MAGGIE MAHAR:** Over the last 12 years a number of people visiting America’s emergency rooms has soared. Yet here’s what’s surprising: The number of low-income people going to ERs has not increased. The increase has come almost entirely among middle-class people and many of them have insurance.**
NURSE: Whose insurance do you have?
PATIENT: Blue Cross.
NURSE: Do you have your card with you?
PATIENT: Yeah.
**MAGGIE MAHAR: So why do they go to the ER? Why aren’t they seeing their own doctor? Many people think that they know what’s wrong with the health care system in this country. Millions of people are uninsured. And sure, that’s part of the problem. But that’s not the whole problem. The whole problem is bigger than that.
DR. JOHN NIXON: I am on top here. Any problem up there? Any problem in the back?
DR NIXON: There’re just not enough resources out there for, not only your uninsured patients, but also your insured patients. Insured patients have a problem also because their doctors, when they call their office and says, “I need to see…” … “We can’t see you for three weeks.” “Well, what am I going to do for three weeks?”**
DOCTOR: Open your mouth.
Health care costs keep going up, up and up and up. But the access seems to be going down down down down.
All right. Do you need anything for pain right now? You do? Okay, we’ll get you something all right? We’ve got to run some tests and we’ll be back.
PATIENT: Okay, thank you.
I’m just glad, you know, that there’s a place to come to, you know. I mean, dying is not no big deal to me, but you know, people have to go through a lot before they get there.
**MAGGIE MAHAR: When I was a financial journalist at Barrens, I wrote many stories about health care. And what I learned was that much of what we think we know about health care isn’t true. And much of what is true is counterintuitive. So eventually I decided to write a book about health care. And when I did I knew I wanted to talk to a lot of doctors. So I began putting out phone calls. I didn’t know most of the doctors I was calling. I was hoping that maybe 20 percent of them would return my call. To my utter surprise 5 out of 6 of them called me back. And they talked. They talked for 30 minutes. They talked for longer than that. They said, “Please, we want someone to know. Please tell people.” To a man and to a woman what they were most passion about was the declining quality of care in this country. Not about how much they were paid or how much they weren’t paid. They were concerned about the quality of care, about what was happening to their profession and how little power they had to do anything about it.
DR. DONALD BERWICK: It is, I guess, politically correct, widely believed, that to say that American health care is the best in the world. It’s not. There’s a much more complicated story there. For some kinds of care my colleague Brent James calls it rescue care. Yes, we’re the best in the world. If you need very complex cardiac surgery or very advanced chemotherapy for your cancer or some audacious intervention with organ transplantation, you’re pretty lucky to be in America.
You’ll get it faster and you’ll probably get it better than in at least most other countries. Rescue care we’re great. But most health care isn’t that. Most health care is getting people with diabetes through their illness over years or controlling the pain of someone with arthritis or just answering a question for someone who is worried or preventing them from getting into trouble in the first place. And on those scores: Chronic disease care, community-based care, primary care, preventive care. No no, we’re no where near the best. And it’s reflected in our outcomes.
We’re something like the… We’re not the best health care system in the world in infant mortality rates. We’re like number 23. There is an index that is used in rating health care systems, which is the rate of mortality that could have been prevented by health care. There are at least a dozen countries with lower rates of preventable mortalities than the United States and not one of those countries spends 60 percent of what we do on health care.
MAGGIE MAHAR: Dr. Donald Berwick is a pediatrician and a revolutionary, really. He wants to overthrow a health care system he sees shot through with waste, inefficiency, self- interest and disrespect for patients. Berwick believes that the people working in our health care system are by and large dedicated and caring people, but they’re stuck in a stupid system. And he calls that a national tragedy.
DR. DONALD BERWICK: If you look at the way we pay for care in the country and say, “Well, what is the underlying theme here?” We pay for doing things. A piece of surgery, performing a test, doing a procedure. Even a visit is a thing. So specialties or medical practices that do a lot of things, a lot of tests, a lot of surgeries, a lot of procedures; They’ll tend to be the higher income earning specialties.
Medical students leave medical school today with enormous debts. Primary care specialties are the lowest paying. If you have a choice between taking 15 years to pay off your debt or seven, you might decide on seven, and that means you can’t be a primary care doctor.**
DR. DAN LARSON: I wonder what your blood pressure is first thing in the morning.
MAGGIE MAHAR: What’s interesting about the fee schedule is that it’s all about what it costs the doctor to produce the service in terms of time and education. Never does anyone ask, “How much benefit is there for the patient?” This might be a service that, on average, lengthens the patient’s life by 5 months, as opposed to having your diabetes controlled for 30 years, which means that you live a lot longer and you never have an amputation. And yet we would pay much more for that technically very skilled procedure that gave you another couple of months, because we look at it entirely in terms of the work on the part of the doctor rather than the benefit to the patient.
DR. DAN LARSON: He has a very soft, like maybe one or maybe two out of six systolic near the apex. Take a listen; let me see if we’ve ever evaluated that…
MAGGIE MAHAR: So we don’t value primary care doctors, generalists, family doctors highly at all. The compensation is relatively low and that’s why we have fewer and fewer of them.
