What do you do when you don’t have enough money to do what you need to do for you or your family’s health? I know, it’s a redundant question? You go without, delay or borrow from your future in the form of debt. According to Reed Abelson and Milt Freudenheim of the New York Times in their recent article Even the Insured Feel the Strain of Health Costs, as employers struggle to keep up with mounting costs to cover their employees, the average cost of an annual health care premium for that employee has nearly doubled since 2001, from $1800 to nearly $3300 a year.

Example after example is delineated in the Times article regarding those individuals who just can’t afford the challenges presented by the rising food and gasoline prices. Those featured families and individuals skip meds, wait longer to take sick children to their pediatrician or are facing staggering bills from health care institutions. According to the accounting firm, Deloitte, the average American income that goes toward health care expenses is now approaching 1/5 of their total household spending annually.

As a hospital administrator, it is never easy to listen to the general public throw stones at the medical industrial establishment, but when it comes to fancy, esoteric diagnostic tools, unproven drugs that can cost $6000 a dose or the very best physicians known to man, bring ‘em on becomes the hue and cry as we, the health care consumer wants nothing but the best for ourselves and our families. This is America. We deserve it.

Of course, if you are looking for elective surgery and you happen to live in England, you will wait on average 1.5 years for that intervention, and if you are in Scotland, it will be very close to 2.5 years before that same surgery is available.

My Democratic friends embrace the hope of the future through proposed health plans that insure the masses. My Republican friends warn of the horrible train wreck those plans will cause in hospital emergency rooms as every George, Dick and Conde will make their way to our hospitals with no barrier in place to prevent them from over running our already strained bastions of care.

Regardless of your political bent, it does seem unconscionable that we have nearly 48,000,000 uninsured accounted for by the government. Most of these uninsured are young, single moms and kids who either can’t or choose not to vote. (No one has ever believed that to be a co-incidence.) This figure also does not include the underinsured and quite possibly may not include any of the 50,000,000 illegal aliens. We are the only industrialized nation in the free world that does not have a true health policy for our citizens.

So what is the answer? The iron triangle of the best, fastest and cheapest health care is something that cannot exist in a system that is still hanging on ever so completely to an acute care based model when the vast majority of our health care challenges are now chronic care cases. We 78,000,000 Baby Boomers are taking more pills to control our varied maladies than existed in total just 20 years ago. Ask your pharmacist how many drugs there are now compared to 1988.

One very real answer to this health problem sometimes seems too simple. Our nearly $2 trillion in yearly health care expenditures includes less than four percent of its total dollars for preventative care. Much of our problems are about wellness.

So, wash your hands, drop some weight, exercise, cut out the saturated fats, stop smoking and live a less stressful life by doing something other than stare at the television…or else just wait for that little blue pill that will help you be skinny, tan and sexy, and then sell the family car to pay for it.

Back in the 70’s, competitive marching bands came into vogue in Western Pennsylvania. Let me explain the before and after of this phenomenon: Before there were competitions, bands were made up of nearly 10 times more students than they typically have today. My bands ranged in size from 120 to 185 students. Once competition came into play, the borderline students were not able to survive. Consequently, it is not unusual now to have 20 students or less in a band.

What’s happening in medicine and in health care overall? The Government is taking a three-pronged approach to improve quality in health care:

1. They are pushing quality through public reporting. (Check a website near you.)

2. Enforcing quality through the False Claims Act. (Check a prison near you.)

3. Incentivizing quality through payment reform. (Check a checkbook near you.)

Senator Chuck Grassley is quoted as saying, “Today, Medicare rewards poor quality care. That is just plain wrong, and we need to address this problem.”

HMO’s are currently embracing “pay for performance” plans for physicians and hospitals. Medicare is introducing value-based purchase plans. Medicare is proposing the linking of quality outcomes to physician payments.

