The Code 5 Service

 I read two articles in the New York Times this week about hospital groups that appear to have put profits over patients even though they are nonprofit entities. One is Providence and the other is Bon Secours Mercy Health. I have long been a proponent for universal health care as opposed to the profit-driven fragmented “system” we have in the United States. What is perhaps surprising is that the two hospital groups the Times explored are nonprofits. The quest for dollars by the medical industry in the U.S. knows no genuine boundaries.

A table and two graphs for context. The source is World Health Systems Facts. First a table comparing developed countries national health systems:

Lots of numbers but the United States has the highest total health spending as % of GDP, among other data. How about healthcare spending per capita? 

Well, the United States spends more per capita than the other developed nations in this comparison sample. But what counts is outcomes, right? Check out this graph:

If you go back to the table, our overall ranking for health from a population perspective is low and our infant mortality is the highest of this cohort. 

The article about Bons Secours gets to the heart of a major factor in poor outcomes. We have large subpopulations in the U.S., e.g. Blacks, whose access to reasonable medical care is poor. We have known for a very long time that the social determinants of health are the largest contributing factors to a person’s health, overweighting such things as genetic makeup. This quote is from the National Academy of Medicine:

“There is growing evidence and professional wisdom to suggest that health disparities do not exist in isolation, but are part of a reciprocal and complex web of problems associated with inequality and inequity in education, housing, and employment (LaVeist and Isaac, 2013; Schultz and Mullings, 2006; Weber, 2010; Williams and Mohammed, 2013). These disparities affect the unborn child through social-emotional challenges such as maternal stress and diagnosed and undiagnosed medical problems, including higher prevalence of gestational and preexisting diabetes in some pregnant populations. In other cases, they are observable at birth, particularly pronounced when prenatal care is unavailable, when the importance of care is not understood fully, and when young children are not exposed to the cognitive and social-emotional stimulation needed to thrive. These and other problems are manifested in parental stress, for example, in mother-headed and two-parent, low-income, and immigrant households alike. Parent and family adversity may reduce the number and quality of resources available and life experiences for children and families in the early years and throughout the life course. Such adversity is exacerbated by structural barriers that limit employment opportunities, increase housing instability, and contribute to homelessness, and that constrain efforts by families to effect positive change.”

As usual, this got me thinking about my career in medicine. I did my internal medicine residency at the Reading Hospital in my hometown of Reading, PA from 1974 to 1977. I admit to having the insouciance of youth. Reading had its share of people who were uninsured for a variety of reasons. The name for the service that provided that care, both in-hospital and outpatient, was the Code 5 Service. The attending physicians rotated monthly to supervise the residents who actually provided the bulk of the hands-on care to these patients. Over three years, I spent 6 of them directly assigned to the Code 5 Service as well as many nights, weekends, and holidays on call for their needs. My understanding was that the hospital wrote off the costs of providing this service because medicine should never be denied because an ill person or their family cannot afford it. The mid-70s are a comparative Dark Age to current times but medicine is an eternal calling. From the New York Times articles, I sadly divine that the bean-counters have won out over the physicians. It certainly never crossed my mind as a resident that I would ask these patients for compensation.

It doesn’t have to be this way. About a year ago we had a retired professor from Cal State LA who now works for a progressive think tank here in the Los Angeles area. He told an interesting story about his encounter with German medicine a few years before. He was at a working conference in Germany for several weeks over the winter holidays. On New Year’s Eve, he was invited to a party. He cracked a tooth at the party and was in pain. He told his host he needed to leave. The host asked why and then announced his tooth needed to be attended to – then and there. To the professor’s amazement, the host called a dentist and he was then taken as the New Year arrived to the dentist’s office, where he had the tooth fixed. He was astounded – this was New Year’s Eve, after all. As he went to exit, he asked the dentist to please bill him as he had no dental insurance or cash on hand. The dentist was amazed – he said, there is no bill. We take care of everyone here and the government will reimburse me. 

Yes, it doesn’t have to be this way. Universal health care is everywhere except in the United States. Maybe we will get smart some day and fix this problem. Maybe.