Health Care Dysfunction in a Single Payer System

Nicholas D Kristof in his Op-Ed Column in the New York Times addresses the dysfunction of the U.S. health care system by addressing the issue of lack of coordination within the system, FROM THE PATIENT's PERSPECTIVE!!!

http://www.nytimes.com/2010/02/21/opinion/21kristof.html?th&emc=th

This is an amusing piece that also makes clear what is the origin of some of the system's dysfunctionality and therefore much of the out-of-control cost escalation. His reference point is to use the health delivery system business model to offer editorial commentary.

He alludes to a Jonathan Rauch piece in the National Journal magazine wherein the provision of air travel is offered under the health system business model.

This is likewise a clear and amusing piece.

http://www.nationaljournal.com/njmagazine/print_friendly.php?ID=st_20090926_4826

Now, we smug single-payer (By the way, we may not be as single payer as we like to think.) Canadians might be tempted to think, "Well, that's the U.S. health care system. That's not us."

I think there are clear comparisons that can be made to provide insight on some of the difficulty we face with our own system.

What we see is a U.S. system filled with independent players, each with its own mandate and mission and governance model. Coordination among these disparate players without explicitly focusing around a single common goal and perspective is impossible.

I had an interesting personal experience some time ago with helping a loved one go through Calgary's at that time regional health system. The chronology worked like this - 911 call, ems with paramedics took over, discharge from ems to admission to emergency services at an acute care hospital specializing in such cases, determination that hospital was not the ideal one after all, discharge to admission to ems patient transportation services to another hospital, discharge from ems to admission to emergency services at the second hospital, discharge from emergency services to admission to an acute care ward, discharge from acute care to admission to rehabilitation in a third hospital, discharge from that third hospital to admission ems patient transportation to discharge from ems to admission to long term care facility.

Within each facility there was control of custody among departments, moving from the care ward to diagnostic imaging or to other diagnostic services, including change of custody from all of acute care, rehabilitation and long term care to diagnostic and other service centres, often within the same building, but change of custody nonetheless.

Every change of custody required paperwork, that is hard copy paperwork, to accompany the patient. The crazy repetition of admission and discharge paperwork that Mr. Rauch speaks of, had to happen all the time. That kind of constant repetition is, as he points out, error prone. What saves errors from happening more often is the alertness of the practitioners involved. That can be compromised when such activities occur over a shift change and the same person is not coordinating activity throughout the process.

Because of these examples and the likes of arguments presented by Kristof and Rauch, the idea of an Alberta Superboard seems sensible. Alberta then has one coordinating body and that should help smooth the custody control procedures among other things.

But again, this does not seem to be done from the patient's perspective. The controls are made from the provider's perspective with the Superboard acting unilaterally. We then have opportunities for dysfunction at every place where any service, public or private, meets the Superboard. The Superboard then takes on the role of the patient and advocates for itself as a patient would be expected to advocate for her or him self.

But the Superboard is not the patient. The Superboard is itself a provider to be added to the mix of providers. It is simply a single bureaucracy that, from the patient's perspective probably makes no difference at all. The patient would previously have dealt with a regional or hospital board bureaucracy, only one bureaucracy at a time per patient.

In the absence of a standardized custody control process to regulate the changes of custody and the coordination of all activities around the patient's needs, we are going to have ineffectiveness and inefficiency, of which ineffectiveness is the most inefficient as we have expended resources to no good effect.

It seems we have developed a single-payer system that emulates as much as possible non-single payer systems. Therein, I believe, lies the lion's share of our health care system's dysfunctionality (ineffectiveness) and out-of-control cost escalation (inefficiency).

I believe that until we organize our health system around meeting the patient's needs from the patient's perspective, we will never get this thing under control and be only somewhat better off than those systems with multiple payers. In other words, we will spiral out of control somewhat more slowly than they do.

It's interesting that when we apply democratic principles to broad societal issues such as health care, we are likely to find the solutions we must have to assure sustainability. We have to decide if access to health care is part of access to security of the person as a right of every person in our society. Once we have decided that, then we have to realize that objective by building a system around patient need instead of supplier capacity.

Mike