The paradox of the American Medicine medication – the health care blog

By Marc-David Munk

In our palliative medicine clinic in the Boston work suburbs, my colleagues and I tended to some of the most sick patients in the city. Through the window, I can see the crops stop towards our squat building in family sedans, wheelchair van and subsidized municipal driving cars. Little lead themselves: most of them carry terrible diseases that make them too fragile or sedation. I look at the patients who are barely capable of dressing, somehow arrive in their Sunday for the clinic.

Our work, as doctors, is to manage their pain and provide moral support and practical help with things such as rent and transport, sometimes also spiritual support. It is an important work, among the highest calls in medicine. However, as noble as this work may be, our clinic does not start to support itself financially. If there was never a reason to spend gracefully on patients and their needs, these visits, with their sick and vulnerable patients, would be examples. In fact, we do not receive enough payment from insurers to cover the costs of complicated work that is necessary. Practically, this translates into a few staff members to help with the appointments, not enough follow-up calls, no one to help with insurance headaches or pharmacy shortages, nobody answering the phone. Our facilities are tired. The simplest subtleties – charm in the waiting room, magazines, a comfortable chair – have long been gone.

There is a feeling of “meager” in the air. It is the feeling of being rationed. It is an absence of all except the really essential; No fullness, a lack of grace. I see meager when my friend, an emergency doctor in a large trauma center, sharing photos of his decaying office chairs: office chairs maintained with a medical band, rooms without functional equipment. The medical supplies which are so rare that doctors keep hiding places in their office and wrap their pockets.

The administrators will say that these sterile conditions are a consequence of the financial shortage. There is not enough money to pay more than support and maintenance of the skeleton. Hospitals perform deficits and reduce the workforce. Keeping the lights on is apparently a question of save money on every occasion. And, with each cup, the meager is growing. All this sounds, on its surface, understandable until you take a step back and you did not realize it. We know that American Healthcare consumes more money than any other country, per capita. Money flows, really floods in our health system. Family health insurance premiums increased by 7% compared to 2023, after another 7% increase in the previous year. The average family policy now costs around $ 25,000 a year.

Which lets me want to reconcile how there can be so much money in the system, with so little for essential first -line care. I know it’s not a complicated answer.

My fifteen years spent as a administrator of health care, a merchant with payers and suppliers, taught me that our societal health money was simply diverted. The intermediate costs, in a wide health landscape, have become so extreme, so unregulated, so usurious, that only one net remains to offer something other than the most stingy first line care.

Here in America, we specialize in the authorization of thousands of organizations, many have not found anywhere else in the world, to transmit unknown costs, well, ourselves. We have group purchasing organizations (GPO) and responsible care organizations (ACO). There are medical service organizations (MSOS) and doctors organizations (POS). Managed care organizations (MCO) and health care organizations (HMO). Medical-hospital organizations (PHO) must also be paid. There are contractual offices, coding offices, compliance offices, accreditation offices, case management offices and complaint processing offices. Many organizations exist to put pressure for a single result; Others exist to put pressure on the contrary. All are costs.

Our six largest health insurers together have income that would make them the 14th most important GDP in the world if they were a country, smaller than Spain but larger than Australia. They generally spend about eighty percent of what they collect for medical care … The rest is their general costs and their profit. The United States has spent almost twice as much as other high-income countries in care, motivated by workforce, pharmaceutical products and administrative devices and costs. Medication manufacturers charge multiple Americans more than other countries for identical drugs. The prices of cardiac implant devices are multiple higher in the United States than in Germany. Hip implants in the United States are more multiple than Canada. Professional fault insurance is overwhelming, some doctors paying hundreds of thousands per year for coverage of responsibility. Electronic medical records cost hospitals to hundreds of millions of dollars to install.

Here, regulatory organizations have been both expensive and essential. The American Board of Internal Medicine reported $ 90 million in costs in 2023 (and there are 23 other specialized tips). The mixed committee pulled $ 208 million last year. Press Ganey, who has a large part of the compulsory survey activity of patients, would have had income in hundreds of millions of dollars (before ceasing to report income figures after being purchased by investment capital). The medical journals is particularly exasperating: doctors write, publish and examine articles for free, but these newspapers are locked behind the Walls. Elsevier’s parent company, with more than 2,500 journals, generated 3.06 billion pounds in revenue in 2023 with a 38%profit margin.

Good luck by saying no to all this. We are stuck. Doctors have no choice but to be certified by the Board of Directors. Hospitals should be questioned. Expensive licenses and permits are not negotiable. We pay what they ask, with increases year after year. On these cocoonized organizations, we impose few requests, few good deals and few consequences for poor value. During my first years in medicine, I had the impression that there was at least a veneer of fullness. These days, I look at our worn clinic and our patients who react with dignity while I explain that their insurer has rejected their fifteen drugs against analgesics.

I wonder when we admit that we are at a point where regulations and administrative games, political contortions and the behavior of oligopolists – the opportunists finally killed Golden goose. I wonder when, in an environment of force of the clinician and heroic commitment to patients, we will know that we have reached a tilting point where it is no longer a skinny environment but that of deprivation, where the balls have fallen and people really suffer.

With so many rooted interests, it is difficult to imagine how it is resolved. For thousands of years, when it counted the most, there is no substitute for the work of a doctor who takes care of a patient, head-to-head. There is still none. But, in the best parts of American medicine, we have settled for a Rube Goldberg type device that works mainly to perpetuate. He extracts real tolls from real people. It is particularly repugnant, only absurd, only American.

Marc-David Munk is an academic doctor in palliative medicine and a former health director in several health care organizations based on private values ​​and supported by VC.