D. Hegde, MS, FRCS, Prof.; Dean

To the Editor,

This is my concise write-up as required by you. I worked in what looked like a perfect system in the United Kingdom in the 70s. Through the National Health Service, the state provided unlimited medical care to everyone. However, most of the 40 years since I graduated were spent in India, with the most imperfect system of all. It is the equivalent of a poorly funded American healthcare system without medical insurance. The state is still incapable of providing basic health to the poor. In recent days, there is an apparent availability of the most modern healthcare for the rich at a premium price – provided by entrepreneurs who have no concern for the poor. The high-tech hospitals, spread all over the country, in recent days, are beyond the reach of most Indians, and are considered expensive even by the rich. (Medical insurance is in its infancy, and we have not reached a stage in which insurance companies take on the brunt.) Paradoxically, modern treatment provided in India is considered “cheap” in the West, and there is a tendency to fly down to countries like India for treatment. While you are talking about an American healthcare system for Americans, we could be developing an Indian healthcare system for Americans or anyone else who finds it expensive to have treatment in their own country.

I am sure the Americans want to develop a hybrid system that is neither as “good” as the UK system nor as disorganized as the Indian model. The Indian “model,” with its mix of state and private enterprises, offers a more acceptable model for the United States. What the Indian model lacks is finance, manpower and organization, and a social commitment by medical personnel. If you inject these elements and take away corruption, you have your “dream” healthcare system.

It is always true that one has a better view from a distance, and I can visualize the problems and the possible solutions for the American healthcare system – better than a native American. With the resources you have, it is easy to solve your problems. Most of your problems stem from the reality of having a patient population that demands the very best and a medical profession that is willing to give it at a premium price. There should be a ceiling on what a patient can demand and what a doctor can offer within a prefixed financial limit. In India, charges are hiked when the insurance companies are billed. Since medical insurance has been in existence in the United States for a long time, and with the tendency to hike rates frequently, the medical bills are now astronomically high, and beyond the reach of anyone without insurance. Without medical insurance, consumer resistance would have kept the medical expenses within limits. The American doctors and hospitals would have been more responsible – realizing the fundamental fact that you cannot hurt your customer. A change in the mindset of the patient (society at large) and the doctor (healthcare system at large) is absolutely necessary for transformation into a better system. A president or a legislation cannot transform a society.

The West is blessed with a population that is well informed medically. (In my country, I take hours to convince my illiterate patients on disease and treatment, while it is a lot easier in the West. On the same account, my patient exposes himself to malpractice. With his ignorance, he can be convinced to undergo an unnecessary treatment that would be difficult in the West.) While today a patient in the United States is using his medical knowledge to see a doctor more often, he should be educated to use his knowledge to reduce doctor consultations, admissions, and drug intake – all of which statistically have a beneficial effect. The fact that most diseases get cured naturally and through body resistance has to be stressed. The notion that a “disease” requires “treatment” should be taken out of the patient's mind. Of course, they should also be educated to accept disease, suffering, and the inevitable death as part of human existence. If you get down to basics you will realize that the inability to grasp this reality is at the root of most medical and medicolegal problems. The patient should realize that “expensive” treatment is not necessarily the best. High-tech treatments should be similarly viewed, since we know that alternative medicine (which in my opinion is nontreatment) often offers a “cure” to even incurable diseases. In India a large section of the population is hooked on Ayurveda, an ancient form of treatment. This, mostly placebo treatment, is considered by believers to be as good as modern medicine in alleviating common ailments. While it would be foolish to have strong beliefs and spend on such “alternative medicine,” we definitely have a lesson to learn. The fact is that most human ailments get cured naturally, through immunity. The patient requires only symptomatic treatment. A visit to the doctor can be avoided, reducing the burden on healthcare.

Self-medication, a contentious issue during most of the 20th century, should be reexamined in the context of an educated and informed population with access to the Internet. To reduce the burden on the healthcare system and to reduce the overall cost, an informed patient should be encouraged to treat himself for common illnesses. This exercise will teach him some basics: Diseases take time to resolve and can recurb. All forms of treatment have their fair share of failures and complications. He is totally responsible for the treatment and cannot blame anyone else; this is vital. A doctor is at risk of litigation even after treating a minor sickness.

