As I woke up this morning, I realized one of the reasons why the Obama health plan — if something entirely watered down doesn’t replace a public plan and other measures — won’t be sustainable. Because of the way it has been formulated — from the tippy top of a very large elite Titanic like iceberg, the kind that brought the unsinkable ship down — it is guaranteed not to address any of the cost escalators that keep health care costs snowballing in this country. No I don’t mean only insurance company costs, marketing, CEO salaries, and all those other huge cost escalators that the plan doesn’t even approach. What I mean are the cost escalators that ratchet up our health care bill every day at the ground level of where health care is delivered. The problem with the Obama plan is that it has been constructed and replicates the very problems that have created the most inefficient health care system in the industrialized world. To create his plan, Obama focuses on elite corporate and medical actors — he talks about and with the execs of big Pharma, hospital CEOs and the American Hospital Associations and doctors. He never mentions nurses or anyone who actually delivers health care at the ground level. He has talked to the American Nurses Association ( a group that largely represents nursing management, ie hospital management). By failing to do that — talk to the people who deliver the care– he ignores one of the most critical patient safety and efficiency measures that we have come to value today — teamwork. The Obama plan is the anti-thesis of teamwork. It’s a plan designed at the top, for the top,and by the top. The problem is that health care costs don’t only escalate at the top — which they definitely do. They also escalate at the bottom — because there is not teamwork at the bottom of the health care edifice where care is actually delivered.
Take end of life care — which we know is one of the highest ticket items in all of the health care delivery system. We know the depressing figures that we spend more on people during the last days of their life than on anything else. Why? Of course, that’s because that’s when people are the sickest. But it’s also because there is no teamwork at the end of a patient’s life when they are hospitalized. Physicians drag out their biggest guns and with all good intentions aim them at the patient. Nurses are often concerned about why patients are being given futile, toxic, expensive care. Hospice could be involved but usually isn’t, until two or three days before a patient is about to die. Docs are supposed to have discussions about code status (i.e DNR) as soon as a patient enters a hospital, but most don’t do it because they find the conversation uncomfortable, so families can’t plan intelligently and patients may not even understand how dire their situation is. Where in the Obama plan do we see any evidence that anyone understands this problem? Where are nurses in the genesis of this plan? Or any other category of health care worker or professional other than docs? What do you think about this? Let me know!