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 30th in the world for newborn deaths on the first day of life. 30th! The top ten with the lowest rates are Finland, Sweden, Norway, Iceland, Netherland, Denmark, Spain, Belgium, Germany, and Austrailia. Our spot, 30th, is worse than any industrialized nation. Life span, you might ask? We are 48th 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.
Moments 
Well stated, Sharon! I don’t think the electorate has had much of a chance to weigh in on the issue though. It’s clearly corporate lobbying that has kept single-payer (Medicare for All) off the table.
Anne, true that. Also true that the corporate lobbying does PR in a way that pulls the electorate along, playing on fear.
I can’t like anything you post; it wants me to be a member and when I use the log on that I used to sign up for your blog, it tells me I’m not a registered member L Don’t know what else to try.
I love this post and would love to share but cannot figure out how to do it Sharon.
D
try registering again? when you register, it sends you an email that you then have to authenticate. (in my list you are listed as a follower)
I think the lack of choice is exactly what we fear the most and it is happening anyway. I am covered and I cannot go to the doctors I prefer so I just won’t get sick!
No, really that sounds horrible for the patient and any doctor, who truly cares.
With a single payer you would in theory have more choice, rather than a bunch of plans and doctors and hospitals wrangling over the best deal they can get. When I look at our health status in the world, it is all a bit sickening.
Thank you, Sharon, for this enlightening, albeit sickening, information. Linda’s comment may have seemed a bit tongue in cheek, but honestly, I have to say that I’m planning on not being sick. This is why I do take a number of supplements, I exercise fairly frequently, watch what I eat, get enough sleep, and have been regularly practicing acupressure for various ailments. (I agree that having a relatively healthy genetic history doesn’t hurt). But currently, except for annual tests like mammography, I am steering clear of the whole system for as long as I can. I only see things getting worse and worse, and in one specific case, a longtime physician friend of mine in Fresno, California is retiring early because he sees the storm coming and is bailing out. And on a side note, it’s also becoming more publicized that fewer and fewer young people are choosing medicine as a career. As the baby boomers (you and me, etc.) become the new elderly population, the soon to be biggest demographic in the United States, we will also likely have fewer physicians willing to play the game, and then where are we going to be? I’m looking into Shamanism, just in case….
Nancy,
Many of us think that it won’t be a storm, just wish more people would in fact be covered. The paper work is much much more than it would be if we had a single payer. The huge volume of paperwork has been true for my entire career and has increased over the years. As for med school applicants, the numbers are actually increased. See the articles below. I am not in a doomsday mode, and we do need more people in the workforce. The issue is that we lack sufficient residency training slots for the students admitted, and that is tied to federal policy.
http://ow.ly/s3KOO
http://ow.ly/s3KNf
Well said, Sharon. I took care of the patient you are referring to, and in the 30+ years I’ve been practicing medicine I have never seen the system so broken. Ultimately we provided poor care because of insurance issues. Unfortunately, the political blame is likely to go to the Affordable Care Act, rather than to where it belongs–health care has become a huge business that is profit driven, with many players (administrators, pharmaceutical companies, doctors, device manufacturers, insurance companies, etc etc etc) reaping riches. It is beyond insanity that “we” think a single payor plan could ever be worse than what we have now. As a physician, I cannot give good care if I cannot follow my patients across the different arenas where they need care (my primary care office, my consultants, the hospital, their nursing home, their mental health provider, their physical therapist, etc etc)–it is discontinous due to multiple insurance companies, zillions of ever changing alliances and contracts, many different electronic systems, “privacy” concerns, and patients being forced to change providers due to their employer. It is beyond crazy. What if our insurance followed us regardless of where we lived, who employed us, whether or not we lost our jobs? Health care should not be like going to McDonalds–it does not matter if a different employee makes your Big Mac on different days, but it matters hugely if you are unable to have a consistent, ongoing relationship with your health care providers. And why should the cost of a service vary many fold for the same service simply because of different contractual arrangements? Why should anyone support a system that spends more than twice as much on administration (negotiating those contractual relationships, managing claims, etc) than other countries with far better outcomes? Until people and their political representatives come to grips with the fact that they are being ill treated and ill served by a chaotic system that measures success in terms of profit rather than health, we are doomed to continue proving to the rest of the world that we are idiots.
I could not have said it better.
Thank you.