The most ideal healthcare system, from a patient's perspective, is a system in which a patient can hop into any hospital with any disease and get himself treated, free. Such a system existed during the 60s and 70s in the United Kingdom. Most patients had heavy files, having undergone series of treatments and operations, merely because they were free. I remember how they enjoyed a system that gave them unlimited access and a carefree pleasurable time. They were even served good food. It is no surprise that it proved to be too expensive for the state, and Margaret Thatcher effectively slimmed it down. What exists today in the United Kingdom is a run-down system. It is interesting that the US government finds it impossible to implement the equivalent of the present National Health Service. Expense is not the only issue. Americans are not used to free medical care right now. Expectations will keep rising once you offer it, in any form. Adaptation is the greatest of human weaknesses, and no planner would like to adapt a whole population to free medical care. It is important that such services cannot be withdrawn afterward for any reason. A total withdrawal of National Health Service is unimaginable in the United Kingdom. Finally, the rising cost of medical care makes it difficult for the state to plan a system.

The menace of litigation in the United States has a bearing on healthcare and cost. It is directly related to a booming medical economy with insurance companies, hospitals, and doctors making huge profits. The patient, who is the only loser here, wants to profit from this unfair system – with the help of lawyers – creating the menace that is America today, for one section of doctors and hospitals. Absence of cordial relationship between doctor and patient is at the root of the problem. A doctor is able to charge indiscriminately because of the insurance company, since the payment is done by the insurance company. The patient is not obliged to the doctor, for the same reason. If anything, he may be sympathetic to the insurance company. Obviously, combating the increase in medical litigation requires many basic changes and not mere legislation.

I am sure that insurance companies do very well even today. The patient has the disease and he suffers. The doctor and the hospital get paid for a service. But the insurance companies make a profit by filling out some forms, and “covering” a “risk.” So far, the insurance companies have had a jolly good time and have enjoyed a booming medical economy. It should be understood that they are responsible for the spiraling cost of medical care. Doctors and hospitals invariably charge more when insurance companies do the paying. In the United States, where the system has been working for a long time, the doctors and hospitals have priced themselves beyond the reach of an individual. The astronomic bills that insurance companies pay are sickening. The fact that they still make large profits, by collecting heavy premiums, shows that this unfair, shady system has found a means of survival.

For centuries, man has defined “greed” as the sinister force that destroys everything. It is this force that is annihilitating this noble profession. A word has to be said about the greed of the patient for “better” medical treatment and a certain immortality, if ever possible.

Lawrence Noriega and Donna Bearden

To the Editor,

Your analysis of the state of the American healthcare “system” (your quotation marks) rightly questions just how systematic our healthcare is in form and function.[1] As it is, American healthcare gives the system a bad name. What with all healthcare costs in effort, time, and, above all, money, it surely seems reasonable that we should have something better to show for the investment. Whether as consumers or providers, there should be evidence that we're getting what we pay for more than what we get – better health, truly effective healthcare systems, and evidence that it all works according to planning and expectation. We're speaking of quality. If not quality then, we should have more assurance than we do that our healthcare is, at a minimum, safe. Regulators, accrediting bodies, internal and external review, disclosure, privacy – that they're all there should ensure safe healthcare. That litigation and third-party payers profit from this lack of quality and assurance of safety in healthcare shouldn't be mistaken for the cause: They're not in charge.

The problem with our enormous and enormously complex healthcare system is that there is no organization and coordination of effort, but above all, there is no one in charge.[2]

Healthcare has givers and takers (call them consumers and providers) but lacks any consensus on just what it is we provide or consume. Even more curious is that as the principal players in American healthcare, consumers and providers have so little choice or say in healthcare delivery or care. We'd like to know that there is some kind of definable service product; we'd like to have some measurable standard by which we could assess efficacy in our healthcare. But lacking authority, recognition, or even understanding of our healthcare, we are left at the mercy of anonymous others. These others assure us, like the plumber, Cosmo Castorini, in Moonstruck, “Copper. It costs money because it saves money. Healthcare? It's the same thing, Loretta.”

The solution is to involve the consumer, not the government, in healthcare choices and decision making.[3] The best way to educate anyone is to make them responsible for knowledge of what it is they are paying for and what they are getting. Automobile insurance is mandatory; why shouldn't the same be true for healthcare coverage?[4] No one would suggest or support that automobile insurance and liability coverage would be standard or one-size-fits-all for a moment. Our age and experience – call it “medical history” – should be determinants of our needs at any stage in our lives. This health record, whether paper or paperless (see the electronic medical record or EMR), should be our property as well as responsibility. Further, like auto insurance, healthcare coverage should exist independent of employment. We care for what affects us personally.

Healthcare savings accounts can continue to be funded by payroll deductions, as well as Social Security and Medicare (for catastrophic care). The individual accounts remain the property as well as the responsibility of the taxpayer. What changes is how we exercise our judgment and choice for the best value, and thus force healthcare into organizing itself to provide quality healthcare and a recognizable system after all. It is high time for this discussion to take place.

Spinnaker Health Partners provides a fuller exploration of the issue, challenges, and approach.