Tuesday, January 29, 2008

U.S. health care system, regional variations - Listening to Floridians About Health Care

Fort Worth, Florida - I’ve learned two things from engaging Floridians in conversation and listening to what they have to say.

One, conversations start with weather. Weather obsesses Floridians. It justifies their living here.. Once they learn you hail from the North, they respond, “How cold was it there?” “You must be so happy to be here!” Or, apologetically, “I’m so sorry about our cool (or overcast, or rainy) weather. It’s usually much nicer.”

Weather opens and closes conversations. It dominates everything in-between. There’s no escaping it. Weather is an obsession.

Two, health care preoccupies, flummoxes, and irritates them. Once they know you’re a doctor, verbal floodgates open. Seldom is heard an encouraging word. Of the health care system, they say, “It’s broken.” “It costs too much.” “It’s a mess.” Or, “I like my doctor, but the rest of it sucks.” Still, they can’t seem to get enough of it.

There’s no single complaint theme. This should come as no surprise. For health care, like Florida itself, is diverse. Florida, our 4th most populous state, has Crackers to the North, New Yorkers and Yankees to the East, Midwesterners to the West, Cubans to the South, and Immigrants, Snowbirds, Retirees, Canadians, Transients, and Veterans (2 million of them, mostly for McCain) Everywhere.

Here are four excerpts I heard on my Listening Tour.

• A 6o-ish woman, a PhD in French literature, a textbook writer, an industrial consultant to French companies in America, and a breast cancer survivor, complained, “My surgeon, my pathologist, and my internist don’t communicate with each other. In reformspeak, we call this “fragmentation” and “lack of coordination.” We say it can be eased electronically by EMRs, PHRs, and e-mail visits.

• A 42 year old married, woman housecleaner, mother of four, whose husband had lost his job, told me, “I had to drop my insurance because we couldn’t afford it.” In reformspeak, we call her one of the”working uninsured,” who comprise 82% of America’s 47 million uninsured. Democrats propose to solve this problem by pouring in more federal money and subsidizing care for all. Republicans say we can solve it through tax credits for all and market innovation.

• A 70 year old married former well-to-do businesswoman, informed me she and her husband have joined a concierge practice. They pay $1500 a year each for personal attention, 24/7 access, and other amenities. She and her husband are immensely satisfied with the care they receive. In reformspeak, depending on your political point of of view, we deem concierge care as “two –tier luxury care,” or “innovative practice design.”

• A 50-ish married, fully-insured Bed and Breakfast proprietress, related this story. She awoke at night with intense rib cage pain. . Not knowing what to do or where to go, she hastened to an emergency room where herpes zoster was diagnosed. She added she has aortic stenosis and will have a valve replaced later this year. In reformspeak, we often say ERs are overcrowded with the uninsured, but the reality is the insured, particularly Medicare patients,. comprise the majority of ER patients. It’s a question of access during off-hours. This partially explains why retail clinics and urgicare centers are proliferating. As for her heart surgery, in reformspeak , we proclaim hospital costs have to come down, but we have yet to find a way to lower them. The problem is we just love those life-saving and lifestyle-saving hospital-based technologies.

Today is the Florida primary. Bringing down the cost of care and covering the uninsured will be on every politician’s lips. Meanwhile and hereafter, more retail clinics and urgicenters will sprout, more obstetricians and neurosurgeons will flee Florida for colder climes in search of lower malpractice premiums, and shortages of 120,000 nurses and 50,000 doctors will make most reform proposals impractical. What good is expanded coverage without access to care?

In a perfect health care world, which I described in an essay “2020: The View from 2006,”October 3, 2006, in healthleadersmedia.com, everyone will be insured, medical bankruptcy will be a historical curiosity, all will have a medical home rooted in a primary care practice, people will shed all bad habits, pricing and quality will be transparent to all, and freedom to chose the doctor and institution of one’s choice, will be unlimited.

That isn’t going to happen soon. Massachusetts universal health plan’s cost
overruns have mounted to $400 million, California’s plan will likely fail because of its $14 billion cost, San Francisco is promising to cover all, and the resilient U.S health system shows no sign of collapsing, Stay tuned.

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