The influenza epidemic has come and gone. The primary physicians have done a “humongous” job in restraint by keeping patients out of the hospitals. This particular virus seemed to cause various pains, some times in the right chest, some times in the left chest, some times in the head, and usually all over. To exchange one or three office calls at $40 or $50 is a tremendous cost savings over a few days in the hospital at $4-5,000. Hats off to the men and women in the trenches of patient care for allaying the anxieties of patients by taking time to listen to the specifics of their complaints, establishing that the ailment wasn’t cardiac in origin, and determining that they should best be followed in their homes. This service to patients resulted in huge health care cost savings for our nation.
The Sacramento Bee ran an ad from one of our hospitals entitled “Don’t Die of Embarrassment.” It stated, “The pain could be in your left chest, your right chest, an arm. . . intense. . . or mild, like heartburn. . . These are all heart attack symptoms. And all too often, they’re ignored. People tell themselves, `Why bother the doctor? I’d be so embarrassed if it turned out to be indigestion.’ If you’re having chest pain and you’re not sure what it is, find out fast. Get help. If you can’t get to a hospital, call 911.”
Of course, 911 gets the patient to the hospital, the highest cost center via the highest cost travel mode. An ambulance ride for 6 miles to the hospital exceeds the 6,000 mile airflight ticket I hold to the international ATS meetings in Boston and back. The managed care networks tell us the average ER visit is $5-600, about 10 times as expensive as a doctors outpatient office evaluation. While doctors are trying to conserve health care costs, trying to reduce them 10 or 20% as safely as possible, spending time with patients, carefully analyzing their symptoms, allaying their anxieties, the hospitals are increasing health care costs by 1000%, increasing our patients anxieties, and reversing all our efforts with $1000 advertisements. Is it too much to ask that our hospitals show restraint, cooperate and be reasonable in trying to reduce health care costs and not trade on common patient anxieties about health?
Restraint in medical practice is not new. David B. Reuben in the NEJM 310:591-3, (March 1, 1984) was already calling for “diagnostic restraint.” A 73-year-old woman with known hypertension, diabetes, hypothyroidism on therapy, and with a prior stroke was admitted with abrupt congestive heart failure. Reuben was in agreement with his resident on the therapy and concurred that ischemic or diffuse cardiomyopathy were the most probably pathologic diagnosis. The more likely of the two was unclear. The resident ordered a radionuclide study to which Dr. Reuben objected since the results were unlikely to influence the patient’s therapy or prognosis. The resident finally conceded that she ordered the study because she wanted to know with a greater degree of certainty, the cause of the patient’s heart failure. Dr. Reuben pointed out that advances in diagnostic technology have allowed us to establish diagnoses with accuracy beyond the capacities of therapeutic intervention. Even in 1984 he concludes that there is not enough money in the health care coffers to support such “need to know” expenditures. Managed care, an interim obfuscation, was obviously necessary to get our attention to point out diagnostic restraint, but will not begin to do the whole job.
Congratulations to SEDMS for spear heading the REACH OUT Physician initiative to improve care to underserved Americans representing the Sacramento County Health Department, UCD, Sutter Health, Mercy Healthcare, MedClinic, SMG, PMG with a $100,000 Implementation Grant.
District Attorney, Steve White, spoke to the Medical Society, PSR, & Capital Discussion Group on violence. He mentioned that crime is slightly down in California and in the USA. Violent crime is up. Crime by adults is down. Crime by juveniles is up. Two-thirds of crime is unreported or undiscovered. In only 22% of the one-third that is reported is the offender caught. California has 133,000 inmates locked up. We have a 455 per 100,000 incarceration rate in our country. S. Africa is second with 311 per 100,000. England is third with 97 per 100,000. France is fourth with 81, Japan has 45, Netherlands has 40 per 100,000. California is in a massive prison bed building program adding 12 prisons to the current 28. With the “three strikes you’re out” initiative, some estimate we’ll need 20 more prisons. Remember when we furiously built hospital beds? Now some administrators feel we will close one-third to one-half of those. Something is missing in the crime equation. Are we really the most violent people on earth? Will we go through the same sequence with prison beds as we did with hospital beds when we figure this out?
The medical staff at Agnews Developmental Center overwhelmingly rejected the department’s proposed by-laws which would have placed psychologists on its medical staff. The Medical Director at Agnews then returned the rejected by-laws to the Department of Developmental Services with her signature on the document unilaterally approving the rejected by-laws.
UAPD attorney Richard G. McCracken wrote a strong letter to the director which states in pertinent part, “a physician engages in unprofessional conduct by practicing in a hospital, public or private, which does not have rules providing for self-governance by the medical staff. The medical staff is not self-governing if its own bylaws can be unilaterally dictated by the governing body of the hospital. If the hospital were to force the changes to the bylaws that have been disapproved by the medical staff, it would deprive the staff of self-governance and render all the members of the medical staff subject to disciplinary proceedings for practicing at the hospital.”
Joseph Califano, Jr, Secretary of HEW under Carter, spoke at the Health Forum at our convention center recently. He outlined important developments in health care in this country: a) the Kerr Mills bill which increased the nursing home industry from $1B to $50B per year; b) the Health Planning Act of 1974 requiring certificate of needs for hospitals; c) DRG’s which required numerous revisions; d) managed care which did decrease cost but increased management costs to the insurance company by $200 billion trying to document every admission and procedure which has resulted in discouraging our best minds from entering medicine and causing our best specialists to retire early. During the Q & A session remarks included: We won’t see a central payer in our country because we are not homogenous like countries that have it; it would put the $trillion health industry in the federal budget; the health industry is the largest and fastest growing industry in this country and it will take 10 years to bring it under legislative control. In regards to campaign reform, it won’t happen until we have a major scandal. We’ve allowed legal bribery of our elected officers. Others would go to jail for doing the same thing. There are other issues on the horizon such as euthanasia which will make the abortion issue seem like a tea party. He suggested we pay for the health care of the poor and the old and put our resources there. We should be able to second that one. Let’s keep Medicare and MediCal solvent. . . His ninth book, Radical Surgery, is out soon.
What’s better than being a doctor…? Becoming a computer systems analyst, according to Money magazine (23-3, pg 70 ff). There are no more dreaded words in corporate America than these: “The system is down.” Your boss is screaming, your clients are whining. What can you do? Call a computer systems analyst, that’s what. Systems analysts are the indispensable people who install, customize, and supervise computer operations at offices and factories across the nation. And now, with their services increasing in demand, it’s no surprise that they have the best job in America. Job growth 110%, job security excellent, prestige good, and stress low. Physicians are still ranked No. 2. But their stress is rated as “high.”
Retirement dreams may be just that. A recent survey (Colonial Life & Employers Council on Flexible Compensation) find workers are saving 28% less for retirement than a year ago. Workers expect Social Security (if still available) and company pension (if any) to provide 63% of retirement income. Maybe Larry Burkett’s advice of restraint is good. “Don’t buy anything on credit, pay off your debts and be sure you can continue your present job past the age of 65 or have an alternate job or one that you are preparing for so that you can continue to work indefinitely.”