The Anti-Model for Public Care
12-27-2010 16:27:00

     It seems strange to find a font of wisdom in a local real estate agent. But that is what happened when I went down to Carlsbad last week.
     My neighbors -- in a condo complex -- had decided to put up fluorescent flood lights to shine on their cars. The lights wrecked one of the beauties of our neighborhood -- its velvet darkness. My street, running a block and a half to the ocean, has no street lights.
     To be down there at night is a huge change from Los Angeles. A multitude of birds, small and large, chirp through the day, the smell of the ocean comes in on the breeze and, as night descends, the stars shine like jewels in a black sky.
     Angry about the floodlights, I called Pat, the agent who sold me the place, an Irishman, a former teacher and, as I found out, the son of a longstanding local surgeon.
     Pat knew a local lawyer, old guy, who then went around and checked out the lights.
     The lawyer gave me simple advice. He said I could pay him or I could pay an electrician to put in low lights that satisfied the neighbors but did not bleed into the neighborhood. For roughly the same amount of money.
     Seemed like a sensible deal. Good lawyer. Old school. No charge.
     So last week, I drove down to meet Pat and Luke the electrician along with the head of the condo association, to work out a plan. We quickly came to agreement on three post lights, and then Pat and I stood around talking well into the evening.
     He had a pretty well grounded theory about a lot of things: the fundamental need for credit and an efficient government in order for an economy to function, based on his experience as an exchange student in Mexico; the reason why the phone company should not be able to claim that it had paid for the lines, because construction costs had been a line item on his phone bill.
     And he suggested a legal line to follow in our battles to preserve open access to court records in the electronic age, by noting that title companies had fought a similar battle and won.
      But most important to me, because my father died at the hands of Kaiser Healthcare, he explained why Kaiser has such a strong incentive to shortchange the people in its care.
     Pat's father is a well-known plastic surgeon with his own practice in Carlsbad, who has kept his rates low, lectures at a medical school in San Diego, and serves on the board of the local public hospital.
     After one of his lectures, his dad asked his students how many were going into private practice. Nary a hand was raised. And what about managed care? Nearly every hand went up.
     Thus it is rapidly becoming impossible to find a doctor outside of the managed care system, or, in other words, outside the insurance companies. And that is a bad, bad place for healthcare to be in our nation.
     After his father had prescribed a drug to a patient, Pat recalled, he received a call from a young bureaucrat at the insurance company, saying a cheaper drug was being substituted for the one prescribed.
     Pat recalled his father's angry response that the substituted drug was quite different and had seriously different effects, and his father's wonder that a person who sounded like an 18-year-old and was without medical training could be telling doctors how to treat their patients.
     In the case of Kaiser, in particular, said Pat, the company pays a set amount for a group of patients and if the doctor stays under the set amount, he makes more money. If he goes over, he loses substantial bonus pay. The system is deeply incentivized to push down the level of care.
     I knew what I had seen with my dad: constant under-diagnosis, usually by misdiagnosing a major ailment as a minor physical problem. Like saying my dad had a sprained ankle when he had a blood clot that resulted in a pulmonary embolism that could easily have killed him, and then by saying he had a groin sprain when he in fact had a cancer tumor, that did the trick.
     They would also delay tests, for months, substitute less effective but cheaper drugs, avoid preventive surgery, push patients out of the hospital with false statements, make it hard to contact the doctors directly, and then pull back nurses after they had been promised.
     I had always wondered how it was that seemingly well-intentioned doctors and nurses could do these things. I knew there had to be an incentive, a hand from the insurance company, pushing the people.
     Pat had the answer. It was all about the money.