As we age, hopefully gracefully, we likely have faced or will face health issues. Please share your thoughts on the topic of healthcare. In doing so, please avoid just “bitching”, but also provide thoughts on how things can get better
Because this can be such a broad topic, here are some examples of areas to consider –
THE HEALTHCARE SYSTEM: What’s good, what’s disappointing, what needs improvement
Healthcare finance – cost, the effects of corporate/venture capital takeover, Medicare, Medicaid
How it has changed for healthcare “providers”, for us as patients over our lifetimes
Access, affordability, insurance, “Big Pharma”
SPECIFIC HEALTH CONDITIONS: Treatment, Prevention
Vaccinations
Memory/Dementia/Alzheimers
Cancer
Reproductive rights/Fertility
HEALTHCARE POLITICS & PPOLICY:
Effects of DOGE
Research and Technology
AI and Healthcare
ANYTHING ELSE?
Martin Geertsma
David H. Johnson
Bruce Parker
I am amused and appalled at some of the comments assigning the blame for our current dysfunctional medical system on “free market capitalism.” A better description would be “Bismarkian bureaucratic socialism with cross-currents of unfair incentives that make our politicians and their cronies rich.”
The key problem is simple: we’ve taken the decision making power away from the doctor/patient.
We should look at Singapore, as detailed in The Cure That Works by Sean Flynn. Singapore covers everyone with a high deductible plan. Then the government sets up what look like HSA’s for each citizen with enough free cash to cover most of the deductible. So Singapore is basically covering everyone for all care (what some of you say you want). The genius in the system is that the patient owns the money in the HSA and they and their doctor have the right to choose which facilities they will use. This property right coupled with the freedom to choose gives them an incentive to seek thrift and quality. Even though the deductible is a small part of the overall spending, the competition for patients drives the entire health care system. Result: Singapore’s healthcare quality is ranked 1 in the world (far higher than the US); all Singapore citizens get healthcare; yet Singapore spends a quarter what the US spends on healthcare per capita.
The Singapore solution is a “market driven” solution – it is in existence right now as proof the method works. We need more Free Market Capitalism not more bureaucrats and rich cronies like insurance companies and big pharma. Let them feel the whip of competition.
This topic arena is not small, as you put one fraction of it – “Healthcare finance – cost, the effects of corporate/venture capital takeover….” To understand this somewhat resentfully-stated topic requires knowing a lot of complicated stuff, at the heart of which is knowing about the “life sciences ecosystem” in America. Most people know only bits and pieces of that ecosystem.
It’s easier to understand why venture capital firms (VCs) do what they do, and earn what they do, if you are aware of how precarious the medical innovation process and ecosystem can be. If one element of that ecosystem doesn’t work or come together for a scientist, that new drug or new treatment may simply fail, or perhaps take so long that the innovation is superseded by some other scientist. I have spent a large portion of my career in the private investor side of life science and health care finance, as a transactional lawyer with a couple large, multinational law firms, representing both VC investors, and also representing small and mid-sized companies into which investors invest. This has involved new drug development (ADHD; HPV, etc.), health care services (IVF; Lucas CPR), medical innovation infrastructure (cell culture media; bone therapies), and more. I’ve seen enough of this to believe in the intended results of the VC portion of the ecosystem, and to embrace their need to earn what they earn.
These days (meaning literally, these particular days in the realm of the Trump Administration), the most prominently referenced (both in the WSJ and NYT, and also in recent court documents) particular piece of that ecosystem is the piece where University scientists apply for complicated grants from NIH and other US governmental entities … and if the scientists and their science is good enough to land such grants to fund the scientists’ laboratories, their Universities will ALSO take and KEEP a large % of the grants to fund the University’s own operational, overhead costs. In some cases the Universities will keep as little as 15%, or more customarily at least 28%, or even the high 60% for some places (yes, of course, 69% vs. 67% – Harvard vs. Yale).
So when the Administration denies grants to any University it directly hits BOTH the scientist and her/his associated laboratory, but also the University itself (for costs having perhaps nothing to do with the scientist). Universities and their medical centers (sidebar – in some cases the medical centers are the actual recipients of grants, with the scientist being on the center’s clinical staff, and in such cases there’s a degree of independence between the University (here, Harvard, for instance) and the scientist and lab. That independence is said, at the moment, to be possibly insulating some scientists from the heat being cast towards Harvard itself, even for medical center scientist clinician who carry the title of Professor of Medicine.
