The perfect health care system is like perfect health—a noble aspiration but one that is impossible to attain. In the preceding chapters, we have discussed many fundamental issues and principles involved in formulating health care policy. A recurrent theme has been the notion that “magic bullets” are hard to come by. As stated in Chapter 2, policies tend to evolve in a cyclic process of finding solutions that create new problems that require new solutions. Policy changes may offer a degree of relief for a pressing problem, such as inadequate access to care, but frequently also give rise to various side effects, such as stimulating health care cost inflation.
All health care systems face the same challenges: Improving health, controlling costs, prioritizing allocation of resources, enhancing the quality of care, and distributing services fairly. These challenges require the management of various tensions that pull at the health care system (O’Neil & Seifer, 1995). The goal of health policy is to find the points of equilibrium that produce the optimal system of health care (Table 17-1).
Table 17-1Major tensions in health care ||Download (.pdf) Table 17-1 Major tensions in health care
|Health of the individual patient ||Health of the population |
|Tertiary care ||Primary care |
|Acute care ||Chronic and preventive care |
|Cost unawareness in medical practice ||Cost awareness |
|Unlimited expectations for care ||Affordability of care |
|Individual physician ||Organized health care team |
|Professional management ||Corporate management |
|Market competition ||Government regulation |
|Inequity in distribution ||Fair distribution |
Dr. Madeleine Longview is chief resident in critical care medicine and supervises the intensive care unit of a large municipal hospital. It’s 5:30 AM, and the intensive care unit team has finally stabilized the condition of a 15-year-old admitted the previous evening with gunshot wounds to the abdomen and chest. Dr. Longview sits by the nursing desk and surveys the other patients in the unit: a 91-year-old woman admitted from a nursing home with sepsis from a urinary tract infection, a 50-year-old man with shock lung caused by drugs ingested in a suicide attempt, and a 32-year-old woman with lupus erythematosus who is rejecting her second kidney transplant. Dr. Longview feels personally responsible for the care of every one of these patients. She tells herself that she will do her best to help each of them survive.
As Dr. Longview gazes out of the windows of the intensive care unit, the apartment houses surrounding the hospital take shape in the breaking dawn. She wonders: Which block will be the scene of the next drive-by shooting or episode of spouse abuse? Which window shade hides a homebound elder lying on the floor dehydrated and unable to move, waiting for someone to find him and bring him to the emergency department? Which one of the unvaccinated kids in the neighborhood will one day be rushed into the unit limp with meningitis? In which room is someone lighting up the first cigarette of the day? Dr. Longview somehow feels responsible for all those patients-to-be, as well as for the patients lying in the hospital beds around her. After these sleepless nights on duty, the doubts about the value of all the work she does in the intensive care unit creep into her thoughts. She has visions of shutting down the unit and putting all the money to work hiring public health nurses in the community, or maybe just paying for a better grammar school in the neighborhood. But then what would happen to the patients needing her care right now?
One of the most basic tensions affecting physicians and other caregivers is the tension between caring for the individual patient and caring for the larger community or population. Many of the most important decisions to be made in health policy—decisions such as allocating health care resources, addressing the social context of health and illness, and augmenting activities in prevention and public health—depend on broadening the practitioner’s view to encompass the population health perspective. The challenge for physicians and other clinicians will be to make room for this broader perspective while preserving the ethical duty to care for the individual patients under their charge.
Like Dr. Longview, the health care system as a whole will continue to struggle over finding the proper balance between the provision of acute care services and preventive and chronic care services, as well as striking the right balance between the levels of tertiary and primary care. Few observers would encourage Dr. Longview to succumb to her despair, close all the intensive care units, and expel all the critical care subspecialists from the health care system. Yet most would agree that health care in the United States has drifted too far away from the primary care end of the tertiary care–primary care axis.
Dr. Tom Ransom has performed what he believes to be a reasonably thorough workup for Zed’s abdominal pain and decreased appetite, including a detailed history and physical examination, blood tests, and abdominal ultrasound—all of which were normal. When Dr. Ransom tells Zed that they will have to work together to manage Zed’s symptoms, Zed tells Dr. Ransom that he wants one more test, an abdominal CT scan. Zed says that he had a cousin with similar symptoms who was eventually diagnosed with advanced-stage lymphoma after complaining of pain for over a year.
Dr. Ransom is in a quandary. He believes it extremely unlikely that Zed has serious pathologic changes in his abdomen that will be detected on CT scan. He could order the scan, but then there’s the issue of the cost. He can’t recall whether Zed is covered by a fee-for-service plan or by one of the health maintenance organizations (HMOs) that pays on a capitated basis and puts Dr. Ransom at financial risk for all radiologic tests ordered. He starts to ask Zed about his coverage but feels a pang of guilt that he should allow these economic considerations to intrude into his clinical judgment.
