Who Built This Leaky Ship?

People who don’t use it, that’s who.

On a recent shift out in the great wide open, I saw a patient who I see frequently in this location. He is a chronically ill man in his 70s with chronic kidney disease and multiple sclerosis (MS).

His MS took his ability to walk, so he is wheelchair bound. On top of this, he has bilateral indwelling nephrostomy tubes which frequently are the source of infection.

He should be receiving dialysis, but he refuses to move to a city where it is an option. Dying in his hometown is preferable to moving to the City to receive dialysis.

He lives in the nursing home (NH), which is attached to the hospital and emergency department. Whenever he becomes febrile, the nurses in the nursing home send him to the ED where we culture his urine, start him on antibiotics and either send him back to the nursing home with follow up or admit him to the hospital.

When he is through with his course of antibiotics, he often goes to the City as an outpatient and has his nephrostomy tubes exchanged. This buys him about 2-4 weeks before his next infection sets in.

It appears we are purposely trying to breed some sort of resistant bacteria in his urine by this rodeo. All of his acute care is generally done by the ED physicians (locums), whereas his chronic care is managed by his regular physician.

Despite the chronic, repetitive nature of his ailments, both teams of physicians treat each infection as isolated, acute events. This is sadly the standard in American Healthcare.

Welcome to the Norm

All over America, we treat patients for their acute issues and then send them on their way. Rarely do we address the underlying issues at play, which have led to the causes of the acute issues.

Even in hospitals, most acute issues we treat are exacerbations of chronic disease: COPD exacerbations, CHF, MI, GI bleeds from chronic anticoagulation or NSAID use, infections related Diabetes or the above chronic diseases. It is the rare patient in the hospital who has a new onset, isolated, acute problem.

Even in medical school, our cognitive training focuses on isolated cases of acute illness because it is difficult to teach concepts of diagnosis and treatment in the milieu of the chronically ill. So, our brains become accustomed to looking for the single, acute issue.

Search satisfaction is a strong bias.

Moreover, the way the systems reimburses us emphasizes episodic, not longitudinal care. This method of care delivery works very well for acute, isolated incidents of illness in otherwise healthy people. Sadly, these people are exceedingly rare.

I posed this question to an ED nurse friend recently and he guessed otherwise healthy, financially secure people made up about 2% of the patient’s he sees. That is in an acute care setting.

So, who came up with this crazy system?

“We build a broken system and then ask people to try to fit into the system instead of tailoring a system around people’s actual needs.” – David Brooks

The roots of our system date back to isolated private health insurance companies. Those companies inherently catered to otherwise healthy individuals with money (those people make insurance companies money, after-all).

However, I think the root of the problem is deeper. Generally healthy and wealthy people designed our system. Chronically-ill 80-year olds are not in government and insurance boardrooms.

Therefore, episodic acute care makes up the bulk of the decision makers’ personal healthcare experience. They don’t know the professional patient, or if they do, they assume he/she is an abnormality.

Indeed, in the broader population, the hospital-dependent, chronically ill are a minority. However, at least in my practice, I spend more than half of my time with people who would fit this description.

So, we have a system designed for the people who aren’t using it, or use it only rarely.

Meanwhile, the people who depend on the system for their continued survival have to make do with a system which treats their care inappropriately. It rewards treating their problems, rather than managing their total package of care.

Is there hope?

In the short term, I don’t see much cause for hope. Too many people are making an absurd amount of money off the inappropriate care of the chronically-ill. And if I am honest, I have to include myself in that group. Effort vs. money, acute care is easier because the system incentivizes it.

I tried to do global care as a primary care doc, but the model of the outpatient setting is one doctor and one-two nurses/medical assistants. You cannot provide the necessary basket of services and harangue all the help you need with such an anemic team.

The system is trying to move more care to the outpatient setting because it is cheaper. However, we have ignored and underfunded the primary care clinic for decades.

As a care delivery model, it is severely atrophied. So, the system is moving sicker and sicker people to the outpatient setting without first strengthening it. As such, people will burn out and turn over and the attempt will fail.

Until the system incentivizes keeping people healthy over treating the sick, any changes will only be a veneer.

6 thoughts on “Who Built This Leaky Ship?”

    1. For all the money and thought that goes into healthcare policy and funding, I think 80% is that simple. We are getting what we are rewarding and everyone is gnashing their teeth and wringing their hands about it when it is just that simple. But the simplest solutions are often the hardest, as they often require the greatest sacrifice.

  1. As always, great topics and great discussions by you. Thank you for sharing. If I can’t be part of the solution, I often feel that I’m part of the problem. I’ve made enough money off of the backs of the poor and it’s time for me step out and do something else.

    1. Thanks for reading. You actually nicely foreshadowed a topic I’ve been thinking about – which is the business of suffering. In a lot of places I work the main non-farm, non-tourism employers are the hospital/clinic/Nursing Home and a prison/jail. I am starting to feel they are not that far apart.

      1. Maintaining poverty is a huge business strategy for healthcare and the correctional industry. A sample article highlights how Kaiser Permanente is building its own low-income housing within reach of their healthcare facilities in order to secure medicaid and medicare revenue streams in the future.

        Housing isn’t believed to be a solution to homelessness and yet such community outreach moves are structured under these pretences.

        At what point are we as physicians accomplices to this paradigm shift? 99% of us are well-intentioned but I hear the road to hell is paved with that.


        1. That is very interesting. I think as long as both are structured as widget providing, per service, for-profit industries, the transfer of wealth from poor/middle class taxpayers to the modern aristocracy will continue. Our continued and increasing presence in the for-profit industry of healthcare certainly adds to our guilt as a profession. It is harder to deduce how much of that guilt we each carry. Lots of industries are doing the same things, should we be any different? On the hand, I think a lot of us feel that we SHOULD be different by the nature of our profession. No win.

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