Man's 4th Best Hospital, page 39
Take away the screen, the human rushes back in. Rushes curious, and lively.
The other wonder was how much patients loved being interviewed on their medical histories and having physicals done by the preclinical medical students—supervised by the old docs, or us. The med students were so nervous that the patients often felt they had to help them out. Real bonds of curiosity, both ways, were formed. Chronic patients had never had such acute doctors. Patients love novice docs. It was alive, crackling.
A 52-year-old woman, a longtime Man’s 4th internist, seeing what we were doing and the crush of really sick patients, said, “I’ve been in the BMS system for decades. I’m a ‘star’ here at Man’s Best, and I’m the most burned-out alum you’ll ever meet. I can’t stand it anymore. HEAL, elitism, killing myself, divorced, joint custody. Can’t stand making money for them, killing me. Don’t know why I went into medicine in the first place. But this, here, is different. Patients scraping bottom, risky, on the edge—unsolvable problems scraping bottom in the culture—and you really help. What keeps you going?”
“Good question. I guess . . . I guess it’s all heartfelt. I don’t mean to be—”
“No no, heartfelt is good. I need heartfelt. Go on.”
“Buckle up.” We laughed. “I came to see that our job as docs is to use our experience with others who suffer, and our vision born of that experience, to bring someone who’s out on the edge of the so-called sick into the current of the human. To take what seems foreign in a person, and see it as native. Being with people at crucial times in their lives, walking them through suffering, taking care. That’s healing, right?” She nodded. “That’s what we signed up for years ago, remember? This is what good doctors do. We are with people at crucial moments of their lives, healing.”
“Oh my,” she said, blinking back tears. “It’s so true. So true it might be—I don’t know—litigious?” We laughed. She blew her nose. Blushed. “Haven’t heard anything like that in decades.”
“We’re looking for more docs. Maybe you’d want to join us?”
She hesitated, then calculated. Metrics piled up. “Oh, God, I don’t know.”
Others said yes. The Future of Medicine Clinic—Care, Compassion, and Cancer—was attracting some good souls. We might just be gathering mass, making momentum.
Through attraction. Getting traction.
* * *
“Billin’ is killin’!” said an Irish voice from the doorway of my office. It seemed vaguely familiar—as if from a recent sharp dream.
“Dr. . . . O’Toole?”
“James Barnacle O’Toole, lately of St. John’s Hospital!”
Suddenly worried, I asked, “Are Gilheeny and Quick okay?”
“Would they be policmen if they were not?”
“Thank God! What are you doing here?”
“I’ve come here, in my quite queer Ulyssical quest, to look into joinin’ you.”
“Dynamite! You showed up at just the right time—our team checkout is now.”
“Strange, is it not, that I happened here at this prescient particular moment?”
“You seem to have the same gift as Gilheeny and Quick.”
“Which is?”
“Seeing around corners I can’t even imagine.”
And so all three of the Dubliners, and Gath, Jude, and a ballooned-up Angel, joined us that day. Fats was finally getting around to part two of his lecture:
*** RESISTANCE ***
“This,” he said proudly, tapping his chalk on the word, “is now crucial.” He winked at Berry, then looked around the table. “How’re we doing, being with the ‘we’?”
All of us except the Runt indicated that we were doing well, having fun with it.
“Dynamite!” he cried, rubbing his hands together happily like they were two old friends meeting. He was so excited that he wriggled. With all that bulk wriggling, he charged ahead, weaponizing the chalk.
“The six rackets of health care wind up being ‘the World’s Best’ only in having the highest cost per patient of any country—over 10,000 dollars for each man, woman, and child. And America’s ‘the World’s 37th Best’ for quality and safety of care—wedged between Slovenia and Croatia—not the place to be. The USA can’t afford treatment for ninety percent of our addicts, or reduce lead for half a million of our kids? And the costs? We spend eighteen percent of our 3.8-trillion GDP on health care.”
He sighed, shook his head, then brightened up.
