Surviving the Medical Meltdown (8 page)

Private industry will not produce the products needed for state-of-the-art medicine. We will have more shortages of antibiotics and anesthetic agents and catheters. Doctors will get used to a lesser standard of care, will become blue-collar shift workers, and will no longer concern themselves with caring for their community. They will be too busy trying to save themselves and those close to them. Like the many dispirited Soviet and British physicians, they will simply accept that they are powerless to change the system. Given our present trajectory, this is what awaits us.

5
WHAT THE MELTDOWN WILL LOOK LIKE

A
lthough we can never be certain about the future, events happening now give us some idea of what medicine will be reduced to in the future. In the last chapter I outlined how the accountable care organizations (ACOs) are pushing us toward this future. But even without them, trends are very evident. Today, all over America, small and midsize hospitals as well as hospitals in inner city, poor areas are closing. Recently, Los Angeles Metropolitan Hospital – a 212-bed facility with an emergency room that served the neediest patients – closed. This came in the wake of a federal fraud case citing “unnecessary care” being given to the poor. Although fraud is always a possibility in third-party payment schemes, the truth is that “unnecessary care” is a term used by bureaucrats to avoid paying providers. And quite frankly, as the money has dried up for Medicare and Medicaid, this failure of payment for
actual services rendered
is happening more and more often.

And the result is predictable: economic failure of hospitals and physician practices that have become dependent on government payment for large segments of their population. The hospitals and offices that will close are those with the least private insurance – as in this case of Los Angeles Metropolitan. These closures result
in larger and larger areas where no doctors or hospitals exist. As reported in the
Los Angeles Times
, these closures affect small and midsize hospitals “that don’t have the negotiating clout or resources of larger hospitals or giant health systems.”
¹
(This demonstrates a principle of economic fascism known as “cartelization” – businesses joining together into massive cartels to be able to afford the legal and financial advisors needed to navigate the maze of government bureaucracy. Small fry businesses are toast.)

As hospitals close, doctors will move to areas where hospitals are available. In fact, physicians are already preferentially locating to areas where there is a high ratio of private to government insurance.

Malpractice insurance costs also aggravate this flight to more “genteel” areas. The naked truth is doctors are more likely to be sued by the neediest segments of society, as well as those hospitalized for high-level trauma.

At one point (I don’t know if this is true today, but it was true when I was an orthopaedic resident visiting Ranchos Los Amigos in the late 1980s) the senior spinal surgeon at Ranchos Los Amigos spinal cord injury center was the most-sued doctor in America and could not buy malpractice insurance at any cost. Was he incompetent? NO. He was arguably one of the handful of the most highly trained, highly experienced surgeons in his field. But his population consisted of indigent trauma and gunshot victims who had been rendered quadriplegic or paraplegic by their injuries but who were angry about their injuries and saw the surgeon as a potential source of money. So, in addition to making less income and having less hospital support, if you practice in an impoverished community, you are more likely to lose your assets to a large malpractice settlement or to exorbitant insurance fees.

The effect of all this is to create huge, expanding black holes where no medical care exists. Already in some areas of Arizona, for the reasons just cited, pregnant women must travel two hundred miles or more to see an obstetrician and to deliver their babies. Needless to say, roadside and in-ambulance births are reported more
frequently. And for those in high-risk pregnancy categories, this means increased risk of complications around the time of the birth. A better option for those who can afford it is moving in with relatives or into a hotel near a tertiary care center as their due dates approach.

As hospitals close, the remaining centers and clinics will have insufficient money to expand their services. But at the same time they will be overwhelmed with patients who are coming in from a larger radius and who are taking advantage of the government’s funding of “free” preventive care.

So even if you make it to such a center, your wait times may be significant. The hospital in Arizona where I used to work is a 250-bed facility with the latest state-of-the-art cardiac care. It is a referral center for about four hundred thousand people. Although you will get great care there, if you go by foot or car to the emergency room with chest pain, you may wait over six hours for an evaluation because the system is overloaded. In the university hospital in Montreal, gurneys are lined up in the hallways from one end of the building to another, filled with patients waiting for days to be seen in the ER.
²
Ironically, my little twenty-five-bed hospital in the wilds of Iowa has no cardiac program, but if you walk in there with chest pain, you will be evaluated with an EKG that will be reviewed by a physician in fewer than fifteen minutes. You may need to be transferred for definitive care, but you will have immediate and potentially lifesaving support, and the total transport time still is less than the wait time in some big-city ERs. Yet these little hospitals – which serve a vital role in our system today – are the ones falling victim to the government squeeze.

As the money further dries up, more and more facilities will close, and you will have to travel farther and farther for care. This means you will need to anticipate your medical needs further in advance, postpone nonessential care, and decide to treat smaller things at home on your own. (The last half of this book is written to facilitate this self-care.)

A second aspect of the economic squeeze on doctors and hospitals
is threefold: it includes the lack of supplies needed to provide care, an inability to provide the latest technology, and the tendency to scrimp on your care to save the facility money.

Recently, the father of the one of my hospital staff experienced recurrent cardiac arrhythmia – irregular heartbeat. He was told by his cardiologist to have an implantable pacemaker/defibrillator, and this recommendation was subsequently confirmed by two other heart specialists. Furthermore, he was advised, in writing, that without this he had a very significant risk of death within two years. In spite of this, an unelected Medicare bureaucrat determined that he did not meet “the minimum criteria” for the implant, because his “cardiac output” was too high. Now, cardiac output is a measure of how well the heart pumps blood. This is significant in other heart disease but has absolutely nothing to do with people who have intermittent arrhythmia. Nevertheless, some nonphysician Health and Human Services pogue
³
consulted the guidelines and refused to authorize the care. But – and this is the kicker – since Medicare had a fee scale for the procedure, my friend’s father – a Medicare recipient –
could not buy the procedure privately
. Once you are a Medicare recipient, if Medicare offers the procedure (even if they do not offer it to you), you cannot privately contract for it – at any price – unless you go overseas. I have had similar denials by Tricare, Medicaid, and other government payers. They are not denying care because they – the bureaucrats – really know better than your doctor. Of course they do not. They are denying care because they are trying to save money, and they do it by denying care to some people so they can offer other care to another group.

