Wednesday, January 28, 2009

Forfeitted Freedoms

So, despite the fact I have a better life as a hospitalist than I had as an outpatient slave, I am finding that the experience of being a hospitalist is making me ever-less hopeful about the state of our country.

Back when I was a wee-tot in residency, I really didn't give a thought to where my taxes went.  I made less than most tenured cashiers at grocery chains.  I just wanted to know what the hell I was doing with patients.  I just wanted to get through another night of call.  I was striving for competence to heal the sick.  I gave very little thought to my post-residency future (since I was in the extreme-minority not scraping for a proceduralist fellowship).  Only 5% of my training was spent in the outpatient setting -- the environment I would be spending 95% of my immediate post-training years.

When I became a hospitalist, and that number went to 0%, my perspective had changed dramatically.  Here I was trying to pay off mountains of debt, negotiating to become the employer of a not-for-profit profit machine, and paying more in taxes than my gross income had been throughout my residency years.  By the time I had managed to set aside some cash into the 401(k), I watched it vanish.  And now I'm watching trillions of dollars of my future being prostituted to keep the imaginary-wealth of the last 10 years from vanishing.

I've become pissed off enough at the corporate suits for asking me to help their multimillion salaries remain inflated while the public-at-large groans that doctors make too much.  I'm in the trenches -- the front-line -- of healthcare in this country, and I'm scraping for my piece of the pie.  I will never make a million dollars a year (at least, not practicing medicine).  But my job is indirectly subsidized by the federal government, as now a huge sector of the automobile and banking industries are.  So to hand irresponsible owners of companies that make shitty cars, and banks that make horrific choices, astounding piles of cash, while our government cannibalizes medical education subsidies to pump more money into the failed and pathetic "quality" incentive programs to physicians, cases me tremendous anger.  

"Expanding healthcare" does not mean giving more people the same shitty government-funded "coverage" that no physician with any degree of autonomy will accept.  They'll still pay (and I'm making numbers up here) the same insulting $40 to for the 30 minute office visit for an elderly person with diabetes, and the same outrageous $30,000 to cut off their feet.

Hospitals are employing an increasing number of physicians.  Our government has made sure the economics are stacked against doctors trying to actually open their own practice.  Those of us unlucky enough to be employed directly by hospitals know that they have absolutely no desire to see people get healthier.  Their bottom line will suffer.  If primary care physicians were empowered to spend the time they need with people to better manage chronic illness (and I really think they're doing the best they can under the current borderline-immoral conveyor belt of patients many are browbeat into seeing) then you're going to see less hospitalization.  Less mindless flow of cash to the hospital to proceduralize people to death.

I'm constantly brainstorming about what we need to do to fix this.  I'm not terribly optimistic about Obama's ability to do this, since I am increasingly hearing the outraged voices of people who have come to demand access to taxpayor-funded entitlement-based reimbursement of medical services shouting that no one has the right to tell them how to live their life.

Under normal circumstances, I agree.  I would have no problem with people who want to eat themselves into oblivion.  It wouldn't bother me if I saw the COPDer on oxygen smoking at the casino.  It would hardly phase me to see the IV drug abuser using her PICC line to shoot up crushed oxycontin mixed with spit.  EXCEPT THAT I'M PAYING FOR THIS  SHIT.

If I have a stake in paying for you healthcare, then hell yes I can tell you how to live your life.  And this is independent of my standing as a physician.  I think this goes for anyone playing by the rules who is not reliant on the government to pay for their healthcare.  You want to live your life as you please?  Fine by me.  When those choices make you sick, you're ON YOUR OWN.  Oh, you want me to pay for your CPAP and Q2 month admissions for COPD?  Put down the fork (or the hamburger wrapper), get off your ass, and put out the cigarettes.  Or buy your own health insurance.

And we really need to stop using the term "insurance".  Think about what would happen if we treated car insurance and homeowners insurance in the same vain that we talk about "healthcare insurance". I would demand that Geico pay for my oil changes, new tires and brakes, even though I drive my car like a rental.  When the lightbulbs go out in my house, I'd call up AllState and demand someone come over to replace them... even though I just leave the lights on all the time.  What would our motivation be to take care of our vehicles and homes if the government just took care of it?  Oh... but they'll only pay for 60% of the cost of the oil changes... what do you think that would do to Jiffy Lube?

Something has to change.  Fast.  The healthcare bubble is going to pop.  But I fear that our concern is being misdirected.  Americans are unhealthly largely because of their refusal to take care of themselves.  And if I read one more article about an outraged smoker who is simultaneously pissed off about not being able to smoke in public, and about the cost of her COPD medications... I might just lose my mind.

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