Health Reform: Magnificent Xmas Present But Needs Assembly

So it's done. The health care legislation has passed and that makes this a special Xmas. Despite its flaws, it is a milestone for a nation that could be so generous with its aid abroad, yet stymied in caring for its own. I clearly could not have been a politician--I would not have the patience of the president to tirelessly campaign for this and to see it through; nor would I have the tenacity of the opponents to the legislation who opposed it to the end.

This morning I will drive in for my rounds at the hospital (my team is on call, bless their hearts,and will stay all day and night, while I get to come home well before nightfall) and I am already trying to digest what this Xmas present means for my patients and for my house staff.  In the last few days we pulled out all stops to get patients home. The ones who can't go home are too ill, and going home may not be an option; instead it might be a specialized nursing facility or rehabilitation place. One or two of these patients have been very much on my mind, long after I leave the hospital, their suffering both palpable and difficult to forget, and making me conscious of the blessings of just walking outside, stepping into a car and going somewhere.
 
Watching the health care reform process from a relative distance, from the front line so to speak, as opposed to being in the generals' tents (though I did get invited to the White House to watch the president on ABC's "Prescription for America" months ago in the summer), here is what I note:

• If you passed out mint and chocolate cookies in the Senate, you would get takers for both, a mix of Republicans and Democrats. Taste is individual after all. Given all the verbiage, the millions of articles, blogs and the like around health care, is it really possible that the only views one could have on health reform align so perfectly with politics? That tells me it was all about the money, all about lobbies and special interests, much more than it was truly about health or the suffering of the needy.
  
• Speaking of money, the AMA (and I am not a member) had much to do with opposing the expansion of Medicare, because of the low rates Medicare pays. It says something about the AMA and its now unblemished record of putting its members' income first.
  
• The disappearance of the public option says that the private insurance companies won. Yes, I know they will be forced to rein in costs, to not deny coverage and so on. But a public option would have put the real squeeze on them. The lobbyists and Lieberman did a good job on killing the public option. The drug companies ... they made an early concession that now looks like a real sweet deal, too good to be true.
  
• The increase in the number of people who will now be insured is fantastic and laudable; that is what it was all about and we should not lose sight of this.
  
• Finding the money to pay for all these newly insured is still an issue and finding the projected savings by cutting Medicare and Medicaid expenses seems very optimistic.

• The issue of costs, which is at the heart of what is wrong with health care, has yet to be addressed directly, I believe. In fact we have done a good job of skirting around some of the low hanging fruit, low hanging but protected by powerful lobbyists. An axiom in this debate has always been that every dollar spent on health care is a dollar of income for someone and any attempt to rein in costs will bring vitriolic responses and dedicated opposition. Well, we saw that.
  

Speaking of costs, I am grateful for the wonderful responses to my last piece on "Spiraling Empiricism: When in Doubt Put Blindfold On And Shoot." An infectious diseases expert and blogger,  Dr. Dan Diekema says:

As the emphasis moves from quickly establishing the correct diagnosis to efficiently moving down a selected pathway, it is sometimes difficult to see the damage done. One illustration: after thorough investigation of a severe outbreak of Clostridium difficile (a diarrheal disease that follows use of an antibiotic and which can spread in a hospital) we discovered it was likely associated with overzealous application of a pneumonia care plan. Many of the patients treated for bacterial pneumonia never had that infection, but the one they acquired as a result of their antibiotic exposure did far more harm.....the report of that outbreak is here:

That's the kind of cost overrun that I worry we won't address as well as we should.

Recently an infectious disease colleague mentioned on a listserve that after a high altitude trip he developed a 'splinter hemorrhage' on one nail (a red vertical streak, looking like a splinter). These are not very specific and can happen from trauma; but they can also come about from heart valve infection. The finding would be ominous in someone who is an intravenous drug addict and presents with fever and other signs pointing to heart valve infection. I got a kick out of the tongue-in-cheek response from Victor Yu (a visionary infectious diseases physician)  to his colleague, which was Victor's way of bemoaning the spiraling empiricism (a term that he coined) and the utter lack of worry about how much things really cost:

"I think you should get empiric antibiotic therapy for endocarditis (heart valve infection)--might as well add caspofungin plus voriconazole (two expensive anti-fungal drugs) for Candida endocarditis. Take these antimicrobial agents for 6 weeks and get a cardiac CT scan. And if that doesn't work, how about some empiric corticosteroids (steroids or prednisone) for SLE (lupus)? That's what House would do."

Not just House, but in too many hospitals this won't be far from the truth; Victor does not mention all the consultants who would be called in, and the many more blood and imaging tests that would be ordered, all of which would add up to a huge bill for a heart valve infection that may or may not be there. It doesn't matter if the patient is insured or not--it's a huge waste of money.  Diagnosis matters; and if costs truly matter, then accurate diagnosis will matter even more.

All said, this is still a historic day. Whichever side you are on, this is a milestone, a real surprise that Santa has brought. We will spend the next few weeks and months and years assembling it for use. Today let's make merry. Joy to the world!