First, let me admit that I don’t believe there is anyway humanly possible to change and improve our healthcare system.  Every component, and there are many, is broken.  Fix one and you are bound to break another.  That being said, if I was tasked with improving our healthcare complex, the very first thing I would do is formulate a list of the key players and the role each plays within the system.

I’d start with the patient’s role.  As long as we are free to do as we wish, whichever overall solution you choose for the provision of healthcare is destined to fail.  Think about it.  I have a melanoma on my chest.  It’s been biopsied and I’ve seen a surgeon.  Monday, I’m seeing an oncologist/surgeon.  I’ll have surgery and that will probably be it.  If I’m unlucky, I’ll need chemo.  The treatment of my melanoma is expensive.

Thirty years ago, my dermatology professor said, “Stewart, it’s not if you are going to have skin cancer, it’s when are you going to have skin cancer.  You need to avoid the sun and wear sunscreens!”  I love the sun.  It’s my God given right to get tanned.  I’ve been soaking up the sun since I was born.  I created the cancer and now I expect someone else will pay to fix it.

The same goes for smokers, drinkers, drug users, anti-vaxers, etc.  People have a right to abuse their bodies and then expect that someone else will cover the expense of fixing it.  Not only do they expect someone else will fix them; but, since they aren’t paying for it, they expect that “everything humanly possible” will be done to keep them alive.

“Everything humanly possible” is what the family of the chronic lunger with cancer who is in the ICU on a ventilator demands of me and the ICU staff.  It matters not that the patient smoked himself to death.  It doesn’t matter that he will live the rest of his life on a ventilator.  The family wants Dad kept alive at any expense!  

Now, let’s look at the same patient where somebody else is not paying for his care.  “Doc, we want everything humanly possible done to keep Dad alive.”  The doc responds, “We’ll do as you ask but it will cost a minimum of $25,000 a day.  How would you like to pay for that?”  Been there, done that.  The family’s response will be, “You know, Dad’s lived a good life, and he wouldn’t want to be in a nursing home.  Bring in Hospice.”

So, how do you build a system that provides and pays for the care of people who hurt themselves knowingly?  Do you take away their right to sunbathe, smoke, do drugs?  Do you strap them to the table and immunize them?  Of course, not!

What about a system that rewards healthy living and penalizes those who do harmful activities?  Unfortunately, that won’t work either.  Mr. C smokes and drinks heavily.  He’s constantly ill and can’t pay his bills.  We’ve done “everything humanly possible” to help him and he owes us $2,500 dollars for care delivered over many visits for several years.  My office is ready to send him to collection.  I bump into him in a local restaurant.  He’s sitting at the bar drinking. “Doc, I can’t believe you’re sending me to collection.  You know I can’t afford to pay you.  You’re an SOB.”  I actually answered him.  “Mr. C, I wouldn’t be able to afford to pay my bills if I smoked 3 packs of cigarettes a day and drank 5 cocktails a day, every day, either.  By cutting you a break, I’ve been subsidizing your smoking and drinking!  That stops now.” How do you penalize Mr. C?  Do you deny him access to healthcare?  Obviously, you can’t!  So, you have to provide care to Mr. C and he will not pay any penalty you impose.

No matter what healthcare system you build, patients who are free to do as they choose will destroy it.  How would you handle the patients who, as a consequence of their lifestyle, consume large amounts of healthcare dollars?

Tomorrow, we’ll look at the physician’s role in this mess.

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