“But! Finally, the data about screens has come out. Recently a few supergood studies on doctor, quote, ‘burnout’—defined by the Maslach Burnout Inventory—have proven that the introduction of screens to medicine has not increased either patient safety or quality of care.” He smiled, as if hitting a food jackpot. “And here’s the brisket! There are three attributes of physician ‘burnout’—one, lack of sense of accomplishment; two, lack of enthusiasm; and three, cynicism-depersonalization. The studies show that all three are correlated with one and only one variable: the date that the Electronic Medical Record machines came in, and began to take over medicine.”
This was astonishing—and made perfect sense. Here, at last, was proof.
“Wait a sec,” I said. “You mean, we docs don’t get up in the morning with a real zeal to have a meaningful relationship with HEAL?”
“Hard to believe, yeah. So the six rackets are worse for doctors and nurses, patients, and hospitals, and only better for the six rackets. The rackets run on money and screens, ‘death by a thousand clicks.’ The only screens worth anything are the ones that do not launder money—the VA, Indian Health, Medicare, and Medicaid. The big question? How to resist the screens that do launder money? It’s simple.”
He searched in an old wooden box of chalk, found a piece fat as a sausage, and wrote in the boldest, chunkiest letters we’d ever seen from him, talking as he wrote:
WE GOTTA SQUEEZE THE MONEY OUT OF THE MACHINES
“If we squeeze the money out of private health insurance, the main problems of doctors, patients, and maybe even hospitals are mostly gone. And like in the thirty-six countries ranked above us, we will have two parallel systems. One, a national nonprofit health care for all. Two, we continue our red-hot private system to sell supplemental insurance to whoever wants it—like they do now for Medicare. And sell ultra-insurance for the boom in concierge and even for Kissy-Sauds all over America. The rich will pay cash, which makes them feel that, despite the nagging truth, they really are worth more.”
He sketched on the board a child’s drawing of the Saudi-Kiss, which looked like an elongated wasp, stinger on top.
“Squeeze out the money, and the three hundred thirty-four people in the Billing Building and the Coders 4 Cash? Gone! No more war across the screen. And what a savings! What’s the biggest cost in American health care? Administrative cost—which is thirty-three percent, 3 trillion bucks a year. Think what that money could do for real-live care. No billing on our doctors’ screens? What a relief!” He paused, mused. “And the care itself has to change. What’s most important for patients? Quality. Quality is paramount, maybe even more than access—’cause access without quality sucks. So we have to pay docs more, for more quality care. The other big thing is to pay not for procedures and process, but for outcomes. For improved care. How to get there?”
He stopped, looked around the table.
“Maybe one thing to try? Have outpatient clinics like ours be run by nurses, nurse practitioners, and PAs? You can do most anything we docs can, and you’re better at getting to the ‘we,’ right? To treat the sixty percent of the walking worried?”
Nods all around. Made sense.
“And then the screens, no longer going crazy with billing, will be at their robotic best, sharing data with the clinics, answering questions—even assisting in minor AI surgery. I mean, it’s happening already, right?”
It was true. All yeses.
“Finally, we gotta deal with social problems: violence, guns, diabetes, and—”
“Diabetes!” Hooper shouted, shooting to his feet. “The epidemic is here! Right now, half the population of California is prediabetic! The Midwest and the South are total fat and sugar! We gotta get ’em before they get sick. When they come to us sick, it’s too late.”
“Exactly,” said Fats. “And what’s our goal? National health care, for all.”
“And are you saying,” Molly asked, “that your goal is Medicare for all?”
Fats hesitated. “Well, kind of . . . I mean, yes, but . . .”
He stopped still. Two or three of his brows rolled up.
“Well, yes, but no,” he went on unsurely. “Mind you, it ain’t gonna be easy to redesign Medicare and Medicaid to jibe with a national system. Real complex. Lotta ins and outs, ups and downs. Complex. Real tight . . . In terms of infotech and servers, retro-engineering and retooling? Way high start-up costs. Complex bureaucratic shuffling, firing, hiring . . . lotta time, money . . .” He shook his head. “I hate to say it, but so far, I got no answer for that.”
Silence. Just beginning, and Fats was stymied?
“I do.”
