Stare into the (economic) abyss

Last Friday, I went to a lunch talk, run by my advisor, who always invites guest speakers to her biweekly shindigs. I attend religiously, partly for the free food (starving med student here) and partly for the opportunity to learn a little more about this crazy crazy world I belong to now.

Friday's speaker was a health administrator from a major hospital system out in the 'burbs. She was very well-prepared -- even had a massive long powerpoint handout -- and spoke quite articulately about what drew her into health administration.

I have to say, though, the content of her talk frightened me. Her job is essentially to track the physicians employed by [Major Hospital System Out In The 'Burbs] and call out the ones that are too expensive. I paraphrase: "Dr. Jones, as you can see in the spreadsheet on page 6, represents a net loss to hospital of $6,000 a month. This is because he treats Medicare patients like private payers."

Now, having spent hours on the phone with Medicaid my clerkship, I'm well aware that Medicaid is terrible insurance that pays for hardly anything. (I wasn't aware, till that talk, that Medicaid pays the hospital a lump-sum per patient/diagnosis rather than a per diem.) But the idea that one should treat Medicaid patients differently -- that is, employ a different, presumably lower, standard of care -- is morally repulsive to me. If the quality differential between antibiotic A and B does not make up for the fact that B is twice as expensive, then we should be prescribing A to both the illegal immigrant in 285-2 and Bill Gates over in the fancy-pants wing.

One other way that the administrator suggested lowering costs was by setting up follow-up appointments for whatever "other" (i.e. non-emergent) tests need to be run. Fair enough, but as one of my classmates pointed out, "What if the patient has a history of not showing up?" There's really no good answer to that, at least from the save-a-dime perspective.*

The rationale for all this cost-cutting is that the hospital can invest in better technology, etc. Great. I just don't see why the poor patients have to get shafted while the private ones sit in rooms fancier than most hotels. (I saw that on the tour at one of the schools I interviewed at. Kind of a shock, to see full-length mahogany mirrors and a window-seat/pullout bed for guests, and a wardrobe in a hospital room.)

This reminds me of a modern definition of chivalry I heard at some point. Treat all men as gentlemen, and all women as ladies.

Unfortunately, I'm not idealistic enough to believe (though I hope) that the system of health care in this country is going to change overnight, or even by the time I graduate. I don't even know if universal health care is a panacea -- probably not. Either way, it's going to be a long slough through politics and government (which are not the same thing, as Yes Minister taught me). But it's something that I fervently believe that everyone in medicine does need to think about, and hopefully do something about.

*I'd just like to point out that I'm probably one of the most frugal people I know. I detest waste of any sort (monetary, mental, or recyclables). I once went into Filene's and was shocked at the shoe prices; that's how frugal I am. But I also happen to think that the dude at the bagel cart deserves the same quality of care as the dude at the White House. Yeah, yeah, filthy pinko commie.

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