Home > bioethics, health care, Obama, Tea Party, U.S. Congress > Town Halls, Tea Parties, and My Further Adventures in the ER

Town Halls, Tea Parties, and My Further Adventures in the ER

Apparently, my kidneys are manufacturing stones like cheap Chinese toys. Last night, I found myself back in the ER with another stabbing pain. This is now what I look for in home sale ads: “Charming Victorian house in diverse neighborhood. Walking distance to emergency room. Must see!”

This time, I thought that a CT scan did make sense, but that wasn’t going to happen for several hours, because all of the CT staff was out sick. So, doped up on morphine, I walked home in the sticky dawn. I then took advantage of my pain-free state to sleep for several hours, but now I’m awake and uncomfortable. Hence, this post.

I’m now in favor of some kind of “cap and trade” program for kidney stones. I’m also in favor of major changes to the health care system. Today’s lesson is that the pieces don’t move especially well together. ER docs, my doc on call, the urologist I’m supposed to see next week — my experience suggests that they won’t check each other’s notes thoroughly enough (if at all), and that there are lost efficiencies all over the place.

But don’t take  my word for it: Here’s what some academic physicians had to say about the cost issue in a recent op-ed piece in the NY Times. Their many useful suggestions include reconsidering the “fee for service” model, which encourages overutilization of procedures. In a given year, for example, the number of CT scans done exceeds .2 per capita (62 million for 300 million people).

In a recent interview on NPR’s Fresh Air, Lisa Sanders, who writes the fascinating (to me and other worry warts) “Diagnosis” column for the Times, picked up on related point with her pithy insight that doctors are reimbursed for “doing” — not for “thinking.” One morning, she explained, she had some twelve patients, who represented the mine run of what internists encounter on a typical day: colds; bronchitis; flu symptoms; pain. Her final patient needed an ingrown toenail removed. Doing that brought Dr. Sanders more reimbursement from the insurance companies than everything else she’d done all morning, combined. Fee for service combined with heavy compensation for procedures, rather than diagnosis, may explain a good part of our current mess.

You may have heard that the evident need for some kind of health care reform hasn’t exactly resulted in universal acclaim for President Obama’s initiative. To an extent, the responsibility rests with the White House for failing to engage and to make clear exactly what’s being proposed, what would happen as a result, and so on.

Obama’s Town Hall Meetings have been a belated corrective to the more vitriolic incarnations of the format that have caught many people, including me, by surprise. Listen in and you’ll hear comments that are only sometimes about health care itself. In this story, one woman complains broadly and emotionally about the death of American exceptionalism. It seems to me that Kai Wright, senior  writer for the Root who was interviewed for the story, is exactly right in saying that health care has provided a convenient flash point for broader anger and anxiety: “What is my place in a vastly changing culture and a vastly changing economy?” is the question he suggests underlies whatever is actually spoken.

Wright also blames right-wing flame-fanners — especially Glenn Beck — for provoking this anger. In the chain of distribution, Beck is the wholesaler, and people like John Stahl, President of the Berks County, PA Tea Party Patriots, are the distributors who work on the local level. Reading about Stahl’s criticisms of “Obamacare” at Arlen Specter’s noisy town hall meeting, I did the only sensible thing: I called the guy. (His phone number is on his organization’s website.)

Stahl, who’s about to turn 65, doesn’t plan to turn down Medicare. This would be an easy but unfair ground for calling him on hypocrisy; as he pointed out, Medicare is a contract on which people (presumably including “John Stahl”) have relied upon. But it’s broke, he says, and so is the whole system. He doesn’t exempt insurance companies from blame for what he acknowledges is a problem with our health care system but puts the lion’s share of blame on lawyers and med mal suits, illegal aliens (and legal ones, too!) using the system, and the insufficient number of doc being graduated  from medical school.

A staunch libertarian (but one who critizes Obama and his staff for being “ideologues”), Stahl favors the free market solution (which I’m convinced won’t work in the case of health care insurance), opposes any kind of “counseling” of people about their legal options regarding end of life care (not the role of government, he says), and even put on a retro, Steve Forbes wig to call for the “flat tax, ” an idea that no one will ever be able to drive a stake through. The flat tax should fix the problem, he says, along with an unspecified dose of tort and immigration “reform.”

