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May
23
2006

At a (very) early breakfast put on today by the Oregon Health Forum, former Governor John Kitzhaber and OHSU President Peter Kohler talked about their visions of health and health care in the future. General agreement: the system must be fixed.

Both men spoke eloquently; there were many memorable lines and anecdotes but two in particular seem to encapsulate their respective thinking: “What is wrong with that fish?” (John Kitzhaber) and “Nurses will not be driving taxis.” (Peter Kohler).

First, we unravel the fish anecdote (what follows is a brief summary of Kitzhaber’s presentation. Check out www.archimedesmovement.org for more information).

Kitzhaber described a boat trip down the Rogue River with a friend from New York. A large salmon floated by, lethargic, scales falling off, a shadow of its former glory. The friend asked:” My gosh, what is wrong with that fish?” and Kitzhaber responded: “Nothing. It is just dying.” Having spawned, it was at the end of its natural life-cycle.

Kitzhaber used this anecdote to shine a light on the ineffective allocation of health care funds in the current system. “We think death is optional,” he said. And we use a huge amount of public money to prove it.

From an individual point of view, or when a loved one is dying, this expense seems appropriate. But many of these end-of-life procedures offer untested or questionable outcomes. Much of this cost is funded by Medicare. Is it reasonable for public money to be spent on questionable outcomes, he asked? From a broader society perspective, it means that we are making an implicit decision to use this public money in ways that prevent government from extending health care to other groups. Why not use public funds to maximize the health benefit of everyone instead?

It is not just end-of-life spending. This anecdote starkly showed how we have stopped making overt policy about health care, instead allowing the system to indirectly make the decisions. He asserted that our system of employer-based health care, Medicare and Medicaid – created in response to mid-20th century social issues – is a core problem. It is no longer relevant to today’s circumstances. Consider the facts.

In the 1950s, our government supported (through passing legislation for tax write-offs) an employer-based insurance system never imagining the effects of globalization and other economic forces. Today, the situation is such that American employers who still opt to offer health insurance are in direct competition with businesses who either choose not to offer it (the Wal-Mart phenomenon) or whose governments take on that expense (Canada).

Second, Medicare was created at a time in history when the elderly were the poorest segment of society. Today, they are the wealthiest. Paradoxically, children and grandchildren (some of whom are too poor to have health insurance themselves) now are subsidizing their rich elders.

Last, at its inception, Medicaid created acceptable categories of deserving poor – pregnant women, blind, disabled, and so on. A presumption behind this is that anyone falling outside of these categories must be “choosing” to be poor because otherwise they would get insurance through their employers. Clearly, this is not relevant today given that most low wage earners cannot afford insurance premiums, even if they are offered.

And why are those premiums so high? The people who don’t have health insurance come to the Emergency Room for health care, the bills are astronomical, hospital costs go up to cover that, insurance rates go up and the vicious cycle continues. The system needs to be changed, according to Kitzhaber, at its roots. He suggested a first step is exposing the insanity of the existing finance system. From this, we can devise a new vision for health and health care.

For instance, he suggested thinking of health care as we think of public education. We assume universal access to a public education. When we are short of funds, we reduce the benefit for everyone, we don’t kick people out of the system. (Interesting fact: 70,000 people were dropped from Oregon Health Plan in the last few years just be redefining who is “poor.”) People who have discretionary income, well, they hire tutors or send their kids to private schools, if they want to.

Kitzhaber suggested that the health care system can be similarly financed to have a basic benefit provided with public funds to every citizen, and then people can use their discretionary income to buy more health care on top as that benefit. Kitzhaber called his presentation “A Road to Revolution.” Indeed, it would be.

Coming soon: Part 2: Why nurses won’t be driving taxis….Dr Peter Kohler talks about provider shortages, new delivery mechanisms and wowed the audience with a technology demo of the cyber-physician of the future.

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Join the dialogue here

May 24, 2006 8:50:39 PM
Tess says

A big yes! As to the point regarding end of life health care, I observed the complicated care my grandmother got at the end of her life. Did it add to her quality of life? No. Was it a huge expense? Yes. Who did it help? Well, I love my grandfather dearly, but it seemed to me that it helped him more than it helped her. But I think that's another issue... though related if you look at it closely. We do tend to focus on "living" at all costs, even at the cost of quality of living - and at a huge cost to those paying the bills.

Why not provide minimum health care? Again I say that I don't go to the doctor - even though I have coverage while I'm in AmeriCorps - because I can't afford the co-pay. I surely can't afford the co-pay on the dental work I need. So, I get no care because I can't afford minimum care. I am potentially building to a situation where I will be one of those needing more extensive care and contributing to the drain on the system because I haven't gotten preventitive or diagnostic care.

...heavy sigh... the whole thing actually makes me tired. I'm sure I'm depressing my imune system.

