As discussed in my last column, I am recovering from a double mastectomy with immediate reconstruction. During this ordeal I have learned a great deal about breast cancer, but even more about America's health care system — most of it not good.
We have some terrific, caring doctors (and I had some), but the system of accessing appropriate care and paying for it is broken beyond belief.
According to the Commonwealth Fund, a private foundation promoting high-quality health care, the United States ranks last of 16 industrialized countries on mortality amenable to medical care (medically preventable deaths), yet we spend more than any other industrialized nation on health care.
Where's all our money going?
Think administration, billing, fragmentation and redundancy. Seven percent of health spending in the United States is wasted on insurance administration alone — a statistic that calls out for a single-payer model. We spend double or triple what other countries do for administration, and the financial incentives in our system reward disaggregated care over efficient coordination.
My last column discussed the pointless and frustrating odyssey in trying to understand medical billing practices. This week, allow me to share my experience with medical silos and the fragmentation of care.
To get diagnosed and treated, I had to visit or interact with at least eight different medical offices or hospitals (never mind the second infuriating and time-consuming job of dealing with my health insurance carrier). I found myself thrust into the role of general contractor for my disease, enlisting subcontractors for various aspects of the job — a responsibility for which I wasn't particularly qualified.
One office handled the mammogram, ultrasound and biopsy, a separate lab did an initial blood test, another place did the MRI. I went to one office to see a general surgeon, a different office to see an oncologist, and another to see my plastic surgeon. Finally I had a preoperative EKG and blood work at a clinic associated with the hospital I went to for the surgery. Any disease management coordination that occurred was left to my primary care physician. And there wasn't much, since as far as I could tell, she wasn't getting paid for it.
In nearly each case, these offices (even those associated with one another) had me fill out pages of medical background information asking the same or similar questions. When information was shared it was often faxed. (Who faxes anymore?) (A shout out to oncologist Dr. Vu Tran Ho whose examination room was actually equipped with instant digital records access!) Each office had its own staff to schedule patients, do billing and interact with insurers. It's hard to conceive of a more inefficient, expensive, redundant system.
Then, when I tried to gain access to my own medical records so I could better understand my own health, the system put up reflexive barriers. Sometimes I was flatly denied, such as by the lab that tested my blood. Bayfront Family Health Center required a formal request from me by letter (and not through e-mail). The MRI office forced me to drive there to personally pick up a copy of the report, and made it clear they would not interpret the results for me.
Before surgery, my general surgeon's office sent me a form that said it was my responsibility to contact the radiology department where my initial biopsy was done, "pick up those films" and "deliver them" to the hospital's radiology department before the day of the operation.
That's up to the patient?
At nearly every turn it was evident that America's medical system is overwhelmed by inefficiencies and profitmaking that make it indifferent or even hostile to the patients it serves.
On the bright side, some help is on the way. Under the Affordable Care Act, rules will be established for the use of electronic medical records that will transform information sharing and make the system overall less error-prone.
Next year, the new law also ushers in "Accountable Care Organizations," which will be networks of multi-specialty doctors and hospitals. The idea is to pay more when health providers cooperate, communicate and coordinate among themselves to further the health of the whole patient. The current model financially rewards excessive, expensive care, with each doctor focused on a sliver of a patient's health needs.
Medical innovator Dr. Stephen Klasko, dean of the College of Medicine at the University of South Florida, thinks the government regulations associated with ACOs are too burdensome but that the concept is "100 percent where we should be moving." He also sees the "bundled payments" aspect of the new law, which pays a flat rate for treatment of the entire disease or injury rather than for individual services, as spurring good, coordinated care. According to Klasko, primary care physicians are the key. If they were paid better, we'd return to the Marcus Welby, M.D., model of personal, relational medicine that would address a lot of the systemic problems.
Meanwhile, experiments are going on around the country to develop more patient-centered medicine. Dr. Bruce Ramshaw, chairman of general surgery at Halifax Health in Daytona Beach and a hernia specialist, is doing trailblazing work around designing medical groups as adaptive systems that are constantly using patient experience and outcomes to improve care.
Cancer is an ugly thing to go through. But the real monster is America's grotesque medical system, with its private insurance overlay. So many other advanced countries have figured it out, delivering high-quality, universal, coordinated health care for far less money. When fully implemented, "Obamacare" will get us part of the way, but 2014 feels a long way away. And the entire Republican Party is amassed against what is America's only current hope for more rational, compassionate, affordable health care.