Stahl’s positions aren’t radical, and he stressed the need for civility in debate. But his idea of civility is broad enough to include even Claire McCaskill’s notorious Town Hall Meeting, which he defended. See what you think:

At the risk of engaging in amateur social psychology, Stahl seems to me very much to fit within Wright’s questioning classes. Laid off from his job in his mid-sixties, a conservative Christian seeing his world changing at a vertiginous pace, Wright has seized on an issue in which he’d seem to have little personal stake, using it as a prism through which his deeper concerns can be reflected. Obama is “not a good person.”  He’s “not to be trusted,” based on his “background.” He and his ideologues are using the public option as a kind of Trojan horse, to get to their ultimate goal of complete government takeover of health care.

Is this code for a kind of racism? That’s much too simple, because Obama’s race may itself be a surrogate, for some, for what’s making them uncomfortable with change, more broadly. The world is caving in on John Stahl, and it’s not fair.

  1. James Ledwith MD
    August 16th, 2009 at 22:15 | #1

    The Tea Party disruptions of public discussion of the health care reform probably won’t keep Congress from moving forward on this essential task, but it will compromise the quality of the final product by obstructing the open dialogue on the issues with our representatives. As a teaching family physician, I thought it was a good idea to send a medical student to a nearby town hall meeting with two of our congressmen. My student entered with a strong interest in the issues and concern for the impact on her plan to become a family physician, but left with a sense of frustration and embarrassment after Tea Party activists disrupted debate. Our Massachusetts representatives learned nothing to guide the shape of the new legislation.

    Concerned by the hyperbole about rationing or pulling the plug? I suggest simply asking your physician how he or she would provide care for you. Concerned about unnecessary tests, or that your primary care specialist has no incentive to promptly read an ER report and talk to the limited-practice urologist who may need to perform a procedure to relieve the pain of a kidney stone? The physician practicing in a “Patient-Centered Medical Home” would do this but the service lacks funding outside of concierge practices for the elite. My prescription is to push Congress to begin reform of our health care system and build incentives to produce more family physicians, and that you hurry to establish care with one if you haven’t yet (Massachusetts has taught us that there are not enough primary care doctors to do the job).

    The free market of private insurance simply doesn’t work in health care. There is no viable option for the low income worker, the individual with a pre-existing condition, or the guy who is laid off with COBRA premiums exceeding the unemployment check. There is no incentive for the young healthy worker to give up part of his income to insure himself until unexpected illness makes him a burden on public plans.

    We all pay for the costs of the uncovered care and the travesty of having neighbors suffer rather than ask for assistance. A few years ago, nearly 1/5 of my patients in private practice in rural Virginia had no insurance to aid them with my bills, their medications, and consultations, let alone hospital care. Now in Massachusetts, it is a real pleasure, a relief actually, that due to Universal Coverage each visitor to my current office can afford to get the care I recommend.

    We will have to make all insurance plans accountable to officials who answer to voting Americans. During nearly twenty years of small town family medicine, I was confronted by the need to push beyond standard procedures to appeal for coverage of necessary care with an insurer. At least a dozen or more times, my patients were fortunate to have a state rep on the state insurance commission. Minutes after calls to his office the coverage for the denied treatment was assured. By the way, this was necessary only with private insurers, not the public Medicaid or Medicare programs.

    Private insurance plans have their place in the market with public plans, which are essential to offer help to those who need it. But should physicians spend valuable time sorting through varying coverage rules and limits for each individual patient? Care will be delivered efficiently to all with basic coverage for all, with uniform rules for all plans.

    Remember, if a small minority obstructs sound civil debate, Americans who want to express views can still call and write to representatives individually or support lobbying groups who will rationally express those views.

    Apologies for blogging your on your blog, John,

    James Ledwith MD
    Department of Family Medicine and Community Health
    University of Massachusetts Medical School

  2. March 14th, 2010 at 16:01 | #2

    This is good information. Would enjoy reading a follow up post.

  3. March 14th, 2010 at 16:01 | #3

    Nice info. Good read. Thanks!

  1. August 16th, 2009 at 10:07 | #1