A patient developed pain in the
pit of his stomach with nausea and vomiting associated with gastro-esophageal reflux
disease. This began shortly after he entered the service at age 19. A clinic
physician prescribed Tagomet, an acid H2 blocker, with refills. He improved while the
refills lasted for about a year and then the pain in the pit of his
stomach with nausea and vomiting recurred. He had a gastroscopy and was told he had
some esophageal scarring but nothing else was found. He was stressed because his wife
was pregnant and he was being shipped to Japan. TUMS, an antacid tablet, gave
transient relief. A year or so later he was evaluated at a regional Air Force Medical
Center and had a second gastroscopy. He was told everything looked good but he had
some scarring and should avoid spicy foods to keep that from progressing. On leaving
the service, he obtained a truck-driving job. He enjoyed his new job. He did well for
years. Then the pain in the pit of his stomach recurred. Some days he couldnít
drive his truck. He was sent to a psychiatrist who placed him on antidepressants.
However, he was not depressed; he just hurt. The pills didnít help. They made him
feel worse. He was fired from his truck-driving job because he called in sick too
often. Since he couldn't work, he applied for disability benefits and began receiving
them. The pain in the pit of his stomach persisted and he had a third gastroscopy at
a private regional medical center. He was told that his esophagus was scarred and
narrowed and they passed a rubber tube to open it. He undoubtedly was talking about a
dilatation. He was given Protonix. It helped relieve the pain until the refills ran
out. The pain in the pit of his stomach recurred. His wife changed insurance plans
and he came in for a medical evaluation.
Private Hospital Care vs Integrated Hospital Care
The high-tech hospital is extremely important
for the complicated and seriously ill patient. However, as this conference repeatedly
pointed out from acquired infections to simple blood transfusion, it is an
increasingly hazardous environment. The consequences extend far beyond the
hospitalization into the ambulatory care arena. As hospitals lose much of their
volume from inpatients, they have increasingly resorted to outpatient medicine.
However, it has repeatedly been shown that outpatient hospital medicine is far more
expensive than similar treatment in a doctor's office - sometimes on the order of two
or three-fold. It also depends on the system and reimbursement mechanisms.
In the average hospital, the goal is increasing
revenue, which is how they stay in business. But it is increasingly costly and maybe
gluttonous. A recent example surfaced.
There is a great emphasis on pulmonary
rehabilitation in recent years. Medicare reimburses for this. I had a patient that
enrolled at the local hospital and he stated that Medicare was billed about $2500 for
the two-week program. There were about 20 COPD patients in his group and he figured
that the hospital revenue for providing one respiratory therapist for two hours a day
to lead this group netted the hospital well over $50,000 for what he estimated at 25
hours of work.
I also had some Kaiser Permanente patients in
my research group that went to pulmonary rehabilitation at KP three days a week for
10 or 15 years. There was no charge in this integrated health care system. I made a
visit to the rehab unit and spoke with the respiratory therapist. He stated that KP
provides these facilities and saves considerable moneys by preventing
hospitalizations. He had the figures to prove that when patients dropped out of the
program, they were more likely to go to the emergency room and be admitted.
The key difference is that the private
hospitals make money on such programs and also make money on the failure of such
programs, which then requires admission to their high-cost center.
KP, being an integrated health care system with
the three arms of Kaiser Foundation Hospitals, Kaiser Foundation Health Plans, and
The Permanente Medical Group, work in concert with each other to reduce health care
costs. They are connected through electronic medical records that allow any
Permanente physician to access a patient's medical record from any computer terminal
within the system. It appears to be a winning combination. They feel that this is the
answer to the insurance dilemma.