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Doctors shut out problem patients
MDs 'cherry pick' to avoid treating chronically sick
Veronique Mandal
Windsor Star
Wednesday, June 02, 2004
People with chronic illnesses are being shut out of doctors' offices and complain that "cherry-picking" doctors are denying them a right to basic health care.
Emergency rooms and walk-in clinics don't want to be used in lieu of a family doctor, so thousands of Windsorites languish in the twilight zone of needing a doctor's care, but having to wait until their condition deteriorates enough to warrant a trip to the ER.
Edna Walkins, 71, who suffers from chronic lung disease, high blood pressure and diabetes, looked for a doctor for five years. Last month she heard a newly arrived physician was taking patients.
"I went to the office and the secretary asked me to fill out an application form. She was very friendly and I thought I was finally going to start getting treatment again," said Walkins.
"But when I called a few days later she told me I was rejected. She said I had too many problems. Imagine that. Isn't that why you go to see a doctor?"
Jason Onichuk, 32, shifts restlessly in his chair, his back brace providing little comfort for his debilitating back pain.
He opens a thick medical file filled with doctor's notes and neurosurgical consultation reports.
He carries the file from doctor to doctor, and to hospital ERs. It always gets him rejected.
Onichuk had been prescribed many medications, including sleeping pills and ulcer treatments. But he said the narcotic painkillers given to him by a previous family doctor have made him a pariah.
In February 2002, Onichuk injured his lower back lifting a 250-pound barrel. Spinal injections with cortisone didn't work. The surgeon recommended surgery in about 10 years.
"My family doctor back then ... was great and did everything he could for me. He also prescribed Oxycontin, a narcotic, for pain."
"He disappeared for six months, and when he came back told me he wasn't allowed to prescribe narcotics and said I should find someone else. Ten years is a long time to wait to get out of pain."
Onichuk began looking for a new doctor, without success. He also started going to walk-in clinics and ER.
"The walk-in clinics would take me one time then tell me not to come back, and I know it wasn't the right thing to do but I started going to ER to get my prescription filled," Onichuk said. "They told me I can't use ER for a family doctor and I'm sure they think I'm just coming for drugs, but all I want is my back fixed, to get retrained, and have a normal life. Isn't everyone in this country entitled to health care?"
. It's very frustrating, since my schedule is hard to work around, and my specialist is only at the clinic 2 half days a week. Anyway, radical reform is needed, and more doctors.
Originally posted by tim_duncan2000
Let's hurry up and implement that here.
Originally posted by Merlin1047
The same thing is happening in the Canadian medical system. Patients who have no need of medical expertise are clogging the system. They do so because it is "free". The predominant socialist mentality is that if something is free, you had better get some of it. Doctors would rather treat nuisance patients with minor or negligible problems because it is fast and easy and pays the same as treating those with chronic and/or complex maladies. As a result, seriously ill patients are rejected. Tragically, they are the ones truly in need of medical intervention.
If a Canadian needs a CT scan, he or she faces a wait of up to two years. So now Canadians come to the USA seeking medical care which cannot be obtained in Canada at any price, at least not within a reasonable time. Meanwhile, Americans go to Canada to get cheaper prescriptions.
Say howdy to each other at the border.
The Canadian health care system.Implement what?
Originally posted by tim_duncan2000
The Canadian health care system.
Originally posted by Isaac Brock
To me there are the three ultimate goals to a medicare program:
1) Provide an acceptable level of medical care for all
2) Reduce the costs of medical care as much as possible
3) Ensure flexibility in the structure of the system as so it can be sustainable in the long term. [/B]
Originally posted by Said1
That's what I thought. As Issac and I have both stated, health care in Canada is not as it is being presented in the media selected in this post. Canadians do not have an "it's free, gimme, gimme" attitude when it comes to health care. There are other problems here of course, they exsist everywhere.
Issac: What is a government paid, private system? If selective choosing of patients is becoming a problem, wouldn't a two tiered system add to this problem as opposed to helping, given the shortage of doctors in the country? How are things in Manitoba?