Life sciences innovation begins with basic research, at which Universities excel. Such research is not yet “applied research”, ie, it’s not yet ripe for what I’ll call “actual use”. As basic research moves through labs, elements of it become applied, ie, applied to specific conditions and purposes. Apart from the birth of new ideas that become labelled as innovation, the process also requires dodging all kinds of “if-then” predictive barriers, and becoming able to demonstrate that, say, a substance may just be able to act on the body in a way that we’ll later call “causal” and/or efficacious. And, to NOT act in a way that would be called toxic, damaging to humans.
This goes on and on (note to reader: this takes years and years usually), until the scientists have begun to tap friends and family and wealthy people (all, called “angels” in the trade) to invest in the scientist’s small 3 person company, to finance things about the process that Universities might not want to cover, or cannot cover.
It’s at this point, more or less, that the scientist might be introduced to an angel who also knows a couple of venture capital investors (aka VCs). And, then begins a dance to try to bridge the life sciences “valley of death”, where inventions go to die. They falter at the precipice where no more money can be obtained from the founders’ personal bank accounts, or from university lab support, or from “seed” financing from wealthy individuals (aka “angels”). If the scientist can persuade both independent VCs and also “corporate VCs” (ie, a VC fund that is owned by a pharmaceutical company) to become investors, the scientist’s team will then have take a key step to becoming a “real” company. But if the scientist is unable to land a VC, many such scientists’ work simply does not move beyond the lab. It is never “developed”. The costs of moving into and through development are simply too large and too different from what the scientist has done before to ever reach patients, or to generate revenues. Thus the little company simply might go no where.
Scientists don’t realize that it’s not just about “the money”. The best VCs bring a knowledge set of their own. They have personal and professional networks that support every investment that they make. They know “how it’s done”. They know “who does it”. They known how to build small entrepreneurial companies. Very few people have these skill sets. And the regulatory process takes years for formally approving the right degree of efficacy, and the right safety profile against toxicity, allowing the FDA to approve the drug in three stages of clinical trials, and then to allow it to be marketed/sold for use in patients. And round after round during year after year of sequential financings, each to finance the scientist’s little company to grow its innovation from inflection point to inflection point, each time rising in value and justifying a higher stock price, and yet more cash to follow. It is very risky business, and some VCs fail.
If all of that goes well, the scientist will find that the cast of players will change substantially. The VCs will no longer need to finance the company’s growth. Their willingness to invest changes into a mandate to sell their shares, either by selling the little company’s shares to a pharmaceutical company or by going public in an IPO (ie, selling its shares in the open market). Suddenly, these ownership changes transforms the small company, and the couple of founder scientists might continue or might step back away from operations, while new executives and people come in. But think of it … before resenting or mistrusting what VCs do, remember that “everyone reports to someone”. And, VCs report to their own investors, the pension funds, insurance companies, endowment funds and other enormous sources of financial wealth who provide the VCs with the industry’s life blood. Years of risk requires reward.
“Healthcare is complicated, who knew???” (Remember who said that?) Not only is it complicated, but a whole lot of high rollers have their fingers in the pie. That’s a major reason why Obamacare had to buckle and swing deals to get anything done, including with Big Pharma, electronic medical records companies, insurers, among others. There are things that could be done, but to make a significant difference it would require major changes as Geoff Berg notes. And, after all, one person’s medical inefficiency/excessive cost, is another’s third home in Aruba.
Whether anything is ever done, one thing that may be irreparable is the relational aspects of care provision. There was a point when some, much wiser than I could ever hope to be, including C. Everett Koop, used to promote the value and sanctity of the “Patient – Physician” relationship. While not everyone in “old-time” medicine always valued the relational aspect of the profession, it at least used to be possible to practice with that paramount. Medicine as “strictly a business” has poisoned the waters that we, as healthcare professionals, used to be privileged enough to drink fully.
I still teach students and residents in my specialty and subspecialty. I am concerned that so many are shunning primary care and the potential for continuing care relationships for limited contact, minimally interpersonal patterns of practice. In addition to the demands for high volume “fee for service”, the electronic medical record has exchanged true open-ended interviewing and true personal interchange for predigested phrases generated by a computer key click. No wonder so many young medical types are avoiding primary care, or leaving it early. No wonder so many express a not so hidden cynicism about their profession,
I once was told by one of my clinical professors that medical practice was unique, a calling and a privilege. Where else could one make use of your extensive learning, your intuition, reasoning, and dedication to engage in the healing “laying on of hands”? I fear that is less and less the case.
