The Crested Butte News Serving the Gunnison Valley since 1999
Measures have led to improvements
Stories of battlefield surgeons have made triage a word no one likes but almost everyone understands. Someone has to make the tough choices about who gets medical care and who doesn’t, so the greatest good can be achieved with the resources at hand. But we don’t connect it with the everyday business of providing healthcare.
Unfortunately triage isn’t a reality only on the battlefield, but also in big cities and small mountain communities across America, where the current method of administering and paying for the healthcare system has decided who of millions of people will get care and who won’t.
For Dr. Robert Brickman, a retired physician, former lawyer and current member of the Gunnison Valley Hospital (GVH) board of trustees, the reality of prioritizing or rationing healthcare is a treatable condition, if not a curable one, that is afflicting the healthcare system as we rethink the way it does business.
At the eighth event of the 2009 Public Policy Forum of Crested Butte on Wednesday, August 26 Brickman asked, “Do we want to give healthcare to everybody in the United States, or just exclude 45 million people?”
There was a collective “no” murmured from the packed pews of the Union Congregational Church.
“Right now there are 45 million people not getting healthcare, so we’re rationing our resources now,” he said. “So that will go on and has been going on since I started practicing medicine, anyhow.”
Throughout his career Brickman, a retired cardiothoracic surgeon and graduate of Johns Hopkins and Princeton University, has seen insurance companies set priorities of treatment and ration healthcare with the understanding that, even in the United States, there aren’t enough resources to “cover everybody for every treatment that might serve some benefit.”
But that is just the system that the United States has in place, according to Brickman, and it has created a cycle of high insurance costs, uninsured people and higher healthcare costs. It is a cycle that is threatening hospitals and doctors around the country, as the government turns to them as it tries to reel in costs.
“By the end of 2008, 50 percent of the hospitals in the United States lost money. The first quarter of 2009 was even worse,” he told the crowd. “We’ve seen the same thing here in Gunnison. When I joined the board about six years ago, the margin at the hospital was about 5 percent and it has gotten lower and lower.”
The reason for the shrinking financial cushion and potential deficits for the hospital is the increasing number of uninsured people who the hospital has a moral and legal obligation to treat.
“Unfortunately this is going to continue until the government or somebody steps in, because this scenario with more and more uninsured or people with larger and larger deductibles is going to continue, because basically healthcare is unaffordable,” he said.
The shrinking budgets mean that hospital facilities are not able to make upgrades and improvements, which is just what is happening at GVH. And with a negative balance in the accounts, the board is sure that no bank will offer them a loan to make capital improvements.
At the same time, the local hospital is forced to compete with neighboring hospitals like those in Grand Junction and Montrose, many of which receive some tax support, when GVH does not.
He equated the local desire to have a digital mammography machine at GVH with an earlier movement to install magnetic resonance imaging (MRI) machines in every hospital.
“I can remember a time when there were more MRIs in Cleveland, Ohio than there were in the entire country of Canada, because everybody had to have one. Once you had one, you had to keep a stream of patients coming through, because you have to do a certain number of exams to pay that machine off,” Brickman said. “That increases healthcare costs.”
He listed other reasons for rising healthcare costs, such as rising overhead in doctors’ offices as a result of paperwork and malpractice insurance. But there is also a rise in costs that is a direct result of the values we hold as a society.
There are the “mercy surgeries” that we sponsor as a society, where an underprivileged person from abroad will get the chance to undergo treatment and “stays here while they recover and then goes back to their country and we’re paying for it,” Brickman said. “As a society we decide that is a good thing, but those things increase healthcare costs.”
There are also conditions of our own society that result in increases in healthcare costs, such as the onset of formerly unknown diseases like AIDS that require a lot of resources to battle. Also, obesity and its complications are another example of an emerging condition that was unheard of three decades ago and is growing quickly—it already consumes 9 percent of the nation’s healthcare expenditures.
Then there is the “Failure of Success,” Brickman told the crowd. “The more successful you are at keeping people alive, the more healthcare costs they’re going to use because there are more of them and they’re living longer.”
Pointing to a picture of a pen projected on a screen, he reminded the group that many of the costs start with doctor’s orders; ultimately, the doctor’s pen is responsible for a vast majority of healthcare costs.
“And then there is the simple excessive volume and intensity of services than what is necessary. When you’re practicing medicine with somebody else’s checkbook, you order things that you think are necessary, but it’s somebody else’s checkbook,” he said. “And the patient doesn’t get the bill until after the services are rendered, so they don’t know what the costs will be until it’s too late.”
For that reason, Brickman said, he would like to see more meaningful dialogue between doctors and their patients, ultimately allowing people to make their own healthcare decisions with the best available information.
In his experience as a physician, Brickman has seen how simple measures to reduce unnecessary steps in the operating room can save doctors time and money and pass those savings onto the patients without compromising standards.
At GVH, steps have been taken to cut costs in every way possible, and the system is moving toward more electronic recordkeeping that will improve efficiency. GVH has also improved the quality of care, which is always good business practice for a hospital.
So by taking steps to identify, with some certainty, effective treatments, limiting excessive services, implementing cost saving measures and removing unnecessary steps in the healthcare process, Brickman believes the national and local healthcare system can provide the vital care to everyone who needs it without going broke.
But the excessive costs are found outside of what is incurred during the actual treatment of patients. Doctors, if they go into a family practice or primary care, are finding it difficult to pay off school loans that can exceed $150,000.
“A medical education has almost priced people out of the market and is almost forcing people to go into specialties, because they cannot repay their student loans if they go into primary care. This is a major problem,” Brickman said.
Crested Butte is seeing that problem manifest itself in an aging population of primary care physicians.
“A few years ago, the average age of the primary care physicians—that is the family practitioners and internists—was 58 years and we didn’t have a succession plan to attract new physicians to the community, to ensure that access to primary care in the community and the access to specialty care,” Brickman said.
To offset the problem, the Gunnison Valley Health Foundation, with the help of a valley resident, is funding three years of a medical student’s education with a requirement that after graduation that student comes to the Gunnison Valley to practice. The hope is that the student will stay as a doctor in the valley for more than his or her minimum commitment.
Without increasing the number of primary care physicians, Brickman doesn’t think providing universal care to all Americans, which was suggested as part of the national healthcare debate, is feasible. There simply are not enough doctors to go around.
“Throwing all of our money at the problem is not the answer. Massachusetts’ healthcare plan, which requires coverage for everybody, is already in trouble,” Brickman told the crowd. “They’ve come to the conclusion that they have to find another way of paying for healthcare; that fee-for-service healthcare in this country, the way it is currently, is out of control.”
These new people who suddenly are covered in Massachusetts, he said, cannot find a primary care doctor because primary care doctors are not accepting any patients who are in the state’s program.
“So guess what’s going to happen when they pass universal coverage: primary care physicians are going to be rationed,” he said.
But while he stopped short of endorsing the idea of universal coverage, Brickman deflected attempts by those in the crowd who would have government stay out of healthcare altogether, fearing that it would become less efficient and cost more.
“There are a lot of successful models in this country and there is no reason why we have to adopt one specific model,” Brickman said. “In trying more things, the ones that are more successful will grow and the ones that aren’t will fade away. But the government, or someone, has to get involved.”
If you missed the discussion with Dr. Brickman, a final forum will take place at the Center for the Arts on Wednesday, September 9, when Senator Tim Wirth will speak on “Resolving Climate Change.”
For more information on the Public Policy Forum of Crested Butte, go to their website at www.crestedbutteforum.org.