Originally posted by Merlin1047
Well good luck with that. I do not understand how you can remain blind to the obvious shortcomings of any bureaurocracy. It appears from all I have read that Canadian medical care is already headed in the wrong direction to effect your first goal. I wish I could cite the source of the article which stated the two year wait for a CT scan, but I read it some months ago in a medical magazine at my doctor's office.
Second, getting government involved in the free market is rarely successful. Whenever prices for goods and services are dictated by government, two things are certain to follow - shortages and surpluses. Shortages of things in high demand and surpluses of those items not desired or required. Proof of that can be found in any communist, totalitarian, or socialist society. Simply look to the former Soviet Union, Sweden (50% income tax), any African dictatorship, Cuba, China, (which is starting to adopt a "market" economy) or Germany whose economy is in decline due to the excessive social programs in effect there. These are just a few examples, there are many more. Government can control prices, but only in the short term. Eventually the inevitable happens and government price controls create chaos. Proof of that statement can be found in this country's brief experience with price control during the administration of Jimmy Carter (our national idiot).
Third, if you can show me a government bureaurocracy that is "flexible", I'd damn sure like to see it. Because that would be a rare critter indeed.
How many major medical discoveries has the Canadian medical system produced compared to the American? Certainly this is not the result of better doctors in the US. Instead it is the result of capitalism at work. Discoveries pay here. Medical entrepeneurs can get rich here if they discover a new cure or treatment. But in Canada, the government regulates the price of medications. If you were unable to get medication from American pharmaceutical companies, you'd be out of luck. If all countries in the world had the same policies as yours, there would be little, if any, research being conducted simply because there would be no profit in it.
Your goals are worthwhile, but using government as an intermediary is no way to achieve them. The only product guaranteed to be produced by government is waste and inefficiency. Seems both our countries already enjoy a sufficiency of those.
Originally posted by Isaac Brock
Well, I can't refute what you've read, but I'll say this. Come to Canada and you'll see that lepers aren't roaming the streets and that we are in good health. Visit a hospital and you'll see that it is clean and staffed.
I don't accept the dogma that because our system is socialized, it is wrong. The greatest misconception is that Canada pays greatly more for medical care than the USA. I've seen studies that have gone both ways, but to be honest, we're fairly close. Socialized systems do work abroad. Most of Western Europe has a socialized system and their economies are going fine.
And it is not worthwhile to bring up Canadian medical discoveries vs. American discoveries. The difference between our two countries is that our medical discoveries occur primarily at the academic level, while American discoveries occur primarily at the corporate level. I don't place any judgement on which is better, but be assured that Canada had and still has its place in medical technologies. I could search a list them all, but I'd hope, in lieu, you'll give me the benefit of the doubt.
The American system is fine, for Americans where there is, and correct me if i'm wrong, an accepted value that stratified levels in health and medice is except drawn along the economic lines of rich and poor. Canadians simply do not agree with the value. Though we do not agree that higher education should free, while many western european countries do.
When you get down to it, it's a question of values and our system reflects our values.
Originally posted by NewGuy
I have a friend in Canada who posted this same article somewhere else and verifies she has the same issues.
She cannot get seen at all and has been to numerous doctors who cancel her appointments and refuse her because they are picking their clients.
Originally posted by rtwngAvngr
So don't get mad when people call you commies.
The British results are grim.
In 1948 the British government made the mistake of suppressing price - it thought that free supply was the answer to helping the poor. The better way would have been to beef up purchasing power, and let markets develop in response to demand.
The NHS was set up specifically to help the poor most, but they still have the worst morbidity and mortality. Instead, the system has favored those who know how to work systems. We have demonstrated, too, that you do not encourage changes in life-style or responsibility by offering free services.
In the UK, all health services are rationed by government. Mrs. Thatcher made changes on the supply-side, but feared the political price of demand-side change. There is the promise of services, but no right to them. There is no binding legal entitlement. No individual financial leverage. No competitive alternative. There are major shortages of staff; low morale; and a rising tide of patient complaints. Costs vary by a factor of six between hospitals for standard operations; there is serious concern about self-regulated medical practice and its quality; government necessarily suppresses information to curtail the demand for choice.
