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    Sick America

    Michael Moore’s recent documentary, SiCKO!, catalogues the growing American dissatisfaction with health care services and providers in the United States. The problem, Moore argues, is the nearly exclusively profit-driven endeavors of US medical care providers.

    Throughout the film Moore points to health insurance and pharmaceutical companies as the cause of the nation’s woes. Ultimately, he proffers a solution in which he calls for the “abolishment of all private health insurance companies.”

    The film hails government managed health care systems like Medicare and Medicaid as being the medicine of the future. Moore presents ample examples of ill Americans being denied treatment or medication by their health insurance companies for seemingly trivial reasons.

    Scene after scene, the viewer is taken from the emotional distress of individuals watching their loved ones die after being denied treatment to shots of insurance company executives callously justifying their companies’ decisions. By the end of the film, the viewer is likely left with a bleak outlook for medical care in America.

    Furthermore, Moore visits physicians around the world in countries that participate in single payer healthcare systems. He tried to build a case against the American, capitalist system of medicine by showing the viewer how successful a healthcare system that functions without cost to the patient can be.

    Largely one sided, the film fails to provide the perspectives of the physicians in America that routinely encounter situations in which insurance companies refuse payment for treatment. Questions about why the system is failing are left noticeably unanswered.

    Some of the twenty four physicians from Stony Brook University Hospital recognized by New York Magazine for being “New York’s Best,” decant their opinions about the state of American health care and the direction it should adopt in order to improve.

    Providing their assessments of the current healthcare system in the US, some of these physicians were decidedly in favor of a single payer healthcare system. Most, however, provided further alternatives to the solution Moore offered.

    “The delivery of healthcare [in America] is flawed,” said Todd Rosengart, M.D., professor and chief of Cardiothoracic Surgery and co-director of the Stony Brook University Heart Center.

    John Ricotta, M.D., professor and chief of Surgery said,” Every system has its problems,” when referring to US healthcare. “The system we have is based on unrealistic expectations.”

    The American perception of what medicine should be, according to some Stony Brook University Hospital physicians, comes from our cultural values. Americans only want the best technology and treatment in the world.

    As presidential elections draw nearer, Americans demand greater access to healthcare and hopeful candidates continue promising “basic” healthcare for all.

    “Americans expect everything for everybody,” says Margaret Parker, M.D., professor of Pediatrics and director of the Pediatric Intensive Care Unit, “however, it’s hard to agree on what is basic.”

    “Where do we draw the line? What is included?” she continued. “Are transplants, experimental drugs, and end of life care basic? All of these decisions are value-based and ultimately individualistic.”

    Part of the problem, according to Ricotta, is that many people do not understand the advanced medical technology available in US hospitals, resulting in its misuse. The largest expenses in medicine are those of beginning and end of life care.

    “Society has not decided what is efficacious and what is futile,” explains Ricotta with respect to medical treatment. If doctors “fail to do everything they can,” he says, they are not fulfilling their duties, according to the American value system.

    The American attitude towards technology and equipment is, in part, fueled by physicians’ waste of resources. Unnecessary procedures are routinely performed in order to quell the threat of malpractice lawsuits. A headache, according to Ricotta, is usually best addressed by taking rest and not necessarily with an MRI.

    In fear of malpractice lawsuits, doctors perform extra tests such as CT scans and MRIs just to be sure they do not miss anything. “Defensive medicine,” says M. Parker, “is not good medicine.”

    Many individuals come to their physicians unnecessarily demanding high technology treatments, according to Ricotta. Their motivation, he continues, lies in their need to “make use of their $6000 a year health insurance premium.”

    The efficacy of new treatments must be evaluated before they are put into practice, according to Ricotta. Often, the low-tech approach is sufficient enough to address the patient’s condition.

    “Medical decisions should be based on society’s needs,” argues Robert Parker, M.D., professor and vice chair of Academic Affairs, director of Pediatric Hematology/Oncology, and associate director of the Stony Brook University Cancer Center. “The US is individualistic; Americans are not conditioned to consider society first.”

