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Who is ruining the healthcare system?


What is our social responsibility to fix this mess called healthcare, get patients what they need and not break the bank in so doing?

Editor’s Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Jeffrey Gene Kaplan, MD, MS, a senior pediatrician and retired physician executive. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.


Jeffrey Gene Kaplan, MD, MSI recently had a medical experience that is telling of the bureaucratic interference the average U.S. patient has to contend with.

A few months ago, my pulmonologist who sees me for obstructive sleep apnea (OSA) said I was doing great and I didn’t need to come back for a year. I did, however, need a different full-facial mask for my C-PAP machine. The durable medical equipment (DME) company who supplies the mask demurred. They stipulated that I had to return to the pulmonologist. Medicare rules.

Reexamining the 80-hour medical resident workweek

It is no exaggeration to say that I spent many hours and made over 20 phone calls to check on the availability and coverage of this item.  In addition, I had to start the entire DME authorization process over because I switched from Medicare Complete HMO to regular Medicare with Supplemental coverage.

What a waste of time! In healthcare information technology jargon, the above completely misses the objective of interoperability as it asks me, the patient and the specialist’s staff to ‘jump through hoops’ and do a lot of rework and duplication.

The DME vendor outsources prior authorizations to the Philippines. Needless to say, we had a difficult, often unintelligible conversation, but that’s not the point of this diatribe-my equipment was in good repair. Only the mask wasn’t doing its job. It didn’t fit right. It kept sliding into my eye.

MOC, recertifications are ‘cancers’ doctors should rally against

Worse, the OSA was not being managed and that can mean preventable hypoxic brain injury.

This DME company calls me on a weekly basis, sometimes more often, asking the same question-“Do you need new equipment?” To add variety, they may add that I have let my insurance lapse!?

Are female physicians leaving money on the (operating room) table?

Regardless, the DME vendor, referencing Medicare’s “rules” (I was a medical director for over three decades-give me a break) went on to insist that I also contact the pulmonologist about the mask’s chinstrap; they wanted a letter confirming the medical necessity of that particular, item! 

Who Is ruining healthcare? 

Are these bureaucratic hurdles making it difficult to get healthcare?  What can be done to simplify things?  Is there good communication between all the players (including patients, healthcare facilities, administration and practitioner)?  Does ‘one hand know what the other is doing’?  Should we tolerate fractionalization of care or a silo mentality-the separation of the physical, mental and social aspects of care?

What is our social responsibility to fix this mess, get patients what they need and not break the bank in so doing? A professor of biology gives us a clue: herders, not out of greed, but out of practical necessity, graze more cattle than the finite, common land can support, ruining it for everyone1.

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This exploitation is analogous to what happens when incentives are not aligned in healthcare: payers, practitioners and patients at the commons are doing what they feel they must without accountability for equity in access, cost-effectiveness, benefit or cost-utility.

I mentioned having a more comprehensive way of doing medical business-making use of the bio-psycho-social model of healthcare, which gives a more integrated view of things; it can be a ‘tour de force.’

According to Steve Abell, vice president of Strategic Services for Arkansas Blue Cross and Blue Shield, “until the payer, medical provider and behavioral health provider truly collaborate -becoming a team, rather than working in isolation - we won't achieve the Triple Aim of improving patient experience and the health of populations, and reducing costs2.”

Why are we wasting money on healthcare with poor outcomes?

Thinking in terms of the Donabedian construct or typology-structure + process + outcome, we must provide appropriate healthcare, comprehensively and collaboratively with excellent, accessible communication; it’s a socio-economic necessity and it's our collective responsibility.

Does experience change our genes and thereby our vulnerability to ill health and disease?

On April 23, 2014, Dr. James Jarvis lectured at the Westchester Medical Center, Maria Fareri Children's Hospital on the topic of "Health Status of Native American Children; Why Every Pediatrician Should Care."

In essence, he spoke about social responsibility and how biology, ecology and the environment factor into our health status and perhaps epigenetics.

Referencing the work of Dr. Vincent Felitti, Dr. Jarvis said, all too often in that population, we can find adverse childhood experiences (ACEs as the CDC calls them) as well as health disparities, high rates of depression, posttraumatic stress, and resultant substance abuse.


Epigenetic transformations

These ACEs have been linked to changes in genes that regulate the stress response, possibly underlying the risk for certain psychiatric tendencies or disorders.  That is, health disparities and ACEs seem to impact physical and psychological health, long term. In addition, stress associated with discrimination and trauma affects well being.

The theory is that ACEs somehow result in “methylation differences in genes that regulate the stress response and that these changes may contribute to an increased vulnerability for developing psychiatric disorders3.”

Young doctors are jumping ship to non-clinical roles

The benefit-cost ratios for interventional programs with disadvantaged children are $5.70 for every dollar spent on a child by 27 years of age, and $8.70 when projected to later in life. There are cost savings in crime reduction, as well.

Upstream costs of social/environmental health determinants

Note: there is a disparity between funding acute medical care and publically doing something about prevention, i.e., the “upstream” social and/or environmental determinants of health. Indeed, by some estimates, “more than 95% of the trillion dollars spent on health care in the United States each year funds direct medical services, even though 60% of preventable deaths are rooted in modifiable behaviors and exposures that occur in the community4.”

Although in the quote Professor Hardin referenced the “tragedy of the commons” he was speaking to issues of our fragile planet, his message is apropos as we debate health care reform. We should become the “keeper of the commons.”

The business of medicine is medical business; it is not insurance business; it is not a shell game by them. It is a right, not a privilege. 



1. Prof. Garrett Hardin (U. of Cal., Santa Barbara): "The Tragedy of the Commons." Science 1968;162:1243-1248. [Free Full Text]

2. Jan. 26, 2016 PRNewswire-USNewswire -- "An innovative, 24-month pilot program aimed at integrating behavioral health and primary care is underway at an Arkansas primary care clinic."

SOURCE: New Directions Behavioral Health

3. Teresa N. BrockieMorgan Heinzelmann, and Jessica Gill"A Framework to Examine the Role of Epigenetics in Health Disparities among Native Americans." Nursing Research and Practice 2013, article ID 410395. 9 pages.

[To download a copy of the ACE survey, see "Finding Your ACE Score."]

 4. McGinnis JM, Williams-Russo P, Knickman JR. “The case for more active policy attention to health promotion.” Health Affairs (Millwood) 2002;21:78-93




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