Modern drugs are routinely denied to patients: for example, only 15% who could benefit from Interferon-beta for MS receive it; there is uneven delivery of combination therapy for AIDS, of Aricept for Alzheimer's and Metastvan for prostrate cancer. Doctors are told not to prescribe Aricept until the patient asks for it - so patients who have to be reminded who they are have to remember to ask for a drug by name.
In renal care we are 21st in Europe; only Bulgaria treats fewer patients per head. These are systematic, imposed failures which worsen the natural constraints of nature.
Cancer care is a particularly shocking concern. More than half of all patients do not see a cancer specialist. We have only 340 clinical oncologists; in the USA I think the figure is 20,000 for a population only five times bigger. Hardly surprisingly, UK survival rates are very poor.
The NHS emphasizes solidarity, as does the OHP. But it has effectively asked us all to join hands and cross the finishing line in the race of life joint last together.
All this results from three things:
1. Driving a system ideologically, by financial targets, on the basis of the visionary idea of "values", which are political and paternalistic.
2. Delivery within an imposed near-monopoly.
3. No individual cost-conscious financial empowerment, which would encourage self-conscious, cost-conscious choice and savings.
The NHS deliberately disempowers the individual. It was intended to do so. Like the OHP, it was designed to satisfy "needs" rather than wants expressed in a market-place. Only experts, doctors and social scientists can know how to satisfy them, we are told. So the patient is not seen as a consumer, deciding what he wants and will pay for, but as a passive recipient of whatever the all-knowing powers on high decide that he ought to have. So consumer sovereignty would defeat the very purpose of a national, socialized health service. This is an ideologically-driven system, retained for political reasons by governments of all parties despite its results.
Consumers with a will to choose would necessarily undermine it, especially if they could remove their money if they were not satisfied with what was on offer. As in the OHP, the idea is that someone can know another patient's needs better than they can know them themselves.
The NHS has failed in its own terms - it is neither free, nor equitable, not effective, nor efficient. It is, however, cheap - unless you happen to be one of the many who are denied service. Wal Mart wouldn't last long selling such a product.
Public ignorance, too, is a necessary consequence of state monopoly - and the public are then told that decisions must be made for them because they are ignorant. The result of the NHS and the OHP must be rationed care, and more not less efficiency. Both are symptoms, not solutions. They under-line that government is guilty until proved innocent - a task of acquittal beyond all the lawyers acting together in this room.
Instead, the individual must be helped to have three kinds of control: over themselves, over providers, and over politicians who use false health-care solutions to buy votes.
The issue is how to use incentives to change the situation for the much better. I suggest that the answer is to empower the individual to ensure three things: good information, which can become self-knowledge for the individual, and then cash in hand to get the job done that the individual wants done - with the realization of what is possible and what is not possible for the dollar. This should exist for everyone - irrespective of employment situation. It can generate self-responsibility, cost-control, self-conscious and cost-conscious choice.
Sydney Webb once told a discussant that his arguments led to Sydney's conclusions. If the proponents of the OHP want what they say they want they had best adopt competitive markets, which are the only way to do the job.
5. The solution - economic instruments:
P.J. O'Rourke wrote: "Money is preferable to politics. It is the difference between being free to be anybody you want and being free to vote for anybody you want." And we know now that the ballot box does not secure personal, individual services like health benefits which are uniquely timely by their nature; politics offers on specific leverage, unlike shopping. Nor can politics register the vastly different preferences of individuals. You can, of course, change the government. This may not help. And by then the patient may be dead.
So consumers must be sensitized to true costs. Everyone must be part of this, if you want a cohesive society, a civil society, and services which are freed from political vote-buying. A huge overall cultural gain would be the world described by Virginia Postrel in her new book, The Future and its Enemies - the spontaneous development in a free society of new and unthought of opportunities, continuous adaptation, a productive and a living system. Rationing is necessary, of course, but by personal choice and by price. Neither the NHS nor the OHP - nor, indeed, the federal system for everyone else offers these potentials.
