The Mirage of Reform

This chapter is eerily similar to the headlines in the paper this week. As McCain and Obama make their final pushes for the White House, we have heard socialism thrown around as an insult. We have heard about privatizing health care, about establishing national health insurance. It leaves one to wonder whether the efforts of either President-elect will come to fruition, or flounder like the efforts before them.

It seems that the greatest barriers to success are interest group politics and division of efforts. It is interesting to note that incrementalism, in this view, served to stratify and distract from a larger effort. As specialty hospitals weighed their options, they chose to go off individually and focus on their own agenda, rather than a group agenda. This is an oft-observed phenomenon. Tiny factional groups will work on their own piece of an issue, not because they are unable to see the larger picture, but because the resources required for collaboration, the high likelihood of failure and the sheer challenge of coordinating a large agenda overwhelm collective efforts. In local government, we are starting to use the term "collaborative governance." This replaces thirty vogue terms before it, but captures the challenge of change in an environment of significantly limited resources. We all have goals, individually and collectively and many of these goals actually have a high level of overlap. Collaborating in way that facilitates the achievement of these goals for more than the individual, however, requires sacrifices from all participants. In a group setting, sacrifice is political. Those who feel compelled to sacrifice sense a loss of power.

As we move towards election day and more importantly, into a new presidency, it will be interesting to observe the efforts towards health care and track them against this chapter and indeed this book. To watch? Interest groups, political compromise and scaling back of goals from the lofty to the achievable.

Chapter 6: Escape from the Corporation

Chapter 6 hints at struggles within the medical profession that pervade today. Even within the elevated rank of physician are strata that separate the "regular" doctor from the specialist. Some of this is attributable to popular television, which is an information source for many people. On shows such as Grey's Anatomy, House or E.R., the doctors who get the most attention are not the General Practitioners, but the specialists, the renowned plastic surgeon or neurosurgeon or the doctor who only takes the most complicated cases. This is further propagated by the online informational sites that many people consult daily to supplant the need for a doctor for every ache and pain. Often, these sites contain a recommendation to seek further help from a doctor specializing in the field. While a specialist is certainly an expert, general practitioners are also highly knowledgeable and in many cases, can treat a variety of common afflictions.

The chapter also hints at the division between physician and other medical professions, one which also persists today. Indeed, although they often work together seamlessly, the division between nurses and physicians is not only significantly separated by gender, but by authority as well. Like the specialists of the early 20th century who were highly qualified for X-ray or radiology, the level of training for associated medical professionals seems to be continually on the rise, no doubt in an attempt to secure some of the authority physicians fought for in the early decades of organized medicine. Physical therapists, for example, are now required to have a PhD to practice. Although the PTs who were certified when it was a B.S. or M.S., the continued rising bar to practice is becoming a barrier to entry for some people. Similarly, nurse practitioners currently require only a masters. However, people within the industry estimate that within a decade, NPs will be required to hold a PhD. The legitimacy we associate with education is forcing many specialists, who are highly qualified with current qualifications, to receive higher and higher degrees to remain competitive and ensure authority.

Chapter 5: The Boundaries of Public Health

Much like public health at the turn of the 20th century, public health at the turn of the 21st retains much of the negative publicity of a century ago. While the practice of public health is becoming “cool” again, at least according to a New York Times article last week, the idea of the County Public Health Department is wrought with stereotype. Be it the commonly served population, who is often poor or minority, or the basic buildings in which care is provided, most people would rather not use public health, given the choice.

However, after our discussions about how to fix health care in this country for the 47 million uninsured, it occurs to me that public health might be the cure. Public health cannot provide everything for everyone. It can provide, however, the basic care that we as a group agreed should be a right. Vaccines to prevent the diseases we thought formerly eradicated, basic check-ups, neonatal care for poor mothers, eye and ear screens for children (although schools continue this practice, early detection is largely held as key to resolving and dealing with these issues), and nutrition information can all be disseminated by a public health department. Furthermore, for many people, the services provided by government are a mystery. For example, people know that food stamps are available, but the process of applying for them seems too laborious. Public health departments can also serve as a hub for more general community health.

But of course the question emerges, how do we pay for this? We pay for this the same way we provide a free, basic education for everyone- through taxes and grants and some in-kind donations. Paying for public health will cost money, but in many ways, we are already paying it. People who use Emergency Room services who have the ability to pay are already absorbing some of the costs of those who cannot pay. People who are not healthy enough to go to work impact our workforce and our productivity. Children who do not have adequate healthcare spread illness to children who do. There are so many discriminatory elements of life in this country, particularly along socio-economic lines. Although paying for public health may have a more direct cost, I believe a full cost-benefit analysis would reveal that the benefits outweigh the costs.

Chapter 4: The Reconstitution of the Hospital

As with many institutions, the history of the hospital can be explained through the view of social science disciplines. As Starr notes at the end of Chapter 4, however, the hospital is an anomaly from almost all of these perspectives. While the early hospital did not maximize profit, which goes against the economic theory that states that firms will always seek to balance marginal revenue with marginal cost, I would argue that hospitals today seek to maximize profit for a number of reasons.

First, competition has increased again. In the last few years, we have witnessed the proliferation of private clinics, often in strip malls or free-standing buildings. While these clinics first handled only minor illnesses, like the common cold or flu, many are now able to deal with more acute issues like broken bones. These clinics have set fee schedules, due upon service. For people without health insurance, however, they may be less expensive than a trip to the Emergency Room.

Second, hospitals have become “big business.” Because the demand for hospital care is relatively inelastic, it can be assumed that consumers are essentially price takers, particularly when critically ill. For some items, patients pay a user fee. Durable medical goods are an example of this. A patient will lay on a hospital bed and have his blood pressure and pulse monitored. When he leaves, the bed can be used again. Because this is an exhaustible good, the fee for use is prorated. For laboratory procedures, economies of scale apply. While a laboratory technician can run one urinalysis at a time, she can also run 8, decreasing the cost per urinalysis. Each patient, however, will pay a cost that reflects the marginal cost of ONE urinalysis. Thus, internal efficiency can increase profit without the knowledge of the patient.

Finally, many insurance plans reimburse by diagnosis. That is, all people who are diagnosed with a disease are estimated to “cost” the same amount, regardless of actual treatment received. It is in the best interest of the hospital, then, to try to come in under the reimbursed cost.

None of these elements of profit maximizing are inherently bad, but the risk of poor patient care does exist. As hospitals struggle with other industries to stay in the black even with rising costs, a loss is inevitable. The question is, however, does this loss represent a loss to consumers (patients) or to hospitals. Both choices have consequences we will continue to affront through the next century.