Empower Patients

"SiCKO" Doesn't Go Far Enough! (Pt.2)

A perfect storm gathers at the hospital bedside for anyone who suffers the slightest ‘complication.’ Michael Moore missed an opportunity to track this storm in “SiCKO.” While he had a visual, he neglected the infrared view.

His insights into systemic problems enabled him to detect the consequences of the ‘medical model’ on the problem of access. However, the majority of Americans face a very different sort of crisis as a result of the ‘medical model.’ It is a crisis in the delivery of their health care at the hospital bedside. This crisis ultimately leads to the gross and widespread violation of our most basic patient/caregiver right: the right to informed consent.

As in any perfect storm, a simultaneous occurrence of specific events brings this one into being at the hospital bedside. Taken individually, each event might be of little consequence, but taken together they produce a hurricane of devastating magnitude that rips through the lives of countless patients, families and caregivers.

Moore shows us in “SiCKO” that, under the ‘medical model’, we reimburse doctors in this country based on the number of procedures they perform. However, Moore neglects to document the impact this reimbursement scheme has on the delivery of health care at the hospital bedside. Specialists multiply on a particular case based on referral, with no doctor wanting to interfere with a colleague’s ability to make money.

Quite simply, doctors compete for those finite reimbursement dollars. Each needs to perform some procedure on the same patient in order to get paid.

Reimbursement works in consort with other events to create our perfect storm. Over the course of the last twenty years, component management has emerged as the standard of care in medicine, entailing ‘a doctor for every organ’.

Naturally, we want people to specialize. No one would argue that the application of science to medicine has produced enormous advances. However, we also need specialists to coordinate their efforts in the care of individual patients.

This has not happened. Instead, patients and their caregivers experience ‘episodic intervention’, another element in the perfect storm: when something happens to one organ, the patient sees a specialist in that organ system based on referral; when something happens to another organ, the patient will see another specialist and subspecialist for that organ system, and so on.

Episodic intervention leads unavoidably to fragmentation and a lack of coordination among specialists in patient care—care that lacks continuity for both patients and their caregivers.

The perfect storm gathers speed as fragmentation and a lack of coordination result in a breakdown in communication among doctors and between doctors and patients/families/caregivers. With no one to care for the whole patient, family members or caregivers are left to their own devices to somehow integrate the care of their loved ones.

They struggle against gale force winds to piece together bits of information from different specialists and subspecialists in an attempt to get a complete picture of what’s happening to their loved one.

As the hurricane makes landfall, this perfect storm leaves devastating consequences in its wake. The initial storm surge in the form of a breakdown in communication leads first to conflict.

Because doctors don’t talk to one another over patient care, they invariably end up arguing, usually in the chart. Pressure builds as the hurricane circles over the lives of patients and their caregivers. In a second storm surge, the conflict among doctors then leads to conflict between the “team” and patients/caregivers, as they attempt to brace against the gross violation of their right to informed consent.

The eyewall in the middle of our perfect storm is clearly medical error. Doctors don’t talk, they fight, and their failure to communicate causes medical error. As many as 250,000 people a year die as a consequence of medical error according to a recent study done at John Hopkins, making medical error the 3^rd leading cause of death in the US, well ahead of motor vehicle accidents.

In short, Moore missed an opportunity to track the perfect storm that exists in the delivery of health care at the hospital bedside in this country. Silos harden through a scheme for reimbursement that incentivizes component management and episodic intervention to create fragmentation and a lack of coordination, which leads to a failure to communicate, a gross violation of patient rights, conflict and, ultimately, to medical error.

At 250,000 deaths a year, this crisis clearly dwarfs the problems of wait times or the amenable mortality rate associated with a lack of access.

"SiCKO" Doesn't Go Far Enough!

The only possible authentic criticism of Michael Moore’s “SiCKO” is that the movie doesn’t go far enough from a patient rights perspective. We can’t blame Moore for this; he simply doesn’t have the requisite experience in hospital-based patient care. However, he could have used his insights into systemic problems to drill down to the hospital bedside in exposing another crisis patients/families face everyday in the delivery of their health care.

Moore makes a critical distinction between the ‘medical model’ and the ‘social model of medicine.’ Under a social model of medicine, a health care system rewards doctors based on the health of their patient populations. Every other industrialized nation uses a social model of medicine. By contrast, Moore notes the US health care system uses a ‘medical model.’ Under this regime, the system reimburses doctors based on the number of procedures they perform.

Moore uses this important distinction to underscore problems of access. When a health care system incentivizes doctors to keep a patient population healthy, patients in that population naturally have ready access. In the US, while doctors have the financial incentive to perform more procedures, insurance companies are motivated to limit the number to increase profit. Moore documents brilliantly how US citizens are caught in the middle of this epic struggle between doctors and insurance companies to make money.

Moore chooses to focus primarily on ‘denial of access’ as a consequence of the medical model. Of course, this is quite understandable given the severity of the problem. However, it would have been very easy for him to have also exposed another consequence of the ‘medical model.’

It is a crisis more deadly than the access problem. It also has a greater impact on more US citizens.