Here's To Our Health
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
6. You can afford the aspirin (buying the aspirin will not keep you
from buying the food or paying the rent).
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.
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
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.
Many other health factors are involved; you can have the gene and never
get the disease, or you can not have the gene and still get the disease.
Even before taking the test, there is already a certain chance you will
or won't get a disease based on factors such as whether other people in
your family have it, your weight, habits, lifestyle diet, and possibly
your ethnic background.
If your risk is already low, for example no-one in your family has ever
had cancer and you have never smoked and you have a healty lifestyle, the
chances that the test will show anything might be so low that it isn't
worth even going through the test, let alone paying for it. This
is why some test are only recommended for high risk patients.
Your risk could already be so high that knowing you have the gene won't
make your risk any higher, so the test would basically be useless.
If the test says you have the gene, there is a certain chance the results
are wrong. In this case you might get stressed or take drastic medical
action for no reason, which is one possible bad outcome of the test.
If the test says you don't have the gene, there is a certain chance it
is also wrong. In this case, the test can give you a false sense of security,
which is another possible bad outcome of the test.
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?
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.
©MM Tom Minkler
Last updated 11/23/00
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