Monthly Archives: July 2017

Healthcare In Rural America- Some Thoughts On An Endangered Species

I’m going to leave the current news cycle, in which Sen. McConnell is trying to get another proposal to repeal the PPACA through a reluctant Senate.  I’ve been thinking about what we ought to do about healthcare in rural America.  Here is a link to a good article on the closures of rural hospitals from the Kaiser Family Foundation a year ago:

http://www.kff.org/report-section/a-look-at-rural-hospital-closures-and-implications-for-access-to-care-three-case-studies-issue-brief/

Rural hospitals face a lot of challenges to their survival. First, much of rural America is losing population.  Since hospitals’ revenue is still based largely on the volume of services they provide, it is hard to pour money into building or maintaining the capital-intensive resources of a traditional hospital when the need for the resources is likely to decline. Lack of investment in resources, though, leaves these hospitals unable to do some of the high-tech, high margin care such as major orthopedic cases and invasive cardiology that supports money-losing lines of business.  Also, the lack of resources causes patients with private insurance to avoid these hospitals and drive to bigger hospitals for all but truly emergency care.  The patients left to use the rural hospitals are those with Medicare, Medicaid, or no insurance at all.

The rural population is older than the nationwide average, and they are more likely to be on Social Security, either due to age or disability, which means that the patients in rural America are likely to be sicker than average, and less likely to have private insurance.  The question is, as hospitals close and access to medical care disappears, will these patients have to leave the country and move to more urban areas in order to access care?  I think the loss of population will accelerate with the loss of access to healthcare and the disappearance of healthcare jobs from these communities.

A supporter of stringent free-market economics will view the collapse of rural healthcare, economies, and populations as the working of the invisible hand, inevitable and perhaps only mildly regrettable.  For those not so completely sold on this philosophy, the article above details some interesting ideas on how to maintain access to healthcare in rural areas.  What I think is most important is that we recognize that we will not serve patients in rural areas best by tweaking the current system of payment for individual services, nor can we expect a commercial market to create access where there is so little demand.  The solution will be a political decision that the government will have to simply commit to having healthcare in rural communities, and then decide how it will be delivered.

American Healthcare: We Basically Need To Start Over- A Book Review of Mistreated: Why We Think We’re Getting Good Health Care—and Why We’re Usually Wrong by Robert Pearl

Dr. Pearl, a plastic surgeon and an executive with the Kaiser Permanente Health Plan, has written a book about the American healthcare system that should make everyone a little uncomfortable.  We want to believe that we are smart, well-informed consumers of healthcare, and that we are able to make good choices in our the best interests of ourselves and our families.  Dr. Pearl shows, with both stories and statistics, that we make irrational choices for our care, selecting doctors and hospitals with less thoughtfulness than we spend on choosing breakfast cereal.  There is no upward pressure to improve the quality of healthcare because we choose our providers and treatments for all sorts of reasons that have nothing to do with outcomes: the hospital is convenient or it has a nice lobby, the doctor did a good job of care for a family member years ago, and so forth.  This kind of decision making is probably all right for low-stakes medical care, like where to go for a physical for Boy Scout camp, but for something as risky and expensive as a hip replacement we ought to show more care.

Patients are not entirely or mostly to blame for poor choices, though.  Dr. Pearl takes up the theme of how our healthcare system creates incentives for providers to do things that are often useless or harmful, all the while insisting that our care is “state of the art,” or at least, “the standard of care.”  If patients have a hard time making good choices, it is often because the healthcare system often gives them bad alternatives.

Dr. Pearl’s recommendations for improving the healthcare system are, to my mind, very sound: capitate primary care so that there are incentives for handling problems efficiently and effectively, not for churning through brief office visits that are paid equally whether they are helpful or useless.  Procedures should be paid in a lump sum for an episode of care.  It is absolutely scandalous how much some hospitals profit by the complications caused by the care they give.  Expensive surgeries should be done at “centers of excellence,” facilities that do a large volume of a certain operation and have demonstrated that they are really good at it.  I was surprised to learn that half of gynecologists do fewer than 12 hysterectomies a year- at some point, if a doctor seldom does something, he’s not doing it often enough to do it well, and should stop doing it altogether.  I don’t share all of Dr. Pearl’s enthusiasm for corporate management of healthcare, probably because I don’t think people outside of primary care understand the complex motives of patients in the office.  It’s a lot easier to manage appendectomies, where everyone more or less agrees on the problem, the solution, and the desired outcome.  Many days I wish office practice were that simple, and that healthcare executives like Dr. Pearl understood that it’s not.  But if Dr. Pearl got the opportunity to reform the way we do the big-ticket events in American healthcare he could do a lot of good before he started telling me how to do camp physicals.

There’s some stories from the annals of behavioral psychology in this book which are there to show that it has been scientifically proven that people are irrational.  I have accepted this for a long time and so I thought these digressions were longer than necessary, maybe others need more convincing.  Altogether, though, this book is a clear vision of how healthcare can be less wasteful, more helpful, and more humane.