464px-Train_wreck_at_Montparnasse_1895 Much is being said of the healthcare system during this election year. Solutions to its ills are plentiful - ranging from socializing medicine to allowing "the market to take care of things." Yet with all of the pundits' self-confident analysis as to the real problem with our healthcare system, one fact is almost never mentioned: it is not a system. The word system is defined as:

(1) A group of interdependent items that interact regularly to perform a task.

(2) An established or organized procedure; a method. (from Webopedia)

Healthcare, is, in fact a group of entities that work largely independently and often against each other. Here is what I mean:

  1. Primary Care Physicians - Loners that usually don't hear anything when their patients are in the ER or at the specialist. They are increasingly isolated from the hospital (by using hospitalists). Pushed around by insurance and now a dying breed.
  2. Specialists - Cozy with the hospitals in the past. Many now do procedures in their office or surgery center they have interest in (so they get some of the money the hospitals were making off of them). Managed care has forced all referrals to go through PCP's, so they seldom communicate with each other.
  3. Emergency Departments - Where patients go when they can't find a PCP. High cost due to CYA (ordering extra tests to protect themselves since they don't see patients back), so insurance companies want everyone to avoid them. PCP's and specialists dump on them when too busy.
  4. TalkDrPB01en Hospitals - They have made big money off of physicians for years, now mostly expensive patients are hospitalized. PCP's are given P4P bonuses for decreasing revenue of hospitals (in theory, at least).
  5. Insurance Companies - The great Satan. The only thing unifying the other parties is their hatred of the insurance industry. The goal of insurers is to maximize shareholder value at the expense of all other parties.
  6. Ivory Towers - Academic medical centers are generally huge money losers that think that any physician outside of their hospital is a bad doctor and other hospitals are far inferior. Physicians in ivory towers are sheltered from reality by not having their salary really dependent on insurance. They are necessary for training of new physicians.
  7. Patients - Patients are the only thing #'s 1-6 have in common. They assume the other parties are working together, but this is rarely true. They are hence the only real link between disparate information systems of the other players in healthcare. Oh yes, they are the ones for whom the others exist (even though it usually is assumed the opposite is true).

Here are some common misconceptions about American medicine:

  1. Doctors and hospitals are on the same side. This is absolutely false. Hospital administrators are generally frustrated with physicians and physicians feel that hospitals are making money off of them without a return for the physician.
  2. tower_of_babel_painting_closeEveryone likes Medicare. I have heard pundits actually say that somehow a "Medicare for all" would be a good thing. Medicare is the low-water mark for reimbursement for physicians who have not given it up altogether. We have a discount plan for self-pay patients in our city. To give a really bargain price, we agree to charge them only 10% above that which Medicare charges. The system would fall apart if "Medicare for all" happened because nobody would stay in medicine.
  3. We know what is going on with our patients - Nobody has the big picture (except perhaps the patient). Specialists don't know why patients are referred; PCP's often don't know what is going on in specialists' offices, in the ER, or in the hospital. Medication lists changed in one location are frequently not changed in others. It is really incumbent on the patient to fill in these information gaps.

A very large proportion of the money in our system goes to the waste that is a result of the fact that it is no system. Tests are duplicated; patients are shuttled around trusting someone knows what is going on, when they are probably the ones who know the most; doctors are not working together and hospitals are working against doctors; insurance companies have lots of information, but use it as leverage to avoid having to pay. It is chaos. It is expensive chaos.

Any steps that are taken in reforming our "system" must first address this chaos. How can that happen? I am not sure, but my vote would be for the two main parties: patients and doctors, to get on the same page.

Scary stuff? It should be.

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