Alex Geertsma, Saybrook
I remember several of the above commentators from ‘back in the day’ and retired from a small town solo family practice (4 years), a year of OB/GYN residency and then emergency medicine in 2018. One of the virtues of EM was never thinking about a patient’s insurance or ability to pay – one did what needed to be done at that point int time. I doubt that a US National Health System could work without a large VAT (on top of current taxes) similar to Europe or that Americans would tolerate the long waiting lists found in Canada and the UK. I do think a public/private system similar to Switzerland would be worth exploring.
My wife and I have established a medical student scholarship for primary care or EM at the University of Virginia – let’s hope the physicians of the future can steer us towards a bette system.
My respect for Tim’s wife and similar caregivers (our daughter is a charge nurse at a university hospital) is immense. And as individuals, (and Scott said), we must try to retain our humanity and dignity as long as possible.
Boola Boola, Buzz Potts
Make healthcare free. For everyone. No exceptions. If you’re sick or need care for any reason, you get it. That’s the way it is in Cuba. I saw that firsthand during my one trip to Cuba in 1980. Two members of our tour group developed upper respiratory infections. They were taken to a clinic, treated and kept overnight for observation. The next day, the doctors examined them, explained they just had colds and would be fine, and discharged them. They went to the front desk and asked if they had to pay anything. The people there said no, just wished them well and waved goodbye. No one asked for their insurance card, passport or anything else. They were human beings who were sick and they received treatment. For free. That’s not only humane, it eliminates all the overhead that makes the U.S. healthcare system the most expensive in the world per capita. If Cuba can do it, why can’t the United States?
“If Cuba can do it, why can’t the United States?”
As Noam Chomsky is fond of saying, that appears to be one of those questions that answers itself.
I am very grateful for the 47 years and counting as a primary care internist. That said, I am disturbed by the fact that I have profited from a bloated unnecessarily expensive healthcare system that has been robbing the public with costly mediocre service for nearly all of my career.
For decades the per capita cost of healthcare has been twice the OECD average while not covering everyone and with middling measurable outcomes.
I have written elsewhere a plan to fix healthcare. The numbers are dated and I could have used an editor but the premises and the solutions are still valid.footnotes 12345
Briefly in summary:
1 The responsibility for the cost of healthcare falls on provider groups.
2. Everyone is covered and insurance is not tied to employment. Coverage is portable and patients can change provider groups any time they wish.
3. The total cost of healthcare is fixed at the annual rate in which this goes into effect and stays fixed at that rate until the per capita cost come in line with the OECD average.
4. Medical groups are held accountable for quality of and access to care.
5. Most doctors are underemployed. That is they get paid to do things that could be handled by someone with much less training. Examples of this are doing annual wellness visits to rote repetitive procedures like endoscopies, cataract and joint replacement surgeries. Medical education should reflect the hyper-specialization of medicine and adjust accordingly.
6. Government can negotiate drug prices and malpractice is scrapped for a system that finds and corrects medical errors and fairly compensates those who have been injured.
The current cost of the Medical Industrial Complex is $4.5 trillion which is more than 6 times the Military Industrial Complex. If that money went back to the government it would have a surplus of more than $400 billion dollars.
Interestingly, there are no bad guys in the current system. People do what they are paid to do. Insurers compete by cherry picking patients and limiting care. Doctors are paid on a fee for service basis so they have no incentive to limit service. Malpractice lawyers and the pharmaceutical industry similarly and quite humanly work to maximized the return on their efforts.
These are my musing on the state of healthcare and how I would fix it and they could be completely wrong. In any case the interest groups above have too much skin in the game to allow this or any meaningful reform to pass. That said, physicians, individually and collectively, have more than a corporate interest in our patients. We have a compact with those patients. Thar compact requires us to maximize their well-being. The cost of healthcare hurts our patients financially and often at some level emotionally and physically. I would therefore submit that it is our professional responsibility to acknowledge our role in this problem and use our collective voice to fix it.
The posts by Debbie Bates and Alex Geertsma I suspect must resonate with many of us who have lost family members of friends to dementia, Alzheimers, and other chronic conditions.