    In some European countries such as Holland, for example, a 75 year-old heart attack patient is made comfortable in his last days. His likelihood for survival is not great, so spending money and using advanced technology to prolong his life may not be in his best interest or in the best interest of society as a whole.

    “There is no incentive to use resources wisely,” says Rosengart.

    How HMO’s and insurance companies dictate physician reimbursement is procedurally based. Doctors who perform invasive procedures such as stent implantation or catheterization for coronary disease are better reimbursed than doctors who send their patients home with heart medication and tips for healthier living.

    The physician who performs noninvasive medicine, according to Rosengart, must see more patients than the physician who performs invasive medicine to secure the same reimbursement. It is quickly becoming more difficult for noninvasive medicine practitioners to comfortably stay in practice.

    “There needs to be compensation for cognitive work,” says Dr. Robert Parker.

    On another note, Moore, in his film, condemns the American system for not taking care of the 45 million uninsured individuals in the country.

    Many of the uninsured, according to Ricotta, are uninsured by choice. Either between jobs or young enough to deem health insurance an unnecessary expenditure, many Americans choose to live without it.

    David Brown, M.D., professor and chief of cardiovascular medicine, explains that no hospital can deny medical care in the emergency room. Inpatient scenarios at SBUH, he continues, are always addressed, regardless of the individual’s insurance status.

    Outpatient situations, however, are handled differently. Non-emergent medical cases require appointments with primary care physicians. Uninsured patients, in these situations, are usually referred to teaching clinics to be seen, without charge, by fellows.

    So, where does the solution to America’s health care problems lie?

    The most highly publicized solution is the single payer, government run health insurance system. This would remove most costs from patients and effectively place physicians on a salary from the government. Many Americans hope that this system would enable complete access to healthcare to all individuals.

    An argument against this solution is in the quality of care that can be achieved under such a system.

    “Physicians that become salaried are more prone to become shift-workers,” says Rosengart. “Most doctors will say that have no time to care properly.”

    Furthermore, a single payer system would result in waitlists and long lines for treatment. A gov
    ernment run system would result in a “maldistribution of resources,” says Dr. Robert Parker.

    Nationalized healthcare would allow the government to determine the number of physicians in any given specialty.

    In Canada, a patient can be on a waiting list for treatment of a hernia for 8-9 months, according to Ricotta.

    In response, Stephen Jonas, M.D., professor of Preventative Medicine, says “Yes, there may be a wait, but it’s not as long as never.” The fear of waiting lists, he argues is politically generated. Enabling access for all individuals, he says, makes this system a potential success.

    “The conflict in the US is that medicine is profit driven,” he continues. “Political change is necessary in order to change our approach to medicine.”

    The ideal system, according to Brown, is one that combines the freedom of individually bought insurance with the security of universal health coverage. Medicare could be given to all Americans with the option to buy additional coverage.

    “Universal coverage is necessary because no one should be denied [treatment],” explains Rosengart. However, he continues, “there is not enough money in the GDP for that kind of coverage.”

    “Physicians and hospitals are an easy target,” says R. Parker. In a scenario where hospitals and physicians are forced to swallow costs of medical procedures when insurance companies and patients cannot pay, resources such as nursing staffs are cut. With fewer nurses, according to R. Parker, the number of medical errors and deaths increase. The quality of care, he argues, is diminished.

    In nations where nationalized healthcare is in place, medical services as well as medications are free or at minimum cost. This situation is artificially maintained, according to some SB physicians. The new Medicare Part D plan prevents the government from lobbying for lower drug prices. Pharmaceutical companies, R. Parker argues, are using the US to subsidize medical costs for the rest of the world. “Unless it’s a developing country, this is not right,” he says

    Furthermore, nations where universal coverage is in place may eventually find that system unsustainable. When outpatient expenses become too great, according to R. Parker, the only way the government can reduce costs is to limit patient access and reduce reimbursements. “All systems ration,” he says.