The desire (and in many instances, expectation) of patients to receive all potentially beneficial care, and the unwillingness of these same individuals in their role as purchasers to spend unlimited amounts to finance health care, creates a strain for all caregivers and systems of care. Physicians increasingly are being called upon to incorporate considerations of costs when making clinical decisions. Debate will continue about the best ways to encourage physicians to be more accountable for the costs of care in a manner that is socially responsible and does not unduly intrude on the physician’s ability to serve the individual patient. Is it necessary to use payment methods that place physicians at individual financial risk for their treatment decisions in order to control costs? Are more global methods available to induce physicians and other caregivers to practice in a more cost-conscious manner? If Zed does not get a CT scan, does that constitute painless or painful cost control?
On the eve of his retirement, Dr. Melvin Steadman reminisces with his son, Dr. Kevin Steadman. The elder Dr. Steadman has practiced as a solo pediatrician for more than 40 years in the same town. The only boss he has known in his professional life has been himself. He has served as president of the local medical society, helped spearhead efforts to build a special children’s wing of the local hospital, and antagonized several of his colleagues when he pushed for a change in hospital policy that required physicians to attend extra continuing medical education courses in order to maintain their hospital privileges. Mel swore that he’d never retire; but he also swore that he’d never let the insurance companies “tell me how to practice medicine.” He has refused to sign any managed care contracts. Facing a dwindling supply of patients, Mel has decided to call it quits.
His son Kevin is also a pediatrician, working as a staff physician for a large for-profit multispecialty group that recently opened up an office in town. Kevin remembers the many nights when his father didn’t get home from work until after he had gone to bed. Kevin’s work hours are more regular at the group practice, and he is on call for only one weekend every 2 months. He considers his father’s approach to medicine old-fashioned in many ways—excessively paternalistic toward patients and irrationally scornful of the pediatric nurse practitioners who work with Kevin. He does, however, envy his father’s professional independence. Just this week, the group practice notified Kevin that he would have to divide his time between his current office and a new site that would soon open in a suburban mall. His schedule will be limited to 10-minute drop-in appointments at the new site, rather than the style of practice that promotes a sense of continuity, one that allows him to get to know his patients over time.
A system of health care formerly managed according to a professional model by independent practitioners is being pulled toward a corporate model of care featuring large organizations managed by administrators. As the role of corporate entities expands, traditional responsibilities toward patients and local communities are vying with new obligations to shareholders. Power relationships are changing, with insurance companies and organized purchasers challenging the dominance of the medical profession. A shift toward multidisciplinary group practice may provide more opportunity for health care professionals to work collegially and implement new approaches to quality improvement to elevate the competence of all health care providers. At the same time, a competitive, for-profit health care environment may induce physicians to compromise their humanity and base their clinical decisions in part on personal monetary considerations.
Aurora can’t wait any longer in the crowded county hospital emergency department. She’s already been there for 6 hours, and the physician hasn’t seen her yet. Her lower abdomen still hurts, but she figures she’ll just have to put up with it for a few more days. She really doesn’t have much choice. Poor, uninsured, and without legal documents, where else could she go? Aurora has two young children at home who need to be put to bed. In half an hour, their father has to get to his night job as a security officer. As she enters her apartment, she collapses, the pregnancy in her fallopian tube having ruptured, producing internal hemorrhage. Her husband frantically dials 911, praying that his wife won’t die.
Over the years, no tension within the United States health care system has been as far from reaching a point of satisfactory equilibrium as the achievement of a basic level of fairness in the distribution of health care services and the burden of paying for those services. The ACA has taken a significant step toward resolving that tension. But because financial barriers remain for millions of people, both insured and uninsured, not all patients benefit from early detection of potentially curable cancers, patients with chronic diseases are hospitalized because of lack of timely primary care, hypertensive patients forego the medications that might avert strokes and kidney failure, and babies are born prematurely and spend their first weeks of life in a neonatal intensive care unit. The poor continue to pay a greater proportion of their income for health care than do more affluent families.
People providing and receiving care in the United States must work together to achieve a brighter future for the nation’s health care system. Changing the future will require that people look beyond their immediate self-interest to view the common good of a health care system that is accessible, affordable, and of high quality for all. A heightened level of public discourse will be needed, with a populace that is better informed and more actively engaged in shaping the future of their health care system. Concepts in health policy based on established facts rather than ideologically driven myths will need to be discussed and debated in a manner that connects with the daily realities experienced by patients and caregivers. The attitudes and actions of physicians and other health care professionals will play a major role in determining the future of health care in the United States. With leadership and foresight among the community of health care professionals, our nation may yet achieve a system that allows the most honorable features of the healing professions to flourish.