There is an old folk tale about the peasant wife and how she solved a problem. Every night, she and her husband found that their feet were cold while they slept, because their blanket was not long enough to tuck in.

To solve the problem, she cut off a wide strip from the top of the blanket and sewed it on the bottom. That way, she reasoned, there should be enough blanket at the bottom to tuck it in at night.

This kind of thinking seems to be what is going on in "health care reform."

Solving the whole health-care conundrum all at once would be too much to ask, but what about starting with one significant change?

Continue reading Health care reform could start with one significant change


The New York Times is reporting that the health insurance industry is proposing an expansion of Medicaid and new tax breaks to expand coverage to virtually everyone within 10 years.

More than few people would argue that Medicaid is barely functional now. Witness that many physicians and hospitals refuse to take these patients because the government does not reimburse enough to even cover the cost of health care. So, without new funding mechanisms, isn't this proposal simply a way to quietly shift the cost to providers who in turn will pass it on to private insurers who in turn, will pass it to, yep, the employees paying for health insurance. What will happen then? Higher co-pays, higher deductibles, more $$ paid by working individuals. In name, we will achieve universal coverage, but will it help the U.S. achieve what should be the real goal? Universal HEALTH?

Continue reading Disingenuous? Ya think?


By Curious George

I’m new to this field as a professional working in health care. Up ‘till now, I’ve only been its victim of its explosive costs; albeit one who has been brilliantly cured, helped and mended many times.

Before daring to make any suggestion about reform, however, I’d love to hear from others to see if I understand the problem. I’m a little confused. Do I have the following view of the situation right?

The United States is the last industrial nation that can’t seem to take care of the health needs of about a quarter of its population without squawking and sacrifice.

Despite this, we have a de facto health education system that ensures a constant undersupply of trained professionals in such a way as to guarantee constant demand and a large reading audience for such waiting-room pillars of culture like People and Us magazines.

Despite this undersupply, we’ve constructed a health care education system that guarantees the vast majority of graduates are so far in debt that their only choice is to become workaholic slaves to health care plantations. Of course, with steady work and a diligent effort they can clear themselves of this debt in time to realize that their only remaining choice is to stay in the system, make more money, and pledge that no one rocks the boat.

And setting the national health agenda, we have two giant industries whose only concern is our well-being: insurance and drugs. With record-breaking profits from an otherwise dysfunctional system, these two industries spread their wealth with obscene management salaries and much-needed gifts, contributions, golf and travel for our poor, over-worked elected leaders.

So, perhaps you can understand why I’m confused. Where’s the problem?

Continue reading Help!


by Dan Handel, M.D. and colleagues

An OHSU physician and reseracher, Dr. Handel has submitted an editorial from the Annals of Emergency Medicine for discussion.

It is the end of another busy afternoon in the emergency department (ED). As you finish up your dispositions, a 35-year-old patient with poorly controlled diabetes and hypertension comes in for a medication refill. Reviewing his medical records, you discover he presents often for medication refills. His demographics sheet is marked as “self-pay.”

“Sir, do you have a primary care physician?” you ask.

“No, I don’t have any insurance, and they all ask for the payment up front, which I can’t afford,” he replies.

You have heard this all before. You return to your desk to refill this patient’s prescriptions yet again, knowing that he will soon return to the ED when he runs out or, even worse, will present with an exacerbation of his medical conditions because of his inability to obtain medications.

Residency trains physicians to handle all medical emergencies that present to the ED’s door, but it does not necessarily train physicians to address the ED’s significant social issues. Physicians’ best acute clinical care may be undermined by the social factors that affect the way their patients receive follow-up care. Read the rest of the editorial (PDF).

Continue reading The challenge of patient follow-up in today's health care environment


Guest column
Angela Heider, M.D.

I recently retired from the practice of obstetrics and gynecology at the young age of 32 and after only two years in practice. My reasons are, of course, complex, but they boil down to the impossible logistical, financial, and familial implications of practicing medicine within the confines of the current system. Alarmingly, four of my young female partners have also elected to hang up their stethoscopes – a growing trend. If we are to reverse this trend, we need to reform our health care system.

Some health policy experts believe comprehensive reform is impossible in the absence of a national disaster. I believe we can make a difference but a really important first step is to make insured people understand the necessity of such an endeavor.

True enough, there are millions of uninsured and underinsured Americans who are clearly suffering under our current system. However, there are many more happily insured Americans who are completely unaware of the horrific state of a system they trust whole-heartedly. The fact is, even wealthy Americans are impacted by the looming health care crisis. They just don’t know it yet.

