Shawn Whatley, Author at shawn whatley md

Medicare Change: 10 Ways to Stop Improvement

Some think Medicare means utopia; we just need more of it. For them, change is bad. Listed below are 10 tired quips people use to stop change to Medicare (with responses).

1. You exaggerate the problems with Medicare.

Not to people dying on wait lists.

2. Medicare worked so far; why change now?

We need to adapt or go extinct.

3. We just need more money.

Budgets never precede greatness. Steve Jobs started in a garage.

4. You imply we – providers, bureaucrats, etc. – are a failure.

No, you’ve done very well even without the best tools. Imagine what we could accomplish with the right structure, aligned incentives, and patient involvement?

5. You have a hidden agenda.

That’s not fair. Look at the good folks working to improve things.

[BTW, this accusation works to undermine anything you want to oppose; it’s impossible to prove the absence of something!]

6. What about control? What about accountability? What about, what about, what about?

All great ideas raise questions; none can be answered with certainty beforehand.

7. This just sounds like [choose your favourite distasteful concept]. Favourite distasteful concepts include: American Medicine, big business, profiting on suffering, etc.

Actually, it’s not like any of those terrible things at all. It’s about giving patients what they need, when they want it, in a way that makes them feel valued.

8. You’re abandoning our core values.

Change upholds the values that started Medicare. We started with an insurance program for acute needs. We now have a warranty to cover routine maintenance. We need to get back to our original vision and build from there.

9. It won’t work here; we are different.

True. We are different, but people are the same everywhere. Canada ranks next to last on many measures (efficiency, service) against European countries. I’m sure we are smart enough to do better here.

10. This is a slippery slope towards American healthcare [or other scary idea].

Common sense provides a guardrail. We let 10 year olds watch TV, but we do not let them vote or drive a car.

Everyone agrees we need change; just not with Medicare. We need adult conversations that move beyond fear mongering, confusion, and character assassination. Change will be forced on us as the first baby boomers turn 80 in 2027. We’ve outgrown Medicare; we must change now, or watch it fail completely.

Holding Patients Hostage: Medicare, Stockholm Syndrome, and Choice

For 6 days, captors held employees hostage in a bank vault in Stockholm, Sweden, August 1973. Police finally rescued the victims and caught the criminals, but some employees defended their captors for days afterwards.

The Stockholm Syndrome describes the positive feelings that victims sometimes develop toward captors by mistaking a lack of obvious abuse for kindness.

Even after long waits, survivors of major illness are glad to be alive and thankful for their care in Canada.

Fear mongering about financial ruin and system change makes patients cling to a system that holds them captive to long waits with no easy options.

Debate centers on whether our system harms patients. It does. But, issues get dismissed as isolated, or labeled as ‘solved’ with wait-time strategies and benchmarking.

Patient harm is the wrong debate.

Holding Patients Hostage

We need to focus on what patients aren’t getting. The public doesn’t really know what they are missing. It’s up to providers to say so. When patients finally get an MRI, they’re impressed. Who wouldn’t be…for ‘free’!

People need to know we have an economy-car version of healthcare at a mid-sized price. For the same or less money, better systems can:

Treat patients like valued customers
Give patients choice about who they see and when
Provide home or office visits
Provide same/next day imaging AND results
Offer specialist consultation within days
Arrange elective surgery within the week with biopsy results in days
Offer electronic access to records
And much more…

Increased Utilization

At this point, quants (quantitative analysts) say, “But that would just drive up utilization.” Utilization equals the number of services provided. More service means more money: always bad in a publically funded system.

But, increased utilization is good if more patients get necessary care.

Quants see spikes in utilization as unnecessary care (even in the face of population growth). They assume providers offer unnecessary care when allowed, fingering providers as liars and thieves. They assume the same of patients; ergo, patients don’t deserve more care.

But, we know patients need more care; they die on wait lists currently. We also know patients would like better service; they want more value for money and prompt care options at home, not abroad.

Food Industry Analogy

Just imagine if we socialized the food industry. Groceries cost thousands per year, and many citizens are malnourished and poor. Socialized food would help. We could set prices and offer only essential items, without junk food, for free in government stores. We could make it illegal to purchase food elsewhere.

Others have tried this: state-run food industry results in no choice, long line-ups, and terrible customer service. Sound familiar?

We Need Change

Medicare was built to prevent financial ruin from acute, major health needs, before modern treatment options existed. Now, most care issues are chronic, multiple, and create arguments over the definition of ‘need’. Medicare began like collision and theft automobile insurance, but it now covers all mechanical issues: a warranty, not insurance.

We are held hostage, unable to change. We defend our captor mistaking lack of obvious abuse as kindness. We must debate whether people should be free to choose more than the bare minimum of care.

(photo credit: tripadvisor.com)

Narrow-Minded Medicine Gives Government Control & Leaves Patients’ Interests Out

Clinicians and bureaucrats wrestle for control with talk of quality and accountability. Both sides crave concrete definitions. Accountability zealots want control of provider’s performance as if chaos would reign without policing.

Healthcare delivery gets shaped using concrete metrics like HbA1c levels, blood pressure readings, or surgical complication rates.

People start to see medicine as nothing-but fixing high blood pressure, or normalizing sugar levels, or replacing hips.

But, if medicine is nothing-but controlling blood pressure or HbA1c, then it’s a product to be managed like any other.

If medicine is nothing-but matching patients with evidence, then quants can match populations with resources without input from physicians or nurses.

If we reduce medicine to technical outcomes, bureaucrats regulate with impunity.

Medicine is more than applied physiology.

Medicine applies science, but it is much more than applied science.

“[Medicine] is the totality of this unique combination which constitutes the clinical moment and the clinical encounter, without which authentic medicine does not exist. No simplistic neo-Cartesian reduction of medicine to sciences of mind, arithmetically added to science of the body and tied together with a ribbon of moral science, is adequate to explain this synthesis. Nor is this merely biology. Neither plants nor animals – granted they become ill as well as humans – can enter into a relationship with the healer in which the patient participates as subject and object simultaneously.” A Philosophical Basis of Medical Practice, Pellegrino and Thomasma.

Sure, we must improve clinical metrics. But, meaningful outcomes for patients are often qualitative, subjective, or impossible to measure. How do we measure surgical judgment beyond complication rates? How do we measure communication skills? Reasoning ability? Aptitude at interpreting non-verbal cues?

We need to learn how to articulate what medicine is. And, it must be hard. It needs to be tough and complicated to capture everything we do for patients. Narrow-minded medicine makes patients secondary.

We need a definition of medicine that starts with the clinical encounter and puts patients’ interests at the centre.