The only real test of every dollar spent that is worth having is the register of consumer wants when the individual knows the true cost, quality, price and likely outcomes. When they know the alternatives in other services and goods, and the opportunity costs. The key change is incentives so we can each manage our own lives for ourselves, with our own moral compass.
We know the kinds of economic instruments we want and which could work.. Medical Savings Accounts are a winner. Doctors could become agents of patients again, and insurance become a sensible buy again. The MSA could cover the uninsured, too. My hope back home is that we can see a regime like this which would release competition with tax cuts, risk-adjusted tax credits, and the prompt to mutual aid co-operative organizations buying care on behalf of their members, rather than via an insurance company.
The individual is the ultimate cost-container. Self-responsibility, too, is at the root of liberty in a free society. And as Enoch Powell, the British Conservative, once said, "there is no meaning in responsibility where there is no power...we cannot be responsible for what we cannot do."
Appropriate federal tax treatment, and with guaranteed insurance renewal, would liberate this vital instrument of change. A portable, means-tested, voucher, risk adjusted, would bring in the poor. The individual would then pay for the coverage they want. Catastrophic cover would be included and the risk-pool maintained.
Of course, the Federal government, the insurance companies and politicians locally are in the way, as are the providers. However, as the genomic revolution comes on line, as the age of mass medicine passes, as the line between the person and the patient vanishes - with all the ethical difficulties that are already arising - we shall see renewed pressures for individual responsibility. The world wide web has already personalized the rationing dilemmas: we need to empower the individual to decide for themselves on the basis of this new knowledge of treatment and patient experience, and to gauge risk and take responsibility for their lives.
The MSA satisfies the prime demands. It empowers the individual. It offers incentives for cost-conscious behavior. It makes people think about choices. It encourages saving. It is an elegantly simple market-based solution. It could replace the failed model of employer-insurer. The savings could cumulate into long-term care plans, which would tackle another time-bomb. Everyone would know what to expect, in one coherent system.
US health care in the broadest view, the OHP and Britain's NHS struggle with how to make relative investment decision between one patient and other. The players struggle, in increasing frustration, with how to control costs and benefit from positive incentives. But they cannot establish what is "optimal" care for an individual; "what is appropriate": what counts as a good outcome; what is the right level of investment for each of us.
All this, of course, emphasizes appropriate access. However, it is very difficult to show a convincing link between access to medical care or even use of medical care and positive health outcomes. This is counter-intuitive, perhaps, but it seems to be the case. The well-known Rand Study in the 1970s showed that families with a $3,000 deductible (in today's dollars) spent about 30% less on health care than families with first dollar coverage, and with no adverse effects on their health!
A study in 1980 by the National Center for Health Studies found a positive correlation between the number of physicians and death rates. Another study found mortality rates fell during physician strikes in Canada and Israel and Los Angeles. They returned to normal levels when the strike ended.
Harris had his short comings, but his changes to welfare, and social spending were needed - the rest is not suited for this thread :. And it's the French who do everything backwards...everyone blames America for Canada's problems, I say blame it on the French :
Originally posted by Isaac Brock
Well, I can't refute what you've read, but I'll say this. Come to Canada and you'll see that lepers aren't roaming the streets and that we are in good health. Visit a hospital and you'll see that it is clean and staffed.
Originally posted by Merlin1047
Isaac, it was never my intention to suggest that Canadian health care was on par with third world countries.
There are two points I'm trying to make in all this. One is that socialism, like communism, is ultimately self-defeating. When people start looking to government to meet all their needs and government starts taxing to the degree that investment and hard work are no longer rewarding, then collapse is inevitable. I see socialized medicine as just another step in that direction. The second is that privatized medical care is superior in many ways to that supervised or sponsored by government. Privatized medical care responds more quickly to a need, if that need produces profit. That is also it's drawback. If you have an extremely rare condition, you may as well plan on dying. Because where there is no profit, private medicine will produce no treatments. Government mandate for development of treatments for rare ailments is one of the very few roles for government in medicine to which I am willing to agree (besides basic licensing and other fundamental regulatory oversight functions).