Continue reading The Rise and Fall of Dr. Mom


Guest column
Joel Ario, administrator of the state’s Insurance Division
Cory Streisinger, director of the Oregon Department of Consumer & Business Services

The authors have submitted this Op-Ed (a version of which originally appeared in the
for discussion on this blog.

You're about to have a baby and since your employer switched to a high-deductible health plan, you care about price a lot more than you used to. You're a savvy shopper, adept at using the Web to find the best deal. So you quickly discover, an Oregon hospital association Web site that tells you the statewide median charge for an "uncomplicated vaginal delivery" is $5,024. More clicking and you learn hospital charges are about 10 percent higher in the Portland area and vary by as much as 40 percent among local hospitals. You're disappointed the site doesn't rate the quality of services. You figure delivering a baby isn't all that complicated, so you're willing to decide based on price. Then things get really frustrating. You learn that the $5,024 is figured on so-called "billed charges" that nobody really pays, just like nobody pays a new car's sticker price, and that this amount might not include other charges, like the anesthesiologist's bill. Your insurer has negotiated a discounted rate, but it only applies to one local hospital. Even worse, the amount is a closely guarded secret - your hospital and insurer won't tell you what it is.

Welcome to the world of so-called "consumer-driven health care" where the rosy rhetoric is well ahead of the reality. You can't find out how much your hospital stay will cost you, but you know it will be expensive. You start to wonder just who can control costs like the multi-million-dollar hospital expansion projects busting out all over the Portland area.

Continue reading Cost Transparency and Affordable Health Care


Guest column
Dr. Donald D. Trunkey, OHSU Professor of Surgery

Dr. Trunkey presented his ideas on health care reform at the City Club of Portland on June 9, 2006.

Access to US healthcare is a lottery, and what used to be a “not-for-
profit” system has become a “for-profit” system.

I would like to begin this dissertation with two relatively recent quotes. “We live in a great country that has got the best healthcare system in the world, and we need to keep it that way.” (George Bush, June 2003) “We do have the best healthcare system in the world.” (Bill Clinton February 2000)

Unfortunately, the evidence does not support the two presidents. One barometer of measuring effectiveness of a healthcare system is the average lifespan and the per capita cost. In the United States, we have an average lifespan of 77.8 years, at a cost per capita per year of $4887. In Spain, the lifespan is 79.6 years, at a cost of $1100. In Canada, the average lifespan is 80.2 years, at a cost of $2792, and in Japan, they live an average of four years longer than we do in the United States, at a cost of $2003 per year. Another measure of healthcare system effectiveness is the infant mortality. In the United States, it is 6.9 deaths per 1000 live births. In Denmark, it is 5.3, France 4.6, Sweden 3.4, and Japan 3.2. In fact, in the WHO Global Ranking of Healthcare, the United States is number 37, between Costa Rica and Slovenia, both developing countries.

Continue reading Dysfunctional Care in a Dysfunctional Healthcare System


I just read about the new Institute of Medicine report on America's emergency care system being "At The Breaking Point" and while I'm usually a big fan of the IOM's work my first impression is they blew it this time. (Let me first put out the disclaimer that I have not yet read the entire report.)

The report discusses the major problems in our hospital-based EDs, including overcrowding, people using the ED because they cannot access primary care, and the burden of uninsured patients. I'm with them so far. But their recommendation seems to be to throw money at the hospital ED system. Huh?! EDs are widely acknowledged to be the most expensive and least cost effective way to deliver care, especially primary care. So why would we sink more money into building more EDs and paying them to see more people (inefficiently)? Wouldn't it make a heckuva lot more sense to build up the primary care system, especially the Community Health Centers and other safety net providers who specialize in caring for uninsured and disenfranchised individuals, and who provide great care for the lowest cost? Then there'd be more access, so fewer people would seek care in the ED, they'd have less overcrowding and less "burden." I think the IOM needs to try again on this one.

Continue reading IOM got it wrong


Awhile back, the consensus was that America was facing a surplus of health care providers. A popular refrain then was that new nursing grads would be “driving taxis” for a living.

Turns out, the rhetoric worked and too few people entered the health care field. Now, just as the baby-boomers reach the age when they need health care more than ever and as the health care system is besieged with other cost and access challenges, we also now face a serious shortage of both nurses and physicians, said OHSU President Peter Kohler during his remarks at a recent Oregon Health Forum meeting in Portland. Nurses will definitely not be driving taxis in the future.

Kohler agreed with Kitzhaber’s premise that fundamental change to the health care finance system is needed (see Part 1: “What’s Wrong With That Fish?”). Kohler then talked about delivery models, which both speakers also said need to evolve to meet current and future needs.

Continue reading Why nurses won’t be driving taxis… (part 2 of 2)


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 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.

Continue reading What is wrong with that fish? (part 1 of 2)



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