A team of four residents (maximum of two at a time in 12-15 hours shifts at the hospital) and an Attending/faculty doctor cares for our family medicine patients when they are hospitalized. Other services have other team structures. Our patients come from our clinic and a number of satellite clinics and are adult medicine patients, women in labor, new moms and their newborns, and some women with prenatal problems requiring hospitalization. The residents are first year (interns) and senior (second and third year).  Our residents are generally smart and attentive and work well with our patients, treating them as individuals with lives outside the hospital and with careful management of the reasons they are in the hospital.  They do a good job running between laboring and delivering women and our very ill internal medicine patients.

Recently when a friend was the attending on the service, a patient with complex medical and psychosocial concerns was admitted.  The team created the time and space to really unearth some of the underlying physical and social challenges faced by this patient.  This led to a carefully orchestrated discharge plan, including where and when she would be seen for ongoing care and what elements that care might contain.

Once again our health care system snatched defeat from the jaws of victory.  The patient’s insurance covered our hospital, but it turns out it did not cover being seen in our neighborhood clinic, which is part of the same health system.  The patient did not get the necessary outpatient care and was readmitted to the hospital.

Last night I heard that one of the major insurers in this area dropped a contract with a major hospital that is used by many physician groups.  Instead they are contracting with another hospital that has its own multispecialty group.  Now all the medical groups who have used the other hospital are rushing to see if the approved hospital will give them privileges to hospitalize their patients. If not, their patients will have to be hospitalized at the approved hospital by doctors who do not know them and whose electronic medical records do not communicate with those of the outpatient doctors from the other hospital.

What has always been clear to me:  the insurance companies will keep their profit margins.  (Oh yes—hospitals and doctors’ groups want to do the same.)  None of this is the recipe for improving health and health status or for curbing health care costs.

The task of trying to provide continuous seamless care for our patients just gets harder and more insane.

Every major country with good health outcomes has lower costs.  Take a look at the expenditure tables in this Commonwealth report.   Look also at : 1) the tables on mortality from index cancers, 2) hospitalizations, 3) deaths in hospital.  For all we spend, we do no better than other industrialized nations spending much less.  According to The State of the Worlds Mothers 2013 report, we are 30^th in the world for newborn deaths on the first day of life. 30^th!  The top ten with the lowest rates are Finland, Sweden, Norway, Iceland, Netherland, Denmark, Spain, Belgium, Germany, and Austrailia. Our spot, 30^th, is worse than any industrialized nation.  Life span, you might ask?  We are 48^th in the world, despite our spending.  Each of the industrialized nations with better outcomes than us also has significant government involvement in setting prices and policy, which our electorate continues to fight.

I am far less concerned with the troubles of the ACA website; gee, my electronic medical record crashes on me all the time when I am up late at night doing my charting.  I have to live with it, boot it up again, and still get the job done.  Even fewer choices of where to get care is ok with me.  That may be a price to pay to get more people covered, at least the way we have chosen to go about it in this country.  But if fewer choices and inadequate technology are accompanied by insane lack of coordination of care across locations AND by rising profits of insurance companies, well then, I continue to not understand how Americans can fear a single payer plan.