We turned our heads. Mo, our in-house computer wizard. She had been able to help solve any glitch in INCOMING—and snafus in our cell phones.
“You do?” Fats said. She nodded. “Okay. Go.”
“Okay!” She stood up next to Fats and took his chunky chalk. The two of them looked like a dangerously obese dad and a trim, sparkly daughter. She wriggled with excitement. “Once we get approval for Medicare for all, it’s a snap to roll out. I pick up the phone.” She held the chalk to her ear. “Hello, is this Medicare? . . . Good . . . Can you get me the techie who’s in charge? Thanks . . .” She waited. Drumming her fingers—who knew she had such stage presence? “Oh, hi—what’s your name? Merlin? I’m Dr. Ahern. Are you sitting at your computer that handles Medicare? . . . Good. Now, go to the box for ‘age setting,’ okay . . . Got it? . . . Good, Merlin. Just to confirm, what does it say? . . . Sixty-five? That’s correct. Now, Merlin, I want you to click ‘delete’ on the ‘sixty-five,’ okay? . . . Yeah, sure I’ll wait. . . . It’s deleted? Good. Now click on ‘zero.’ That’s right, the number zero? . . .” More finger drumming, staring up at the ceiling. “You did it? Great. Now click ‘save’. . . . You clicked ‘save,’ great. Now, just to double-check that it’s changed, close it and then open it ag— You already did that? . . . No, I don’t think you’re a dope, Merlin. I think you’re a real smarty. . . . You’re welcome, my friend. . . . What’s that? . . . No, we’ll do the nano-gritzels later. Hey, thanks for giving us Medicare from zero to death for all!”
We laughed, hard.
“It sounds ridiculous,” Mo said, “but it’s—”
“It’s true!” Fats said. “We got a whole great national computer system already in place, so it’s just one click! Wow-wee! A star is born! Let’s hear it for Dr. Mocha!”
We applauded. She blushed. The first blush I’d seen in the FMC all year.
“I can vouch for Medicare,” said Dr. Ro, “both as a doctor and as a patient. It almost never makes a mistake; everybody likes it. And a few years ago they did lower the age two years. Without a glitch. Y’know something? If you chart the health of Americans over our life spans? It peaks at about twenty, and then goes down, down, down until sixty-five—when it shoots up in a hockey-stick curve of better health. Why? Because Medicare kicks in. We gomeres love Medicare! With cheap supplemental insurance, we never see a bill—”
“And what happens,” Fats went on, “once we have national insurance? What happens to private for-profit health insurance? Still there, still available as a parallel system for those who want additional coverage. Heavily regulated. Like Holland, Germany, Australia, and most other sensible countries. BUDDIES? Blackmailing INSURANCE and sucking money out of HOSPITALS and outpatient clinics? Gone. BIGPHARMAFDA drug prices? Not totally gone, but—wait for it—prices negotiated wayyyy down.”
He chalked an arrow, going down off the board from BIGPHARMAFDA and, bending clumsily, continuing on the floor until he hit the Runt’s shoe. Fatly, he straightened up.
“HEDGERS FOR HEALTH? Unable to place bets on the stocks of health INSURANCE or even derm practices? Gone.” He beamed. “And since every procedure costs the same nationwide, no more war-gaming the codes, no Coders 4 Cash! Gone.” He shook his head in amazement. “And the final miracle, done with that one click? No more HEAL, no more EPIC! Picture it! The billionaire cheese farmer in Dogpatch-as-Disney, Wisconsin, dumping machines into the trash? Gonzo gone!”
“But,” said Runt. “How”—gesture—“to”—gesture—“pay for it?”
A solid fiscal question? Go, Runt!
