Sunday, August 26, 2012

Health Care, "Obamacare" and Vietnam

I'm a Family Physician, at, what many would call, the "front lines" in health care.  I'm also a Vietnam Veteran, former Army officer, helicopter pilot and a graduate of West Point, Class of 1968.  My reflections on health care cause me to reflect on Vietnam.  How do the two relate?  Both were non-declared wars.  We won the major battles in both.  We lost or are losing both wars.  Why?  How?

In Vietnam we were confused about the overall strategy, but our tactics won every major battle.  One could say the same about health care.  We have no overall strategy, but our weapons to fight disease are superb.

Morale in Vietnam deteriorated when front line troops were instructed to become killers instead of soldiers.  Body counts replaced mission accomplishment as the focus.  The troops found a way to hide from their role as "killers" in illegal drugs, from marijuana to heroin, and mental health problems such as PTSD.

Health care is starting to fade into numbers instead of patient care.  Misguided quality initiatives follow IT installations in which billing software is modified into Electronic Medical Records (EMR)for clinical use, resulting in patients and their narratives being ignored into a sea of numbers.  Nurses hang onto bar code readers instead of holding onto patient hands and hopes.  Caring professionals are becoming despairing professionals.

Patients are being turned into numbers and bar codes.  Their hopes and dreams, which should be the basis of "Quality" measures, are being ignored.

Robert McNamara, Defense Secretary for Presidents Kennedy and Johnson was the leader behind the Vietnam body counts which devastated troop morale.  The Patient Protection and Affordable Care Act (PPACA), also referred to as "Obamacare", has now taken the lead with numbers-oriented policies and protocols that will move us closer to the demise of health care. 

"Meaningful Use" (which I sometimes refer to as "Meaningless Use") is the term used to refer to the government mandates for approved Electronic Medical Records, which may reward primary care physicians with taxpayer dollars (up to $56,000 per compliant physician).  The numbers game is polluting the push for developing the Patient Centered Medical Home (PCMH), which is supposed to help patients, into the development of, what I refer to as, "Payment Centered Medical Homes", with over-emphasis on physician reimbursement to try to "buy" medical students into Family Medicine and other primary care specialties.

Family Medicine is a relationship focused medical specialty.  The patient-physician relationship is the heart of Family Medicine.  It is our essence.  It is being ripped out by the current direction of health care.

Is health care becoming another Vietnam, with massive expenditures and worsening outcomes?  It feels that way to someone who's been involved in both wars.

What do you think?


  1. While I am not directly connected to the Vietnam war, I lived through that period of time and could never understand why we gave back territory as soon as we took it and advanced. As far as Obama is outrageous. How will we ever pay for it and just who will benefit in the end? It has to go. mas

  2. I love your insightful and thoughtful blogs, Pat. A few thoughts from an “old” roommate from the Academy…
    Obamacare and what will follow…or how advances can be steps backwards…the joys of government interference…
    EMR (electronic medical records) is all about efficiency and accuracy…but it has been a source of inefficiency and tremendous expense to many medical practices. It also brings with it an inherent disconnect between the doctor and his or her patient…because the patient typically gets to see the doctor’s back while data is input to the patient file. Of course there is a way around the disconnect…the doctor can hire additional personnel to enter the data as he dictates it…but that seems wasteful and expensive…but it does help the unemployment rate.

    When the government focuses on numbers rather than patient care and patient outcomes, care will suffer. Given the tidal wave of baby boomers hitting the Medicare shoreline, at a time when the government is virtually bankrupt, is the setting for a perfect storm.

    The government will seek to ration care by setting up review committees to determine what level of visual impairment qualifies for surgery under Medicare or Medicaid. In addition, anything that can slow down the flow of patients through surgery centers for needed cataract surgery will be used. Second opinions were used years ago in Florida. They slowed down the volume for a short period of time, but then were recognized as simply increasing cost.

    The next approach will be to reduce the fees paid to surgeons and facilities for cataract surgery. Once these reductions are in place, the cataract landscape in the US will be like that of the UK. Surgeons will opt out of providing surgery in the face of reduced fees. Why take on the stress and time out of the office to perform cataract surgery when you can earn as much or more by seeing patients in your office? And this doesn’t even consider the significant accountability associated with cataract surgery. Patients quickly know whether they had a good outcome or not. There will be a growing shortage of surgeons that will result in long lines of patients waiting for cataract surgery. Patients might suddenly find there is a two year wait to get back good functional vision.

    It’s a scary thing when the government steps in the middle to “help make things better.” We all hear the knocking at the door and that voice saying, “I’m from the government and I’m here to help you.” That should be seen by all of us (patients, doctors, and voters) as a red flag not to be ignored.

    Lots more could be said, but that’s my myopic viewpoint as a cataract surgeon whose been watching this for the past 30 years.