On the walls of my former hospital was posted the “mission statement,” which read, in part, that the hospital’s mission was “rational use of resources.” In my role as rebel
with
a cause, I pointed out that my Hippocratic oath committed me to do the best for my individual patients, not withhold the hospital’s resources at the expense of my patient. “Rational use of resources” makes sense if you are a lightbulb manufacturer. Let’s say 100-watt lightbulbs are
selling well but 40-watt bulbs are not. It makes sense to “rationally reallocate resources” by shutting down the 40-watt production line in favor of the 100-watt line. But how does this apply to health care? When government or any third party controls the purse, it means they decide to deny care to some to give it to others. Usually this is done on the basis of the utilitarian principle of the greatest good to the greatest number. This dictates, and is practiced in every socialized system of medical care, that the very young and the old are sacrificed as being unproductive in favor of working taxpayers.

Denials of care are couched in terms such as “not medically necessary,” “deemed futile,” “experimental,” or “does not meet standard of care” – none of which may be true. The point is simply to save money, and hospitals can do this only by rationing care. That’s all fine and good if you are not the one being rationed! And this is supported by a propaganda program that makes people feel guilty about spending too much on themselves or their aged loved ones.

Recently I was consulted to see an elderly woman with a broken hip. This was a very simple fracture that could be stabilized without even opening the skin except to make three puncture wounds and slip in three threaded titanium screws. I have done hundreds of these, and the actual surgery takes about ten minutes after anesthesia and positioning. Postoperatively, we get people up walking within a day and out of the hospital within three days. Without the surgery, the patient would not be able to walk until (and if) the fracture heals – weeks to months. And of course, for a ninety-year-old, this is often a death sentence, since weakness and the chance of pneumonia go way up in the elderly who quit walking. Nevertheless, the patient’s daughter – a nurse – decided that surgery was too aggressive and too much “end of life care” and opted for nursing home placement. And her mother agreed – not wanting to be a burden. Before this the alert patient had been active and living alone on her own. What a tragedy. But this will be the “standard of care” in the future.

Overregulation has resulted in lack of supplies and the latest medications. Cancer drugs are constantly updating as new science
improves our treatment options. But Medicare (along with the FDA and other players who caused the inflated prices to begin with) is now trying to save money by denying the use of some of these latest drugs. In many cases they “allow” the use but pay so little for the drugs that the providers cannot afford to dispense them. And patients are prohibited from paying the cash difference to obtain the drug. Some oncologists were actually paying out of pocket to supply these drugs to their patients when it really made a difference.
⁴
But this could not be sustained for long, and most of these drugs are no longer in general use.

To make matters worse, FDA and OSHA have closed many drug factories by demanding that they bring their old factories “up to today’s standards” – something factories producing the cheaper drugs cannot afford to do. The result is lack of basic drugs, such as Armour Thyroid and tetanus vaccine. At a major trauma facility, I was unable to get tetanus toxoid for patients for about two months due to a national shortage. (It is important to keep your tetanus vaccine up to date
before
you get injured because you may not have the vaccine available exactly when you need it. Routinely, ten years is the time that tetanus vaccine is deemed effective. You should consult your physician now and make sure you are up to date on tetanus. Also, discuss with your pharmacist which drugs you take that are at risk of shortage now or in the future. In other words, make sure your medications are not on the “endangered” list. If they are, time to stock up as noted in
chapter 15
.)

A third aspect of the collapse will be loss of medical records. Already with the government-mandated EMR (electronic medical records), the quality and availability of your medical information has diminished. I know, I know… the pointy-headed guys in Washington told you that computerization would solve everything – that no duplication of tests would occur because your doctor would have your whole medical history at the touch of a button. Let me assure you: that assertion is anything but the truth. In fact, on computerized charts it is now much harder to read and understand your
history, and working in a clinic today is like practicing medicine with Alzheimer’s – with no memory of past events and starting afresh every visit. One of my physician friends with a high-volume ENT practice said to me, “I just hope the patient will say something to remind me who they are and why they are here.”

Some of the problems of EMR are simply ones of newness and implementation. But sadly, some problems are intrinsic to computerization. And this fact is lost on one-size-fits-all government guys.

Because there is no “industry standard” EMR, the record generated at hospital A cannot be often accessed by hospital B directly. You may be able to look at it on a CD brought physically (i.e., via “sneaker net”) from one hospital to another, but it is unlikely that it will integrate into your current record. (In the old days, paper was universally understood and accessible.)

And then there is the problem of organization. Some EMRs are simply organized chronologically without thought to the type of information being stored. So a patient’s EKG is put on top of the orthopaedic visit, which is on top of the list of primary care visits, which are on top of laboratory data. It takes so long to find the
relevant
medical history that doctors do not have time to both find your history and see you in the clinic in the time allotted. Imagine trying to find a file in your computer that has no specific name and is just stored by type and date. Could you do it easily? No. And so to compensate, in my clinic, your entire medical history (which I actually have at my fingertips) is condensed into a one-line handwritten sentence that my office manager places at the top of a clipboard sheet.