    On another note, preventative medicine, according to a number of SB physicians, is the best direction to take American health care in.

    “We have no good system of preventative care,” says M. Parker. “Our reimbursement system is procedurally based.”

    “We must shift funding away from hi-tech, end of life care towards funding prevention,” explains Brown.

    If more individuals sought preventative care when they felt sick, hospitals would have fewer patients, according to Brown.

    “Sickness is a spectrum,” explains Ricotta. Although a preventative medicine approach is not helpful to those on the far end of that spectrum, it can help those who are not very sick.

    A “pay for performance” system like the one found in London as featured in Moore’s film, may also encourage preventative care. Physicians in London are given extra reimbursement for encouraging patients to address health-endangering activities early. If a doctor helps a patient quit drinking alcohol, for example, he would be reimbursed for his interventional actions.

    Tort reform, according to many SB physicians, is another partial solution to healthcare problems and perceived lack of access in the US.

    A cap on the maximum award for pain and suffering, according to R. Parker is necessary. This action, he argues, would result in lowered malpractice insurance premiums and ultimately translate into less practice of defensive medicine. This action would discourage physicians from wasting resources.

    Healthcare, according to Ricotta, should not necessarily be provided to all. “People are resistant to rationing,” he says. “It is difficult to make the distinction between doing everything possible and keeping one alive without any meaningful future.”

    In nations such as Denmark, according R. Parker, if a heart attack patient is found to be a smoker, the health care providers limit the care given to him. They argue that they cannot support self-destructive behavior. Other limiting factors to medical treatment in many European systems, according to Ricotta, include age.

    This same attitude needs to be developed in America, according to R. Parker. “Can we justify asking society to pay,” he asks, “for the poor decisions of others?”

    Conversely, Jonas argues that our healthcare system already rations. “We already ration access to medical services by things like race and economic background.”

    Another alternative is a healthcare system that features “health care savings accounts.”

    “Improvement of the quality of life is good,” says Ricotta, “but there is no sense that the individual should pay for the care they receive.”

    A health care savings account would force patients to be financially tied to the services they receive that thus use them more wisely, according to Ricotta.

    A loaded account provided to an individual by his employer would be supplemented by his own out of pocket expense and a set deductible cost. For example, hypothetically, the employer would annually provide an employee a $1500 account to which he adds $500 from his own funds. Furthermore, the employee would have a $2000 deductible fee. At the end of the year, the employee would be given the remaining balance of the health savings account as a bonus.

    These measures together, according to some SB physicians, would encourage patients to seek preventative care because of an incentive created by their personal financial responsibility to their own medical care.

    “Patients would think twice about what procedures are needed and scrutinize their physicians more,” argues Rosengart in favor of health care savings accounts.

    “A major reeducation is needed to bridge the disconnect between costs of medical services and costs to the patient,” explains R. Parker.

    A free market solution to medical care is another possibility. “Medical consumerism,” says Rosengart, “would encourage patients to use resources wisely.”

    “When money matters,” he continues, “individuals will do the right thing to stay healthy and seek preventative care.”

    Rosengart, who has practiced in London, says that people in nationalized health care systems still pay if they can. He argues that a free market system would also allow physicians to have greater control of the quality of care they are able to provide.

    “There is a reason why capitalism conquers,” he continues.

    M. Parker offered her skepticism of a free market approach. “It could work to limit unnecessary waste of resources,” she says. “However, this is a two edged sword. Unless it is properly understood, it could cut preventative care.”

    Faced with the prospect of cutting extensively into their own incomes for medical treatment, there is a fear that individuals, especially those of poor health or low economic status, may begin to avoid seeking medical treatment.

    Ultimately, according to R. Parker, “the solution cannot be a band-aid. It must address all elements” of our current situation.

    In summary of the current predicament faced by Americans with regards to healthcare, Ricotta calls for a health care policy that addresses the “cost effectiveness of care giving strategies, provides accessible care to all individuals regardless of their economic condition and ties personal responsibility to access.”

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