Health Care– What’s Missing?

The current crisis in health care is more than an argument about universal coverage versus “free market” medicine or costs.

Case example (this is  patient currently trying to get appropriate care):

Noting a chronic cough the patient was referred to an ER and had a CT scan which showed a fist sized anterior mediastinal mass.  Within three days she had a needle biopsy.

The first result of the biopsy came 5 days later and was inconclusive.  The specimen was referred to a university center and five days later (almost two weeks after the CT) the patient was informed that the biopsy was inadequate to make a diagnosis.

Her family doctor referred her to an oncologist and made arrangements for a surgical consultation both another 10 days later–into the fourth week since diagnosis.

On seeing the oncologist she was admitted to the hospital ostensibly to be seen by a surgeon and to have a PET scan.  The surgeon never visited the patient and the PET scan could not be authorized without a diagnosis.

The patient is now 4 weeks post CT scan and still has no diagnosis or treatment plan.

Medicynical Note: The patient has been seen by an ER doctor, primary care physician, radiologist for biopsy, pathologist (indirectly), oncologist 1( in the office), oncologist 2 at the hospital.  In the rush of their respective businesses, it appears that no one except the ER doc has taken seriously the patient’s problem and the need for  expedited evaluation, and treatment.

In our non-system we have given little attention to improving health care delivery and providing better value.  In the case cited everyone’s priorities seem to have taken precedence over the patient’s.  No one to this date has acted as if this were a serious life threatening illness.  The patient has accrued thousands of dollars in costs and yet has no diagnosis or treatment plan.

As the Harvard Public Health Review has noted:

Across the United States, trust in institutions that guard the public’s health and provide care has fallen to an all-time low. Patients mistrust insurers and pharmaceutical companies, and lack complete confidence in their doctors; physicians, in turn, are skeptical of clinic and hospital leaders.

The article also notes:

Since then, Shore notes, service has declined while premiums have risen. News headlines have fueled public suspicion by spotlighting both tragic medical errors (Boston Globe reporter succumbs to cancer chemotherapy overdose) and fraudulent practices (a hospital scam to bilk Medicare of $2.6 million). Meanwhile, government has been unable to resolve two problems Americans consider urgent: rising health care costs and the growing ranks of the uninsured.

Part of the problem is that in our non-system  financial incentives are aligned to encourage utilization of services with little consideration of organization, order, efficiency or value.

A New England Journal article on biomedical research sums up the situation:

Since the mid-1990s, the United States has invested approximately 4.5% of its total health expenditures on biomedical research. In contrast, only 0.1% supports research in health services, comparative effectiveness, new care models, best practices, and quality, outcome, or service innovations. This funding will increase to approximately 0.3% from appropriations in 2010 health legislation.

We need to not only develop new technology but must improve our delivery system.  Wasted resources jeopardize our financial well being.  Wasted time to diagnosis and treatment jeopardize patient’s lives.  Our system, such as it is, too often wastes both.