The following is a reprise of my column from the Providence (RI) Journal in September 2009. As we contemplate the potential impact of Texas District Court Judge Reed O’Connor’s ruling to strike to the Affordable Care Act, let’s consider life before the ACA (when this piece was written.). There is much more here to review. We have no “health system” in the United States, only chaos.
Mad as Hell!
“So, I want you to get up now. I want all of you to get up out of your chairs. I want you to get up right now and go to the window, open it, and stick your head out and yell, ‘I’m as mad as hell, and I’m not going to take this anymore!!’” So concludes the iconic scene in Paddy Chayefsky’s 1976 film, “Network” when Howard Beale, the unglued anchorman played by Peter Finch, goes on-air in a rain-soaked trench coat and ferociously blasts an impromptu lecture at his viewing audience. Moments later, the action captures city residents opening their windows and following through on Beale’s advice.
We’re in one of those “mad as hell” moments in the current health care debate. Some of our fellow-citizens have taken up the Howard Beale call, expressing themselves at town-hall meetings around the nation. But these public howlings are also filled with hyperbole, exaggeration, and downright misinformation about the Obama administration’s health care proposal. By contrast, the voices of physicians and providers – from the health care trenches – are largely silent, or muffled, while politicians, policy wonks, and corporate lobbyists dominate the airwaves.
In the process of having to listen, I too have finally gotten “mad as hell” and here’s what galls me:
- I’m mad as hell that so many of my patients are uninsured or underinsured and as a consequence “no-show” their appointments, can’t pay for their essential medications, and often land in the emergency room with avoidable illnesses.
- I’m mad as hell that the health insurance industry continues to consume 25% of the health care dollar in administrative costs while providing so little to improve the quality of patient care. Their strategies – such as obtaining “pre-approvals” for procedures, drugs, and office visits – amount to nothing more than bureaucratic delaying tactics, designed to frustrate both patients and providers.
- I’m mad as hell that the nation cannot get a grip on health care costs. Overwhelming data (see Dartmouth Medical School’s “Atlas of Health Care”) demonstrate huge regional disparities in Medicare spending. However, regions with the highest spending often have the poorest health outcomes. We do not have the political will to apply evidence-based guidelines and comparative effectiveness research to reduce unnecessary expenditures or procedures. Rationing? Yes but rational rationing, not the arbitrary limits imposed by the insurance industry.
- I’m mad as hell that a perverse fee-for-service payment system continues to over-reward specialists for procedures and underpays physicians who spend time in the office educating, advising, counseling and caring for their patients. This system adds fuel to fire of procedure-driven medicine.
- I’m mad as hell that physicians’ ownership of health care facilities, such as nursing homes, hospitals, dialysis units, urgent care and imaging centers, continue to give our profession a bad name. Conflicts of interest abound when physicians benefit from referrals to their own facilities.
- I’m mad as hell that a sick and suffering health economy has severely degraded the quality of medical education – so that medical students and residents have little time to speak with, examine, or most importantly, “think” about their patients. Constrained by work-hour rules, trainees must deal with rapid inpatient “thru-put,” overseen by an overworked, under-compensated faculty coping with a Sisyphean task of educating our future doctors in a hostile environment.
- I’m mad as hell that the pharmaceutical industry continues to perpetuate the lie that the enormous patient-borne costs of non-generic drugs are due to “research and development” and deny that so much of their profit is directed toward the marketing of “me-too” drugs. Most of my patients cannot afford newer drugs. I’m also furious that that a large federal entity, Medicare, has been legislatively restricted (by the enactment of Medicare Part D) from bargaining with the pharmaceutical industry to reduce drug costs.
- I’m mad has hell that the “mainstream media,” particularly cable television has oversimplified and “dumbed-down” the health care debate, turning legitimate issues into falsified fodder feeding slick, simplistic smear campaigns. The nation sorely needs, for example, a thoughtful discussion about how to approach the medical, economic, and ethical questions imposed by the enormous cost burden we face at the end of life.
Most of all, I am mad as hell that so many of my fellow-physicians are detached and largely un-involved in the health care debate. Like Howard Beale, I want to say this to my colleagues: “I don’t want you to protest. I don’t want you to riot. I don’t want you to write to your Congressman, because I wouldn’t know what to tell you to write…All I know is that first, you’ve got to get mad.”