White Coat Underground

Health care is infrastructure

There’s a lot of talk about there about “economic stimulus” and “infrastructure”, but what is “infrastructure”? Traditionally, it’s the basic physical and social structure needed for a society to operate. Roads, sewers, utilities, schools—these are the “guts” of our nation. Without these things, and the pooling of resources they require, we are nothing more than an anarchic collective coexisting on a shared continent. Much of what is defined as infrastructure is about the basics of life—food and its distribution, public health, safety. How is health care not a part of that?

When we talk of investing in infrastructure, we cannot leave out health care. There are basic changes that need to be made to insure the continuation and improvement of a civilized nation.

Universal access

By whatever means, health care must be available to everyone physically living within our borders. Anything other than universal access is nonsensical. We currently “cover” the uninsured, but in expensive and irrational ways—by forcing them to only seek catastrophic care, burdening us all. Any rational nation must provide basic preventative care (not that we can make everyone use it). This care must be based on the best standards of evidence, and allow patients and providers sufficient freedom to interact, but with some less chaotic form of rationing—one that is explicit and ethical, rather than implicit and punitive.

Quality care

We know a great deal about what does and does not work in medicine. We are also learning that a fractured and fractious health care system does not operate safely. We must make it easier for physicians to practice safely and rationally. This may mean having universal standards for compatibility for electronic health records, so that a patient’s health information is portable. If I receive a transfer from another hospital or doctor, I shouldn’t have to wait days to receive poor-quality photocopies of records. This leads to medical errors and duplicated efforts.

It also means giving physicians easy access to tools such as performance standards, without punishing them for their patients’ failures. I would love to have easy and portable tools for monitoring the progress of my hypertensives and diabetics, and to be able to see how I measure up against evidence-based goals. This has to be done in such a way that I am not punished when a patient doesn’t follow my advice. It also has to allow me to track information in a way that is compatible with my practice. Currently, I report diabetic data to two separate entities, on two separate forms, both of which are crappy. It’s possible to engineer out “crappy”.

Rational supply of providers

Right now, 2% of American medical grads chose primary care specialties. There are many reasons for this, among them crushing medical school debt and relatively poor reimbursement in primary care. If we want an adequate supply of primary care docs, then we have to supply them, either by changing the market forces by paying them better, or by explicitly recruiting them via strong incentives.

This is just a starting point, but if we are going to pour a trillion dollars into the economy, much of it on “infrastructure”, we would be insane to leave out the biggest ongoing infrastructure cost in the U.S.—our health care system.

Comments

  1. #1 MartinDH
    February 10, 2009

    Hear! Hear!

    But it’ll never happen in the country of the brave and the free. US citizens demand the right to die of neglect in underfunded emergency rooms.


    Martin

  2. #2 Rev Matt
    February 10, 2009

    I’ll go a step further. For at least 20 years I’ve been arguing that healthcare and education are National Security issues. Without them, any other long term National Security efforts are a farce.

    Universal healthcare, universal education. The only things that are absolutely sure to result in a net gain to national productivity, security, and strength.

  3. #3 Bob O'H
    February 10, 2009

    Hear hear! As a foreigner, who has only visited the US twice, I’ not sure I have a right to get involved, but your healthcare system does get me angry. It’s almost as if you’re not a civilised country.

    This utter lack of willing to look after the poor does put pay to the argument that the US was founded on Christian values, though. :-)

  4. #4 Donna B.
    February 10, 2009

    If I understand correctly what’s in the stimulus package, you’ll get an electronic records standard. But you, as a doctor, will be supervised and punished for not meeting some as yet undefined standard.

    It seems reasonable that the government establish and maintain an electronic records system. It’s the second part I can’t stomach. That is, if I understand it, and I certainly am capable of getting it wrong!

  5. #5 SimonG
    February 10, 2009

    Like Bob, I find it incredible that you Americans put up with such an inadequate health system. If it were my country, I’d very much want to change things.

    The cynic in me says that it wouldn’t work as an infrastructure package: any sane revision would result in reduced costs, which would thus not be an economic stimulus.

  6. #6 khan
    February 10, 2009

    If I understand correctly what’s in the stimulus package, you’ll get an electronic records standard. But you, as a doctor, will be supervised and punished for not meeting some as yet undefined standard.

    It seems reasonable that the government establish and maintain an electronic records system. It’s the second part I can’t stomach. That is, if I understand it, and I certainly am capable of getting it wrong!

    Explain how this would be worse than the current system.

  7. #7 Donna B.
    February 11, 2009

    khan, I think the electronic records part is essentially a good thing. My second sentence may not mean it’s actually worse than the current system, it may just be the current system getting engraved in stone, thus becoming actually harder to change.

  8. #8 Gary Baumgarten
    February 12, 2009

    National health care will be the topic of News Talk Online on Paltalk.com Monday February 16 at 5 PM New York time.

    Please go to http://www.garybaumgarten.com and click on the Enter The Chatroom button to join in the conversation.

    Thanks,

    Gary

  9. #9 PalMD
    February 12, 2009

    So, you’re telling me there’s something called “Paltalk” that I wasn’t smart enough to claim? Damn.