Medical Care System in the United States: Looking at the Road Ahead

What is happening to the medical care system in the United States? And what is going to happen to it in the road ahead? This topic is currently being discussed on a bioethics listserv to which I subscribe. An ethicist wrote there a very succinct description of what is happening and perhaps what to expect. With the permission of the ethicist, I am reproducing it here. I do look forward for President Obama to come up with plans for a better healthcare system for all patients including their healthcare providers. However, personally, I think it will take more than just to put all medical records on computers. And, you know, as the ethicist implies, there should be “widespread ground-level discussions between individual patients and their (vanishing) primary care physicians about the concrete ends of medicine as applied to them. “ What is it that can be done for the patient but also what should be done within the limitations of any system? What do you think? ..Maurice.

Truth is, as professional organizations such as [American College of Physicians] have observed, the morale of primary care docs and the supply of same is low. There is an entire boomer generation of MDs that are counting their shekels in anticipation of exiting the system were they to take an economic hit with the introduction of more "reform." The current generation of trainees, weaned on the requirements of limited work-hours, are encouraged to understand their vocation as shift-work. The didactic model of trainees actually seeing and dealing with the consequences of their therapeutic intervention has, accordingly, been gutted. The "mistakes" avoided by the absence of adequate sleep are just being kicked down the road, giving rise to a generation of attendings who never learned from said "mistakes," not being around to see them, and not being required to own them, thus creating a generation of attendings who commit mistakes without any awareness or responsibility for same.


The old model of a primary care physician who sees their patients in the clinic and in the hospital is increasingly rare with the segregation of duties into "hospitalist" and "clinic doc" is on life-support. The idea that "extenders" will solve this problem is folly: Extenders will simply shift the delegation of duties to individuals with less training, less experience, less oversight and less responsibility than MDs.


"Preventive medicine," for all its virtues, won't fix this problem, just kick it down the road. [For example, in the field of nephrology], the vast uptick in the number of prevalent dialysis patients can be attributed to the success of preventive medicine: Since the vast majority of patients with chronic kidney disease (CKD)(but not end-stage disease) die from cardiovascular complications before they reach end-stage, interventions which permit people with CKD to survive their (previously fatal) MI or CVA permits more people to live long enough for their kidneys to fail. Such are the wages of success.


Anyone enamored of the virtues of socialized medicine should closely examine the economics of end-stage renal disease,ESRD being the only disease category with a fully-funded entitlement under Medicare, cost the government $22.7 billion in 2006. In context, 0.6% of Medicare beneficiaries consumes 6% of the entire Medicare budget. (Private payers account for another $12 billion annually). These are sick patients, progressively older (wages of success again), with a panoply of medical problems which require a competent and attentive internist to manage (correct drug-dosing in this population alone is worthy of a graduate course). By all means, this entitlement has meant that hundreds of thousands of our fellow citizens are above ground rather than below, but not cheaply.


The ESRD model reveals a truth about the economics of health care: "Health" is a bottomless well, economically speaking. Draconian top-down line-drawing will have unintended but often forseeable consequences, and the affected players will unsentimentally shift their positions accordingly. With so many moving parts, top-down interventions will inevitably give rise to examples of what Bastiat called "What is seen, and what is not seen."


As the failure of the Oregon plan showed, those who lose in a system of scarce resource allocation are often quite sympathetic. Coarsening the capacity for sympathy for the unfortunate to achieve system-wide economic sustainability has its own consequences. What is conspicuously missing from all this is any widespread ground-level discussions between individual patients and their (vanishing) primary care physicians about the concrete ends of medicine as applied to them. Getting all weepy about the way it used to be is just sentimental self-indulgence....the old model is under hospice care. But until that conversation is had in some broad, effective way, my grandchildren will be paying the monthlies on the third mortgage we're now taking out on our health care system.

Graphic: The Road Ahead photograph from Mythsnlegends