As I have written before, hospitals will no longer be paid for hospital acquired conditions. That seems like a rather simple fix, but to appropriately determine if the condition was not acquired at the hospital, extensive testing must be added pre-admission at considerable costs to the hospitals.

James G. Sheehan, Medicaid Inspector General of New York said, “We are reviewing assorted sources of quality information on your facility to see what it says and if it is consistent. You should be doing the same.”

Except for the financial implications, not unlike my competitive band story, the goal was to work toward perfection. The public reporting of quality of care is intended to:

1. Correct inappropriate behavior

2. Identify overpayment’s

3. Deny payments

The False Claims Act, on the other hand has different goals. When asked how he viewed the False Claims Act, Kirk Ogrosky, U.S. Deputy Chief for Health Care Fraud said, “You will see more and more physicians going to jail.” I guess the prisoners will be receiving better care.

Where’s it all going? Competitive band. Will it improve health care delivery? Probably, for the patients who can find the few docs and hospital that will be left? I recently had a conversation with a young computer specialist who took care of physician practices. He said, “Doctors and hospitals haven’t figured it out yet, but they are simply becoming data entry centers for ‘Big Brother’ as the facts and figures are accumulated to be used against them any way the payers decide to move forward.”

Looking back at the school year that included gym class twice a week for the entire year, rich courses in music and art, and remembering a time when priorities included those classes intended to make every student well rounded, we have to ask, “Is education today better?”

Maybe this is all too complicated to get our arms around, but if there are 78 million Baby Boomers, and the Medicare Trust Fund is heading toward bankruptcy, then we probably will see every rule in the book being applied to keep from paying out money, because there is simply not enough money to go around.

Will health care improve? Once we understand that technology is not the end all and cure all that creates healing; once we endorse prevention, wellness, optimal healing environments, and systems approaches to health and wellness, health care will improve. I’ll bet you that it will have very little to do with the rules that are unfolding right now and much more to do with the creation and acceptance of a National Health Policy.

With the passing of Tim Russert, we are all made critically aware of the fragile nature of life and our need to embrace every moment as a gift.  Obviously, within a split second, every aspect of our lives can change, and, as in Mr. Russert’s case, can end.  This is not a blog about instant death, and it is not just about recognizing our mortality.  It is about preparing for our passing carefully.

Liz Szabo, a writer with USA Today described in a recent article the cancer patient experience by saying, “Patients with advanced cancer often don’t know how long they have to live or how chemotherapy will affect their lives.”  According to a study by the Journal of the American Medical Association, many physicians either don’t give patients that type of information or the patients only “hear what they choose to hear, or very often misunderstand what is said to them.”

This situation often leads to patients requesting incredibly disruptive and sometimes painful therapies that have no hope of succeeding.  According to the study, more than 20% of Medicare patients who have advanced cancer begin a new chemo regimen two weeks before they die.  Many times patients are admitted to hospice days or hours before they die.

What has been observed in cases like this was that the patient often misses the opportunity to repair relationships, get their spiritual house in order or even prepare the necessary documents such as advanced directives.

Where is this going?  Sarah Harrington, an assistant professor at Virginia Commonwealth University School of Medicine in Richmond, co-author of the quoted article, indicated that “in the last few weeks or months of life, a lot of good work can be done.”

One of the points brought up in the article was that only about 37% of physicians told patients how long they had to live. This fact was not surprising to us because we have seen dozens of patients who were admitted to hospice over the years return home and live several more months or years. This particular prediction is not always dependable. The other fact quoted in the article, however, was that many patients learned more about their cases from other patients than from their physicians.

The article concluded with the suggestion that “patients and their families may have to take the initiative in finding answers to important questions.”  Thomas Smith, co-author and Chairman of Hematology and Oncology at VCU’s Massey Cancer Center suggested that the following questions should be asked by any patient in this situation:   What are my options?  Can I be cured?  Will I live longer with Chemo?  Should I consider Hospice or Palliative Care?  Who could help me cope?  What do I want to pass on to my family to tell them about my life?

