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What reformers and their opponents should know

I’ve never had a guest post on MCM but an email from a colleague inspired me to ask if I could publish it not as a comment but as a post.
The writer addresses the issues laid out in my post earlier this week about the inherent conflicts in many Americans’ desire to pay lower taxes while getting whatever care they want from whomever they want.
Here’s the guest post.
Your most recent posting and photos brings to mind a case I am now reviewing of a woman who is suing a nearby city for a sidewalk fall. She has more than a decade of treatment and I have gone thru over 4000 pages of files for everything from GI problems, multiple orthopedic interventions including several ineffective spine and knee surgeries, obesity, migraine, ‘fibromyalgia’, history of hysterectomy at young age for pelvic pain, multiple bouts of depression and anxiety, history of domestic abuse, opiate dependence, multiple work comp, auto and disability claims. Her pharmacy records alone are a 59 page printout from 2006 through 2009. Providers include primary care, GI specialists, Gynecology, MSW, Psychiatry, Psychology, ARNP, chiropractors, massage therapy, acupuncture, neurosurgeons, orthopedists, physiatrists, physical therapy, neurology and some I have may be forgetting. And the file even includes over 100 pages of emails to and from the patient and the various providers.
I could go on. My task focuses mainly on causality of the recent injury claim to her back and spine complaints. As a psychiatrist I have been engaged along with other physicians because of the big picture; emotional issues are likely significant or primary drivers for her multiple somatic complaints, surgery, narcotic consumption and life decisions in general. Her demands for this injury are about $600,000 according to the referring attorney, with the inference being that her current problems are the result of a minor slip and fall in 2006.
I found myself wondering how much her care has cost the rest of us and how little of the care had any real value in terms of doing anything meaningful for her health and her life. She currently has chronic multi-system pain complaints, history of multiple surgeries without obvious underlying pathology or positive outcome in most cases, and she is now opiate addicted. My impression is that there may be more than a million dollars in care that she has received over the past decade or more. It is far from clear whether health reform would in any way change this for better or worse but she represents the Pareto principal (ie 80/20 or 90/10 or 95/5 rule in her case) in practice and she is far from alone. I am likely one of the minority of people engaged in the health debate who actually see individuals that reflect the problems we face in society and in health care. This case is an example of how we as a society medicalize emotional and social problems and the extraordinary level of waste represented by many medical interventions, to the degree that the interventions side-step or avoid what is really going on – but spend extraordinary resources in the process. Most practitioners can likely share similar stories from their training or practice, but it seems to be a secret hiding in plain sight. Consider the difference between this scenario and the meager resources available in much of the world for life changing and saving care. The cost of her care could vaccinate large geographic regions in the 3rd world and actually save lives if we could somehow reallocate the resources.
I find it interesting that some folks like us are willing to pay more in taxes for a better society, while we likely use relatively little in terms of government services – while many who rely on government largesse, like those riding power chairs because they are too lazy to walk, who may be collecting their own Social Security and Medicare while perhaps pulling out far more than they ever put in – are holding tea parties. Many of these protesters are one pink slip away from no health care and no income, yet they protest for who and for what?

10 thoughts on “What reformers and their opponents should know”

  1. Bravo! Nice to hear someone address the elephant in the room. I’m sure we all know at least one of these individuals personally…the entitled. I always think how sad it is that this is the only way they know of to get attention and companionship….to seek medical care for neverending lists of ailments when some effective therapy and an Rx for reality would do the trick much better.

  2. Why do both private and public health care systems make any payment whatsoever for inappropriate, medically unnecessary, known to be ineffective and (incidentally) potentially harmful “treatment”? Studies show that poor outcomes of improper treatment (particularly surgery) results in more treatment (more surgeries and sometimes a lifetime of narcotics for the residual of the poor outcomes of improper/unnecessary surgeries. Why not have a rule that if the treatment doesn’t fit the guidelines (that’s a hornet’s nest in its own right) , and the patient is either worse or unimproved by the non-guideline treatment, then the doctor can’t be paid by the insurer.

  3. Great Job Doctor but she will be healed when the check clears. That is a fact when medicine is driven by litigation.

  4. What are the chances that she has any idea of what the billed or paid amount for her care has been? Little to no chance. One of the primary drivers of our out of control healthcare cost is the complete lack of cost transparency and a consumer that doesnt care because someone else is paying the bill.
    My company processes healthcare claims. I have a claim sitting on my desk in which the provider billed $155,000 for one day of radiation treatment. Fortunately the PPO discounted the claim by 45%. What a deal!!!

  5. Everybody knows greenbacks are the best medicine. The doc makes sense up to the last couple of sentences…try tort reform instead

  6. There is another side to this when it comes to the obvious call for “tort reform.” The state across the river from my farm provides sovereign immunity for cities. What this means now in practice is that the small city across from me has decided not to enforce its sidewalk laws because they can’t afford the personnel to inspsect and hand out citations. The result is that large stretches of the sidewalks are now death traps– sheets of ice daunting even for the young and agile. I have talked to the mayor about this and all I got was belligerence– that’s just tough. So old people fall and smash their hips? They can’t sue, so who cares? That’s tort reform in action. Careful what you wish for.

  7. Karen – thanks for the comment.
    What facts and research do you have to support your assertion that tort reform is more important? All the evidence I’ve seen suggests otherwise – tort reform would have little, if any effect on health care costs.

  8. Con on Joe you have been a consultant long enough to know that any meaningful change to healthcare has to include real tort reform. It is very real that doctors perform tests and unnecessary proceedures to protect themselves in court and patients sue because they did not like the outcome, whether it could have been prevented or there was any actual malpractice. The story that started all this is a prime example of what is wrong in America’s healthcare system. We should try tort reform before we adopt NICE.

  9. LP – thanks for the comment.
    I don’t agree that any reform has to include tort reform. What data do you have that supports that position?
    I’d suggest you consider the number of Americans injured and killed due to medical malpractice, and compare that to the number of suits that are filed. There is a malpractice problem, and an insurance problem, but the tort problem is more urban legend than fact.
    I have seen little evidence that reforming the tort system will have any appreciable impact on health care costs.
    let me know what you find.

  10. As a 30-year veteran in the healthcare industry, I do see the merits of both sides. I think there is some common ground.
    First…I would increase the utilization of HSAs. It is a powerful plan, that when used right…saves money and rewards the consumer. By adding some tax credits AND increasing funding for state high-risk pools, we can get this thing done without going into more debt.
    Just my two cents.

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Joe Paduda is the principal of Health Strategy Associates




A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.



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