Years ago during one of my annual visits with my wonderful late personal physician Harvey Klein who was on the faculty of Cornell Medical School and somehow developed the impression that I knew something about healthcare economics stopped in the middle of his examination pushing different parts of my body in unaccustomed ways, “Mr Kau, Can you explain to me why Weill Cornell (NY Hospital) is spending millions of $$$$ for a new cancer facility, when across the street there already exists [referring to Memorial Sloan Kettering] one of the world’s premier cancer hospitals. Though in my little journey through spacetime I’ve not had any direct professional experience with a hospital or the medical profession, I quipped that the cardiologists [my doctor was a cardiologist] were to blame. With statin therapy and other diagnostics, the death rate from heart attacks was steadily declining, and the $$$$ for the medical establishment were in treatment of chronic diseases.
Not all heart attacks are fatal, and a “stroke” [I’m not a doctor] which does not end life has many consequences for living family members akin to what Debbie Bates and Alex Geertsma have shared.
Some of you may know of Daniel Kahneman, a Nobel prize winner in the field of behavioral economics and “rational” decision making. Jason Zweig of the WSJ wrote a piece in the WSJ that Kahneman’s last decision was to set the date for the end of his life in Switzerland. I personally have lost two wonderful acquaintances, who chose a date for an exit from this strange world we find ourself living in.
To quote Shakespeare, “To be, or not to be, that is the question.”
Best to all
Randy Kau
Berkeley 1970
I’ve heard the same story as Gerry has told from my colleagues in community practice of pediatrics and internal medicine. Physicians, while far from perfect, are not the reason health care costs are so high and there are barriers to care.
Indeed, many medical students today are first generation Americans, children of immigrants, or first generation in their families to attend college. The financial burdens on physicians in training are substantial.
Having numerous hospital administrators and insurance companies with gazillions of vice presidents making more substantial salaries than most pediatricians and internists is wasteful and bizarre given the loan debts we burden our students with, in my view. Little or no value added to the system in almost all cases. All this has developed while nurses, medical technologists, etc. are strikingly underpaid, accounting in part for the shortage of these “in the trenches” practitioners.
Well, this topic is right in my wheelhouse. I retired from practice as an internist/gastroenterologist in May 2021, and the first thing I did was complete a memoir about my career, from the time I decided to go into medicine as a sophomore in college, the pre-med courses I had to catch up on (required some summer school), the application and interview process for medical school admission, the basic science and clinical years in medical school (Yale), the onerous (to say the least) years of post-doc training, 3 years in academia, 14 years with a very dysfunctional multi-specialty medical group, 18 years as a solo practitioner (they were the best until it became untenable) and the last six years with the last small internal medicine group practice in my community (also very enjoyable). This description may sound very heavy and over the top, but I can assure you it is an enjoyable and at times quite humorous read (it’s available at Lulu.com online and is called Beneath My White Coat). Rather than recapitulate all my observations here, I urge you to read the book. Having said that, however, the change in medicine over the past 50 years has been astonishing and not always in a good way. Even as Elon Musk and RFK Jr started gutting research careers, preventive medicine, and public health, we are faced with the anticipated cuts to Medicaid and children’s health care. Physicians have been faced with a slew of reporting requirements, documentation responsibilities, increasing medical school tuitions, and diminishing revenue that makes traditional practice almost untenable. Doctors have been accused as being partly responsible for the increased cost of healthcare despite continuing reductions in reimbursement. For example, when I gave up solo practice, Medicare paid me an average of $72 for a standard office visit. My overhead, lean as it was, ran to $160,000 a year, so do the math. If my practice ran exclusively on Medicare patients, I would have had to see over 2,000 patients just to break even. And by the way, Medicaid averages 57% of Medicare reimbursement. It’s no wonder that now that we are all on Medicare, fewer and fewer doctors are accepting Medicare insurance. I generally agree with all that Neil Blumberg highlighted. The profit-driven model of healthcare today by private equity firms, hospital conglomerates, and the insurance and pharmaceutical industries is sucking us dry, and it’s time to try something else.
Neil Blumberg MD here in Rochester NY, where I’ve been in the academic practice of transfusion medicine/hematology for 45 years. Don’t see patients these days and heavily involved in undermining a century of dogma about transfusions and transfusion immunology with my internist hematologist wife and collaborator, Joanna Mary Heal MBBS, MRCP.
