OUR HEALTH PLAN
COMMUNITY GOVERNED HEALTHCARE THAT WORKS
2017 Jim Rickards, MD, MBA
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INTRODUCTION
A s a child, I remember visiting my grandmother in the hospital where she was fighting pneumonia. It was a nice, community hospital, the kind you might find in any number of towns or cities in the U.S. Given her age, she had several chronic medical issues including Parkinsons disease, like the actor Michael J. Fox, which contributed to her current condition. While these issues related to her stay in the hospital, they were just a part of the problem.
She lived alone and could not drive. As a result, she was also probably somewhat depressed. The hospital offered her all the support she needed for the moment, but of course, this came at a costnot just monetary cost, but the discomfort of being away from home and in an unfamiliar environment.
On this visit, however, she had shown dramatic clinical improvement. I remember my dad kept trying to get answers as to how she would get home, who would help her make appointments with her regular doctors for follow-up, and who was helping transition and coordinate her care.
It turns out, my dad was the one doing most of the work figuring out next steps in the transition of her care. He was a sales manager for an electronics company and, other than the address of the hospital, he didnt really know much about the operations of the healthcare system.
While there was great medical care available and she had incredible providers at the hospital, the building and loosely connected network of providers and services wasnt really a system. There was no group of individuals and entities working together under one common mission and vision, with one global budget, and no way to measure its performance in aggregate.
No, there wasnt a system, but there were many parts of a system working for my grandmother. There were the doctors, of course; the non-emergency medical transportation providers; the insurance company; the meals-on-wheels folks; the pharmacist; and the home health aide, the social worker, and a whole host of others. They were all there to helpbut they were doing it in a way that was not coordinated, which resulted in frustration, inefficiency, and probably a lot of waste.
I remember the day came that my grandma was going to be discharged. We went to the hospital early in the morning. My dad asked many questions, trying to figure out next steps.
He traveled a lot for work and knew airlines were, for the most part, able to pull together pilots, mechanics, planes, ticket counter attendants, baggage handlers, etc., all to get individuals where they needed to go with a clear plan detailed on a ticket. They were also able to do this, for the most part, on time and at a cost you clearly knew ahead of traveling.
This didnt seem to be the case when trying to make the short trip from hospital to home. We were finally told by a nurse that the teamin other words, the doctors, the social workers, pharmacists, physical therapists, and transportation service providerswere going to get together to come up with a plan to get Grandma home. We waited and waited. As a kid at the time, I remember I didnt mind the wait because there was cable TV to watch in the rooma real treat in the late 1980s.
Slowly, throughout the course of the day, I realized what was happening. There was no team, there was no meeting, and there was only somewhat of a plan. We had been so naive to think that this system and this team of varied providers worked together and were going to develop a cohesive plan for our grandma recovering from pneumonia.
My grandma was eventually discharged to home and we were able to fumble through the process of helping get her there. But I couldnt help wondering why it had to be this way. I couldnt help comparing the process to my fathers at work. Sure, this wasnt air travel, but there were similaritieslarge, physical structures dedicated to one service, highly skilled professionals, high costs, and the risk of life and death. If we could streamline air travel, why couldnt we do the same with healthcare?
While going through medical school, I kept the idea and possibility of this team, this coordinated effort, in mind. I was always on the lookout for it. I figured that, because my grandmothers facility was a community hospital, they must not have had the resources of the well-funded, tertiary-care academic systems where I received my training. What I learned was that, if anything, these seemingly well-funded systems were even less coordinated, because there were so many more resources, so many more services, and so many more ways to pay and bill for care.
As I began my medical practice in a small town in Oregon, I had fully accepted the healthcare system for what it was, with all its shortcomings in coordinating care. However, my frustration with it continued to grow. As a radiologista physician who interprets medical imaging exams such as CAT scans and x-raysits not necessarily a good thing to really get to know your patients. The exams we perform are expensive and can expose you to radiation, which comes with its own risks. The less frequently we see our patients, sometimes the better, in terms of their health.
What frustrated me was that I was seeing the same patients come back repeatedly: an alcoholic who would have a CAT scan of his brain every Monday because of an alcohol -withdrawal seizure, a teenage girl with an unintentional pregnancy for the third time in two years, and a diabetic slowly losing his leg because the disease was poorly controlled.
I knew I was doing everything right interpreting the various imaging exams. My colleagues in internal medicine and the emergency department were delivering great care. The problem is this: ninety-nine percent of patients lives are lived outside the four walls of a hospital or clinic. Thus, multiple determinants healthsuch as socioeconomic factors, education, and housingimpact them in far greater ways than the medical care they receive.