“Good question,” said Fats. “Back when Man’s Best was best, a pediatrician named T. Berry Brazelton went before Congress to solicit funding for a national preschool health-care program for kids that would save a ton of money for care in their futures. He presented the whole thing in detail, and a congressman sneered, ‘How are you going to pay for this?’ T. Berry replied, ‘All it costs is one missile per year.’ They shot him down. No program.” He shook his head. “You want depressing? Now fifty percent of our tax dollars go to the military. Ten days of Defense is about a whole year of the National Institute of Health.” He let this sink in. “So we gotta change our priorities. I bet if we stop just two of our wars—say, the Midasian and the Eastasian—we can start great health care. Like the more civilized nations of the world that’re not screwed up by sick dreams of being ‘the Best Country.’ That—and a teensy-weensy one percent tax on the point-zero-one-percent rich, who own everything—gets you all the money you need, forever, to provide health, instead of making money off disease.”
“I doubt that will ever happen,” said Jude. “We on the rez have been lobbying for those two things for, oh, only about a hundred years.”
“Probably not,” said Fats. “But here’s what will. First, admin costs. When we get rid of the for-profit system, we automatically cut out the thirty-three percent administrative costs and free up each year 1.2 trillion dollars. As opposed to the three percent Medicare admin cost. So we save thirty percent. Second cost cut? A huge decrease in drug costs from our leverage in buying drugs in bulk from the monopoly of BIGPHARMAFDA. And then lots of other cost cuts kick in. Like freeing employers from having to pay for their workers’ health care—and collecting what they had been paying, as a tax.”
“Well, Fats,” said Hooper, rocking hard, “this is totally great. But how do we actually get rid of insurance?”
“Y’mean get to that one little ‘click’?” We all nodded. “Not easy. But listen up. Has anyone, in a crowded theater when somebody falls down onstage, heard the cry go out: ‘Is there an insurance executive in the house?’”
Laughter from all.
“Exactly. We are the workers. We do the work. Without us, there is no health care. But guess what. We doctors don’t even have a union. Nurses have a union, a great union—Angel, Molly?”
“The best,” said Molly. “I’ve been on strike three times now.”
“And how many of those times did you win—get what you wanted?”
“Three. The Women’s 2nd Best caved before we even had to strike. Nationally, we’ve never, ever lost. They need us to function at all.”
“Bingo! Nurses have a union, teachers too—but docs? Ally with nurses? ‘Oh, no, I can do it myself!’” He looked at Berry. “Women! They actually like getting together—and look what they’ve gotten. They’ve never lost.”
“So how do we get to national health?” asked Eat My Dust. “Write our congressmen? The guys with spines of linguine? Paid for by the world’s biggest lobby, insurance? Fat chance.” He looked at Fats. “Ooops. I mean, uh, thin chance.”
“Forget our representatives. They only act when they’re paid off or trapped.” He wrote:
WE DO THE WORK
WE GOTTA DO WHAT WORKERS DO
“Es-strike!” shouted Humbo. “Indignación! Juntos!”
“We’d get killed for striking,” said Naidoo. “For putting our patients at risk.”
“But the way our nurses’ strikes worked,” said Molly, “is we got the patients to join us. Almost all of them have horror stories of treatment. Health care’s the number one issue for Americans.”
“Totally,” said Fats. “The key is getting patients, doctors, and nurses—and even hospitals—to join together as allies. All three groups hate BUDDIES, and really hate INSURANCE, right?”
Shouts of “Right!” “Yeah!” and “Caramba!”
“Patients are taking their own action now,” Dr. Ro said, “against the same things as us—yesterday there was a huge protest downtown of mothers against Sanofi Pharma and Eli Lilly for jacking up the price of insulin five thousand percent. Guess who’s going to win that one.”
“I love it,” Berry said. “We join patients, doctors, nurses, and hospitals together. The inclusive ‘we.’ And there’s a huge movement in voters now too.”
“But,” said Gath, “the payments to me from Medicare and Medicaid are ridiculously low. I can’t feed my kids on them. And I’ve heard that there’s no way that any of the big teaching hospitals can survive on Medicare payments either. Never.”
“True!” said Fats happily. “And that’s our opportunity! When push comes to shove, and the hospitals are hunkering down against us docs and nurses and patients, we bring them into a grand alliance with us, to join in on our one big demand: Unless we docs and nurses and hospitals get paid at our current levels, which are way above Medicare, we will not go along. The key is that alliance. If we stick together, we can’t lose.”
