Free Markets Won't Save Health Care

I hate to be the one to break it to conservatives, but there are no free market solutions to America’s healthcare problems. Free markets exist when purchasers have the ability to make informed choices. If widget maker A makes a better widget then widget maker B and sells it for the same price, consumers will eventually choose widget A. Widget maker B will have to lower its prices, improve its quality or go out of business.

Patient care is not like widgets.

Purchasers of health care services have no accurate way to compare health care providers. The most commonly used measures of quality are dependent more on the provider's ability to convince patients to do what they should than they are on the actual care provided. An example of this is colon cancer screening. There is no effective way to measure the skill of physicians providing colonoscopies, so insurers instead measure screening rates. I know of a physician who screens for blood in the stool based on office exams, in direct conflict with the recommended testing protocol. He knows this is not as accurate, but he doesn’t care. He has the highest rate of colon cancer screening in his medical group, and gets a large bonus as a result. His quality is low, but his quality ratings are high.

Hospitals are similarly motivated to meet inaccurate metrics. One of the most important complications on which hospitals are measured is ventilator associated pneumonias. Patients on breathing machines are already seriously ill. If they get pneumonia while on a ventilator mortality rates increase dramatically. It makes sense that hospitals be given incentives to develop policies to improve outcomes by preventing these infections. As a significant amount of money is tied to this quality measure hospitals have aggressively searched for ways to lower the complication rate. Many hospitals have found an easy way to improve their scores. When ventilator patients get pneumonia, they call it something else. Voila! No more pneumonia. Patients still get sick, but hey, the hospital numbers look great.

Inaccurate quality measurements are a major problem that has not been addressed by Obamacare or any of the other proposals currently put forth. We live in a world where looking good at times pays better than doing good. Insurers, hospitals, medical groups and physicians are all looking for ways to improve their bottom line. Most are trying to do a good job taking care of patients but good care is not a guarantee of financial success and institutions that don't succeed financially can't help anyone.

If we are ever going to reach a solution for our healthcare problems we will need to begin by making sure that incentives are aligned with patient outcomes. The best way to do this is by establishing systems where keeping patients healthy leads to the highest profits. There is no perfect system, but any good solution will need to make patient health the key to success.

- Bart

The Doctor will see You... For $3500

My grandmother went to the doctor this week with a sore on her leg. She came home with a bill for $3500. The bill had nothing to do with the treatment of her leg wound. The bill was to cover the doctor’s new annual membership fee. If she does not pay it she will be forced to seek care elsewhere. She is 95 years old and on a fixed income and will need to either pay up or move on.

Her doctor left me a lengthy voice mail explaining his fee, informing me that it will allow him to spend more time with each patient and provide high quality care. What it won’t do is cover any of her visits for the year. Those are extra and will be billed to her insurance. The $3500 is for access alone.

The fee seems exorbitant and it is. A typical senior citizen goes to the doctor 6 times a year. The fee works out to a payment of an additional $600 per visit, an astronomical sum.

While the charges are insanely high they are becoming increasingly common. Doctors who cannot make ends meet on what insurance companies pay are looking to their patients to pick up the slack. Especially for older and sicker patients, insurances don’t pay enough to cover the time needed, typically only about $120 for a 30 minute visit. This may seem like a lot, but after factoring in overhead ($160 an hour) and unpaid time spend on refills, phone calls and emails, the end result for the doctor paid this fees could be a salary of about $120,000 a year. While this is a good wage for many people it isn’t enough for a doctor with student loan debt to live in Southern California, where mortgages for a modest home can exceed $4000 a month. Many doctors are desperate to find a way to increase their income.

While this is understandable, the $3500 fee seems excessive. It seems that a doctor with 2000 patients in his practice could make ends meet by charging much less. $100 a year would result in a $200,000 a year increase in salary and make up for what insurance pays. Why charge $3500.

My recent experience answers the question. The majority of patients won’t pay the smaller amount either. My office provides a wide array of services, from guaranteed same day access and short wait times to digital visits and email communications, that are not covered by insurance plans. To cover the cost of these services, on January 1 of this year we started charging an annual access fee of $120. While we thought this was reasonable and affordable we have lost over half of the 1000 patients to whom we billed the fee. In their minds the additional access and services just aren’t worth it. It is apparently easier to find 200 patients willing and able to pay $3500 a year than it is to find 1000 patients willing and able to pay $120. My grandmother’s physician has figured this out.

