, you’ve got to consider everything, so if it’s not what you think it is, you’ve got a fallback 2nd or 3rd idea for what the problem could be. Obviously important to reinforce this concept into our heads. Over, and over, and over again. And then over some more.

But one area where I think we’re lacking–because medicine has changed so much–is the treatment of the chronic disease. We focus so much on the acute still in medicine, when our patients have primarily shifted to the chronic. Sure, as residents we have clinic time where we see patients as outpatients in a chronic disease setting–but most of our residency (and much of our medical school) training is still focused on the acutely ill patient. While this definitely hammers home important concepts in many diseases, which can then be translated to the outpatient basis, I wonder if there’s more we should be learning. If you look at physicians as a whole, they’re not working in hospitals, taking care of acute patients. They’re working in private practices, seeing outpatients.

What should change? A couple ideas:

1. Focusing on trends, not on specifics
2. Focusing more on prevention if the disease will be life-long
3. Time management with patients
4. Changing the culture so that patients expect to come in when they’re well and when they’re sick
5. How to stay energized and avoid burnout
6. How to maintain relationships with patients over years
7. How to work efficiently and effectively with other specialists/generalists
8. The differences between acute care and chronic care
9. Explaining chronic versus acute care to patients

A lot of this you can pick up on your own with trial and error, tips and tricks from attendings, and good social skills–but it seems like it’s this gaping hole that medical training is de-emphasizing, even though it’s the bulk of “practicing medicine” as professional physicians.

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