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Basics

There are several things we've got to understand about health care:
 

Health care is always a science of probabilities.

When you take an aspirin or any medicine, you are in fact weighing the probabilies of the benefits vs. the harms and considering the cost.  You are deciding:

1. You have a headache (it hurts 8 on a scale of 1-10).
2. You want to feel better (you would accept 2 on a scale of 1-10).
3. Aspirin is likely to make you feel better  (I am making up all these numbers, but let's say that in all patients in research studies, it reduced the headache by 80%, 90% of the time.  Let's say you found that for you, it reduces your headaches almost completely (90%) almost all of the time (98%)).
4.Aspirin is not likely to harm you (children with flu have died from Reyes syndrome after taking aspirin; aspirin also causes stomach on intestinal discomfort and bleeding, but let's say for you it only hurts your stomach mildly when empty, say 2% of the time).
5.The cost of the aspirin is worth it's benefits (the high chance that the aspirin will get rid of your headache is worth the small price for each pill).
6. You can afford the aspirin (buying the aspirin will not keep you from buying the food or paying the rent).

Choices

What if the chances the aspirin would end your headache were only 50/50, and the chances of vomiting as a result of taking the aspirin were 33%, and the chances of a heart attack from it were 3%.  What if one aspirin cost $100?  How would these factors change your decision to take the aspirin?  How bad is your headache?  If your headache is practically killing you then you might put up with more costs or side effects than if the headache were minor.  What if there is another brand of aspirin that has better treatment and fewer side effects (60% chance of improvement in headache, only 20% chance of vomiting, 1% chance of heart attack), but it costs twice as much ($200)?  What if you need 2 pills/day for two days, which would cost $400, but paying for it would mean you couldn't pay the electric bill that month?  These are the variables that all nurses and doctors address everytime they care or recommend any care, medicine or treatment for a patient. The patient should actually be making these decisions, but generally the physician, with his or her greater knowledge, is recommending what is supposed to be best for the patient.

Tests

Every medical "diagnostic" test you get has a certain chance of being wrong or misinterpreted.  In common tests this chance can be low.  Say you want to get a test to see if you have a gene that might cause you to get breast cancer.  (Keep in mind that genes don't cause the diseases, they only might increase your risk of getting them by varying degrees.) There is great information on this type of test here on the National Cancer Institute site. Every test has certain probabilities associated with it that you and the doctors need to know about before deciding whether you want it. Some factors include: Most tests have known probabilities of each of the above outcomes, in addition to other mitigating factors, which you and your Doctor should discuss before making any decisions about whether to have a test or not.

Insurance

Take the street or block you live on and pretend it is a self-contained insurance company.  Each household is putting money into a health fund that will cover all the medical expenses for the whole block.  Some may contribute more, in an agreement to get more care. (Pretend one household doesn't put any money in because they don't think they will get sick and they say they can't afford the monthly expense.)  If you were the doctor on your block, which "aspirin" discussed above would you recommend for your patients?  Remember, the more expensive aspirin works a little bit better, but costs $100 more per tablet and you have limited funds to work with for the year.  If your aspirin doesn't work, people may get worse and/or come back and demand some more expensive prescription treatment that will make your costs go up.  But $100 extra for each aspirin might mean you can't afford to buy enough band-aids for the year.  You could get cheaper band-aids, but they might fall off and need to be replaced more often, increasing costs.  If someone needs a major operation (for example a bone marrow transplant; once again I'm making up these numbers), that only has a 50% chance of keeping them alive for a maximum of 5 years, but costs two million dollars, would you give them the operation?  If they complain that you aren't treating them, what would you say?  Add into this that you need to hire good personnel, provide training and development to keep them, buy new equipment that will provide better, cheaper care, do research to find the newest, best treatments, and decide what to charge everyone on the block next year.  If it's too much, they may go elsewhere or decide they can't afford it.  But if someone is dying or gets into a bad accident, someone, somewhere will have to treat them, even if they haven't contributed any money.

What if someone demands to have the bone marrow transplant, but you say no, because if you spend all that money, you know that other people will die over the next year or more for lack of proper facilities, personnel, equipment, medicine, experimental treatments or care that you could have provided with that two million dollars?  And what if they sue you and add a bunch of court costs to your budget?

Doctor MO

This is what Doctors and insurance companies alike have to face.  A Doctor can decide that a patient needs a certain treatment, but any money spent on one patient means it can't be spent on others.  An HMO that is run exclusively by doctors still needs to set priorities and address the same issues as the HMO.   Doctors also don't always agree on the best course of treatment.  Medical schools don't always teach the same things, and doctors might not always keep up with the latest advances. In order to come to an agreement and standardize care within an organization, Doctors often create guidelines for treatment that are expected to be followed by all the Doctors in an organization. Specialty organizations that publicize diseases such as Diabetes and Cancer often issue the same type of guidelines developed by physicians and research experts.

For Profit or Not

In a for-profit Health Care Organization (HCO), some of the money raised from dues payments has to go to shareholders as profits.  In a completely non-profit HCO all the money goes directly back into care for patients.  However, the legal definition of "non-profit" means that you can have an organization divided into separate legal entities, such as a Medical Group of Doctors combined with a Health Plan for insurance, where as long as a certain number of those legal entities are non-profit, the organization as a whole can qualify as non-profit, while one of the entities, such as the Doctors in the Medical Group, could still make profits.
 

Know Our Rights

The bottom line is we have the right to know what our options are and it is up to us to know what choices we have and to decide what treatment is best for us.
 


Links

American Diabetes Association
American Association of Diabetes Educators
American Medical Association
Centers For Disease Control and Prevention (CDC)
Diabetes Life Network A list of various Diabetes organizations
ehealthinsurance.com Get quotes from various insurance companies
Food and Drug Administration (FDA)
Kaiser Permanente
National Cancer Institute
National Center For Complementary and 
Alternative Medicine (at NIH)
National Institutes of Health

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©MM Tom Minkler
Last updated 11/23/00
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