This does not bode well for the future of medicine. None of the current health care plans being discussed in Washington D.C. or Sacramento address the reality that good medical care costs a lot of money and that quality doctors require competitive salaries. Patients unwilling or unable to pay extra for services will find it increasingly difficult to find a primary care doctor willing to see them and will be increasingly unhappy with the options available. It seems we are headed for a crisis of inaccessibility.

The solutions to this problem are too complex for a blog post but there is one thing of which I am certain. These solutions will not be easy and will be expensive.

-          Bart

The comfortable Christian message

She had been raised in the faith since she was a child. Church had always been a part of her life and she had accepted the teachings of the faith without question. Then she entered law school. It was while she was there that she began to have her doubts. 

The source of her doubt surprised me. I expected to hear that she had struggled with deep theological issues or a perceived lack of alignment between her faith and the teaching of modern scientists. Her thoughts did not run that deep. Her concerns were much simpler. She just didn't like what the Bible said. She struggled with the Bible's definition of sin, especially with regard to the church’s teaching on sexual sin. She simply could not understand how a loving God could allow people to be born with same sex desires and then say that these desires were wrong.

We talked for quite a while, returning again and again to her discomfort with God’s seemingly arbitrary nature. As we talked I thought of how our conversation embodied one of the major challenges facing the church today. The Bible's teachings do not make sense to the world in which we live, and the world demands answers. What response do we give to those who define love differently than we do? What do we say to a world that struggles with the moral positions set forth in scripture?

The common answer, one that I have heard from people in my own church at times, is to avoid emphasizing specific sins or God’s judgment on them. The theory is that people who otherwise might come to a faith in Christ could be driven away by talk about the need to repent,change or leave any lifestyles behind. Better to introduce them to God’s love and let God change them over time.

This theory is appealing as it reduces conflict. It is appealing, but it is wrong. It presents a half truth about the gospel message. The truth is not only that God loves us, but that He loves us in spite of the fact that we are wretched, self-indulgent sinners. The truth is not only that God calls us to Himself, but that God calls us to die to ourselves, to leave our desires behind. The truth is that God wants us to be truly happy but that true happiness can only be found in Him, not in fulfilling our own desires. Every person who wishes to follow Jesus will have to lay aside some desire with which they were born, some tendency present since birth. They do so because they accept the truth that we are not okay the way we are, and that we need to change. They do so because they understand that the blessings of eternity far outweigh any joy earthly life can bring. 

My friend demonstrated the real issue for many who claim faith today. She wants to pick the parts of the Bible she agrees with, to decide for herself what is true and right. In so doing she reveals the truth-  She only believes part of the Christian message, the part that makes her feel comfortable and good about herself and others. The whole Christian message is much more difficult. 

- Bart

A Broken Mirror, But No Bad Luck

I wanted to be home. It had been a long day at the office and my trip had been delayed by an empty gas tank. I was late, I was hungry and I was in a hurry. I was two turns from home, on the busy street beside the local park that backs to our housing tract, when I saw it coming towards me. Bouncing out between the cars was a bright yellow soccer ball.

My foot instinctively moved to the brake, fearful that the ball would be followed by a child running out from between the cars. My fears quickly passed as a I saw a fence along the curb. The ball was alone on its journey into the street. As I came to where the ball was it took a high bounce that brought it to the exact height of my passenger side mirror. At 30 miles an hour a soccer ball generates significant force. I heard a “pop” as the ball hit the side mirror and then saw the mirror disappear from its plastic casing. I pulled over to survey the damage.

The plastic casing was intact and still attached to the car but the reflective piece was completely gone. There was naked black plastic in the place where reflected objects are "closer than they appear to be". I sighed and walked the 100 yards to retrieve the missing piece, back to where the soccer ball had appeared and the mirror disappeared.

As I walked, thoughts of frustration and anger began to rise, including, “Why was a child kicking the ball toward the street?” “Why wasn’t the coach paying attention?” and “I shouldn’t have to pay for this!”

I found my cracked mirror underneath a truck parked adjacent to the low fence alongside the practice area. I picked it up and turned toward the field and looked for the coach. He was a young man, in his late twenties or early thirties, standing about 30 yards away. He was absorbed in the impossible task of trying to get the attention of fifteen 6 to 7-year-old boys. I held up the mirror and called to him, “Excuse me!”

He immediately looked over. When he saw the mirror in my hands his head dropped and his hand went to his forehead in a gesture of frustration. He walked over to me with an apologetic look on his face. His words matched his expression. “I’m sorry,” he said, “They were supposed to be on water break and he kept kicking the ball. I told him to stop. I will tell him and tell his mom.”