Palliative care is not limited to cancer.  All end-of-of life diagnoses qualify patients for hospice and palliative care.  Tim didn’t need or have this opportunity, but for those who do, embrace it. The primary thing that can be delivered to the patient and their family is the comfort of having caregivers dedicated to helping you move through your transition.  It is what they do.  These amazing people, volunteers, employees and physicians are dedicated to “paying it forward.”

So, as we eventually face our own mortality, as we evaluate what it is that we want to share with our families, as we consider the legacy that we wish to leave, having a clear mind and looking to those professionals who can help us is not only necessary, it is imperative. This transition can come in the blink of an eye.

“Money doesn’t make you happy.  I now have $50 million, but I was just as happy when I had $48 million.”
–Arnold Schwarzenegger

According to an article in Internal Medicine News by Mary Ellen Schneider, spending on health care in these United States is projected to reach 20% of the gross domestic product on the one hundredth anniversary of my father’s birth, 2017.  Of course that projection is only an estimate made by CMS, the Centers for Medicare and Medicaid Services.  That estimate is, of course, based upon a continued escalation of nearly 7% each year for the next nine years.  In lay terms, that escalation would mean that the total dollars spent on health care would hit $4.3 trillion…Whatever a trillion is? I still can’t fathom a billion of anything.)

We all should realize by now that this spending in the public sector, Medicare and Medicaid, will increase due to the first wave of Baby Boomers entering the Medicare system in 2011.  My 78 million peers, like the lemmings, are working their way toward the proverbial wall, and for those of you who will have to carry the load until we are wearing our wings, that is not a pretty financial picture.

The same economists from CMS are predicting a decrease in reimbursements to physicians over the next several years while Home Health will likely grow faster than most other sectors except perhaps prescription drugs.

What does it all mean?  We are spending more on health care in the United States than any industrialized country in the world and, truthfully, our overall age of death is significantly surpassed by many of those “spending less” countries.  How can that be?  Well, for one thing, we have 47 million uninsured citizens in this country and no one really knows how many illegal aliens. Why so many uninsured?  They don’t vote.  The vast majority are young, single mothers with small children, and this does not take into consideration the illegal aliens who are also not insured.

Back to the answer. . . prenatal care is inadequate and infant mortality in the United States is still an embarrassment. A few of the countries that do better than us in the world in infant deaths per thousand are:  Australia, Austria, Canada, Czech Republic, Denmark, Finland, France, Germany, Greece, Ireland, Japan, South Korea, New Zealand, Norway, Portugal, Spain, Sweden Switzerland and the United Kingdom.  Hmmmmmm?  Could it be because we spend 30% of our annual health care dollars on the last thirty days of life, and less than 4% of our monies on preventative and wellness care?

Of course, Hospice would be a tremendous help.  We could reduce expenditures on end of life care, properly care for our babies with the excess funds, and ensure that our uninsured are properly covered as well, but what politician is willing to touch that electric third rail of the electorial subway tracks?

We could begin by putting in a network of sidewalks, bike trails, and walking trails.  We could actually walk once in a while and treat our bodies like a true temple, not the “Temple of Doom.”

One of the least often heard issues revolving around these expenditures is the continuation of our archaic hospital system.  It is based on the acute care model, and the vast majority of our diseases are chronic.  We rush the victim to the hospital, patch them up, send them home and then rush them back again without any commitment to behavioral modification.  I have seen individuals reverse their heart disease from diet, exercise, and stress management.  Why can’t we embrace this concept, reward these activities, and change our society?  The millions of bicycles in Europe are no accident.

So, as I’ve quoted in some other blogs, “Change or Die,” or just spend ourselves into oblivion as we attempt to prop up a system that should have gone out with the Industrial Revolution.  Good luck kids, your ole man needs you to keep working to cover my health insurance.