May 26, 2006 11:31:44 AM
sweet lou says

Obviously, the healthcare system is in jeopardy. There is wide spread agreement from pretty much all sectors. But the thought of having to deny end of life care to someone just to save money for others is making a deal with the devil. Who gets to decide what procedure is too expensive? The patient? The doctor? The lawyers? Do the wealthy truly deserve the opportunity to new and dramatic life saving medical care simply by virtue of their portfolio? How about the poor, should they content to live out their “natural” life spans knowing they are contributing to a greater good? And what about the age factor? Do we tell a senior citizen their life is less important than that of a premature baby? Or is someone going to tell the new parents that the medical care their kids need is too expensive and they should have waited until they were wealthier to have children?

We all like to think that if it was us lying in a hospital bed somewhere with bleak survival prospects, we would have the clarity, strength and nobility of spirit to make the hard choice – to wave off dramatic interventions and die with dignity. But the truth is, most of us in that situation will be tired, scared, sick and desperate to hang on until all possibilities are exhausted. Medicine is about hope. Basing healthcare on a cost/benefit ratio kills hope, and widens the gap between disparity of care for rich and poor.

May 26, 2006 12:28:22 PM
S. Shearer says

It is important, I think, to consider this issue both from the individual and the broader society perspective. And by who pays. For an individual, end-of-life "hail marys" are about hope. Without hope, life (no matter how short its future span) is unbearable. For society, however, these expenditures, assuming they are public money, may mean that many of those lower-income people you mention, sweet lou, will go without even basic health care because the public money is gone. You make decisions based on proven procedures with public money, no different than a basic premise of the now-ruined Oregon Health Plan. Sure, in the end, this is health care rationing, but when using public funds, is there any other way to do it???

Jun 8, 2006 1:50:32 PM
sweet lou says

I agree, in principle. But in practice, "rationing" too often simply means services go to those with best advocates. Or the most money. Or the highest visibility. The very term "end of life care" presupposes that this period in life is somehow less valuable than "middle of" or "beginning of" life.

Society exists, at least in my definition, to serve life. No qualifiers needed. The need to ration healthcare based on arbitrary standards is a sad continuation of class warfare. The wealthy are able to get the care they need while the rest of us are forced to rely on the vagaries of cost benefit analyses.

Jul 15, 2006 11:32:52 AM
Liz Baxter says

Sometimes we need to take the presumption away that talking about ‘changes’ automatically means that there will be fewer services available. The comments so far have discussed possible changes to health care at the end of life. There is another possible frame - if we can begin the conversation by asking 'what services would we like to have available for us as we near the end of life' (which we must also remember can be people of any age - not just older adults) then we may begin to envision care options that are neither high-tech or high-cost.

I'd like to be able to have my family around me, be in a comforting situation for me and for them, not be in pain, and - as much as possible - to have had someone spend time with me hearing my last wishes and acknowledging them. Now, I understand that not all deaths happen like that, but the important part is that we may not have to take away or limit benefits for patients. I only want to die in a hospital if there is no other alternative.

If we can provide options that are closer to what we would actually want for ourselves or our family members, patients may opt for those lower-cost alternatives without being precluded from the high-cost ones. The Archimedes Movement gives us an opportunity to declare what the benefit should look like if it were accomplishing what we identify as its goal.

We know that the current health system cannot be sustained; and we know that so many of our fellow community members are not covered within this existing system. People in multiple states are identifying creative ways to get more people covered. The remaining challenge is due to the fact that we are covering people within the same broken system. The Archimedes Movement is posing a question that few are asking elsewhere. What are we trying to achieve with public dollars (the vision)? What should guide the design of a new system (the principles)? If we acknowledge that we have limited public resources, what should we purchase with those dollars that will benefit the entire community who has invested their public money into it?

Jul 17, 2006 11:10:59 PM
Stephen Gregg says

It is fashionable to challenge the practices associated with end of life care, and such other matters as smoking, overweight, and other "irresponsible" personal behavior. The assumption is if we could "solve" these obvious problems, health care would be less expensive for all of us.

Do we really, really believe if we waived a wand and caused all these annoying issues to disappear, that the payer and provider community would simply roll over, take a 20-40% decline in revenue, without a vigorous adjustment? How long would it take our medical establishment to refocus? I am convinced we do not understand the elusiveness of the "cost monster".

Jul 18, 2006 11:42:31 AM
Sara says

No they would not, no question. It is against human nature to agree to be paid less tomorrow for the same service provided today. A cultural shift is required...moving from the "health care industry" to "health" somehow.

Insisting on price transparency (see other column) is a good first step to addressing the "cost monster." The problem however, is that pricepoint.org and other public sources of data only post CHARGES for health care. Few people pay that amount because of the highly confidential discount contracts between hospitals and insurers. So even these attempts at transparency are not "real." How can you fix a system when no one really knows what's going on on a macro level?

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