All thoughts of anger and frustration faded as I realized the truth of what had happened. A young coach was doing his best to control a group of energetic little boys. One of them had kicked a ball at a time and in a direction he was not supposed to and a freak accident had occurred. The young coach was now confronted with a middle-aged, shirt and tied man holding a damaged mirror. The coach was fearful of anger and a demand for compensation.

I looked at the coach and the players and realized that the cost of replacing the mirror would likely be a significant burden to them and little burden to me. I could likely rant and rave and claim my right to compensation but what was the point in that? I felt my angry heart soften.

“I can afford to have the mirror fixed,” I said, “but I think he should know what happened so he can learn to be more careful.” The coach called the little boy over. The boy looked fearful as he approached, as if he was expecting to be yelled at and punished. He was clearly relieved when he learned that neither was going to happen. I showed him the mirror, told him I knew it was an accident, but that he needed to be more careful, because it costs money to fix things even when they are accidentally broken. Then I walked away.

As I walked back to my car I realized how much I had changed over the years. Growing up my parents had instilled in me a strong, albeit corrupted sense of “right” and “wrong.” I was taught to assert my rights and get what I deserved. Grace and forgiveness were not Barrett family values. On the rare occasions that forgiveness was given it always came with a price, a debt that would have to be paid or guilt that needed to be felt. There was no such thing as an innocent mistake to my father.

I thought back to the lectures and verbal abuse I had received as a child for innocent mistakes I had made and the associated ever present fear of doing wrong. I remembered times when my father insisted that I confront someone who had wronged me to demand that I get what was coming to me. That was the Barrett way. As i got into my car I took comfort in the realization that it is not the Barrett way any longer.

I drove away with the realization that the coach and the boy had no idea who I was, no way of knowing how to find me in the future, and no way of ever paying me back for the damage that I had been done. I decided that this way, the way of grace, is the best way to respond.

-          Bart

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A Baby Taken, Hearts Broken

I wasn’t ready for the tears. Patients don’t typically cry during visits for diabetes, especially when their sugars are well controlled and their labs are all normal.

The tears started when I deviated from the standard medical questions. As I was wrapping up the visit I asked, “How is the rest of your life going?” Immediately they came, prompting the need for a box of facial tissues as well as additional questions. It was clear her heart was broken.

She had lost her grandchild a month earlier. The child hadn’t died, it had been taken away.

He son and daughter-in-law had adopted a daughter. Unable to have a child on their own their prayers had been answered when their adoption attorney found a woman unable to care for the baby she was carrying. They brought her home the day she was born. Life was perfect and she was perfect and my patient was in love with her grandchild.

28 days later the birth mother changed her mind and in an instant the child was taken, taken to live in a car with her birth mother, never to return to the family that had fallen so completely in love with her. They were left with an empty nursery, broken hearts and the question, “Why?” echoing in their minds.

My heart broke along with my patient’s as she told me her story. I battled to hold back tears but eventually gave in and let them flow. I thought of my adopted daughter, of how she had immediately and permanently captured our hearts, and imagined the magnitude of my patient’s loss and the depths of her grief. I struggled to find words of comfort and solace. we talked for nearly 20 minutes. 

At the end of our conversation we walked out of the exam room together. I stopped at the nurse’s station and said good-bye. She turned to walk to the exit, paused for a moment, then reached into her purse and turned back. As she did I noticed she had her phone in her hands. “I want to show you something,” she said.

She quickly scrolled through her photos and stopped on the image of a beautiful month old baby. Her hands trembled as she showed it to me. “This is her,” she said, telling me what I already knew. My heart broke again for her as I looked at the photo. Impulsively I touched her shoulder and guided her back into the exam room. I closed the door and held the phone with her, joining her in staring at the picture.

“Can I pray for her?” I asked. I looked at the photo with tears in my eyes and prayed. I prayed for God’s protection and love, that the child would grow up healthy and loved, and that she would one day be reunited with her adoptive family in heaven. It was a helpless prayer, the only thing I could do. I gave her the phone and a hug and she left the office. 

Her story reminded me that I live in a world full of hurting people. I am surrounded by broken and breaking hearts, by people wondering where God is and what he is doing, people who are losing hope and struggling to make it through the day. People who have a burden they need to share with someone else, people who need love and prayer and someone to care.

I am reminded that no matter how busy I get, I should never be too busy for them. I need to be open and aware, to be the one who asks the right questions and then takes the time to listen.

- Bart

Thanks for reading and sharing. Please pray for the baby, for the family that has her and the family that lost her. 

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