It’s almost holy writ that our health care system is dysfunctional, unnecessarily expensive, with great inequalities in care depending on economics and geography. I’ve seen diseases that were routinely rapidly fatal (e.g., acute promyelocytic leukemia) become routinely curable, and many other examples of terrific progress in reducing suffering and extending health and life span. But there is no doubt that the critiques of the system are largely accurate. So what is wrong and how can it be fixed? First of all, there are large sucking sounds of resources being diverted from health care to largely parasitic institutions such as for profit hospitals, pharmacy benefit managers, insurance companies, needless administrative growth and, of course, private equity and related for profit entities. So I think healthcare needs to be non-profit or at least public utility in its nature, much like the military and electricity. Ideologues think differently, but practical experience suggests otherwise. So how does change occur? Slowly, with great resistance from those who will lose power and money. But I think the answer isn’t necessarily government administered healthcare, as in Canada and the UK, but something more along the government regulated health care in Germany, for example. Here’s hoping for our grandchildren’s generation that some changes can be made to make health care more effective for all, and less expensive than it is today.
If you wish to know more about what goes on, from a satirical but accurate viewpoint, watch Dr. Glaucomflecken’s videos. Short, to the point, and painfully hilarious. Will Flanary is an eye doctor who has had a few brushes with death in his life who sees things as they are.
https://www.instagram.com/reel/DHq5DBLJkp9/
Rule #1: Don’t get sick.
Rule #2: If something happens face it with as much grace and good humor as you can muster.
Rule #3: If you have to go down the rabbit hole of big-time medical intervention, do it with caution. There are always side effects and unintended consequences.
Rule #4; We all die eventually. It’s an adventure.
Cheers, Scott Simpson
Rule #1 is solid advice. And the others as well.
My suggestion for those suffering from stomach ulcers or similar digestive conditions: try drinking raw cocoa mixed in warm (not hot) water with raw unfiltered honey. Works better than Maalox, and tastes much better as well.
Also, don’t take medical advice from retired software engineers (that would be myself).
To quote my pharmacology professor, there is no such thing as side effects. There are effects, some we like, some we don’t.
This is Tim Bates’ wife, Debbie, replying. Tim was diagnosed with Alzheimer’s (or mild memory impairment) around 10 years ago.. He was assured that he had enough knowledge and intelligence to continue working as a Superior Court Judge until the fall of 2017 when he retired.
He is now very impaired. Cannot read, write, or speak more than a word or two. Still knows the people in his life and is very much the same person he has been. Luckily, no aggression or delusions. He is often frustrated by his inability to speak but is basically happy.
I am not aware of others in the class with Alzheimer’s or other forms of dementia. But I assume they are out there.
Debbie – Thanks so much for your posting. I didn’t know Tim well, but from what you note, he has attained what Kingman Brewster charged our class with – being one of the nation’s thousand leaders. Your news of him brought for me a memory of my limited time with my father. We were estranged for many years after his divorce from my mother. It was my wife, a former hospital chaplain, who dealt with end of life issues almost daily, who convinced me many years after Yale graduation, to connect. She related regrets of family once their loved ones were gone about missed opportunities.
My time with him, though limited, led us to great insights and a degree of peace for which I will always be grateful to my wife and him. I did spend some time with him during his increasing dementia. While he seemed to remember all of us in his family less and less, I always felt when I spoke with him about our past and what could have been that there was a glimmer of remembrance in his eyes.
I know how hard it is for you to see Tim the way he is now. I also know you will treasure his deep down feelings about you and your loved ones no matter outward appearances. Peace to you and your family.
Alex Geertsma, Saybrook
I’ve heard that playing music, especially oldies, can be very helpful in these kind of situations.
Dear Debbie Bates,
Thank you for letting us know about Tim.
I hadn’t know of his condition. Although I didn’t know Tim personally, I did know him by reputation while he was at Robinson & Cole, a fine New England law firm with which I often interacted. I am so sorry to learn about his condition, and also about its effect upon you. I do wonder how you are holding up in this taxing, often lonely journey, now 10 years and onwards.
Like you, I also don’t know of any others in our 1970 class with Alzheimer’s or another form of dementia, although they easily could be out there, as you say. And, for everyone whose loved one has such a condition, there’ll you’ll find company.
Best wishes, Al Sokol