What Kind Of Patient Are You?

For most of you out there, I will never meet you. You will live long, prosperous, healthy lives. You will raise families, remain gainfully employed, go to church, give back to the community and generally live. You will play by the rules. You will have your ups and downs and life will go on. What I describe in my blog and experience in my life as a hospitalist represents a very skewed representation of America. I am often lambasted by others for being unHappy and distressed with my situation. That couldn't be farther from he truth. What I try and present to you on the Happy Hospitalist is the gross abuse running rampant in our health care system. The abuse, I believe, entirely the result of third party rules and regulations, has become intolerable for many health care providers. Enough to make many quit. The abuse running rampant by the few has also had the effect of driving up prices for everyone looking for health care security.

So I ask the question, what type of patient are you? Are you contributing to the demise of the third party model so ingrained in our current culture. A third party model whose cost structure has risen exponentially due to rapidly rising costs on the few. A third party model which must pass on to others the costs of a few. The following is my breakdown of America's patients, as seen from the door of the hospital room. What kind of patient are you?

1. Young and Healthy. These are the patients in their 20's -40's. They come in with single episode disease, treated and get better. And go on living their lives with no long lasting effects. Cellulitis, traumatic DVT, pneumonia, cholecystitis, less lethal trauma trauma, suicide gestures. This is the ONLY model that third party insurance works well for, in the current environment. If you are healthy and young, you are insurable. You can't insure a burning house. You are insurable because the likelyhood of having a problem is low. If this was the only population being insured, your ability to afford health insurance would not be in question, for most.
2. Young and Chronic Mental Illness. These are the 20-40 year olds with in and out of the psychiatric wings on a regular basis. The frequent mental fliers. They have schizophrenia, bipolar disease, depression, dysthymia. They are difficult to manage and expensive to treat. They consume lots and lots of resources. They are often on the Medicaid roster. But we get a lot of functioning adults with recurrent suicide attempts who have no insurance. You have to be really messed up to get on the government mental health roster. I rarely see any of these folks with private insurance, because most of them are incapable of holding down a job.
   
3. Young and Chronic Medical Illness. These are your young folks with Type I diabetes due to noncompliance, drugs and alcohol abuse. I never see the controlled DM I patients in the hospital. And most if not all admissions for DKA are related to noncompliance, usually due to drugs and alcohol. We also occasionally see exacerbations of multiple sclerosis, seizures (not a common population though). Sickle cell crises. New onset stroke. HIV complications. Problems related to alcohol and IV drug abuse in general. Chronic pain syndromes, usually back and abdominal. These folks are rarely insured. Nor are they insurable for that matter. They are just screwed. They probably have hundreds of thousands of dollars in medical bills and they don't care. They likely have horrible credit having nothing to do with their illness. They just lack any sense of personal responsibility. And before I get spammed by Happy Haters, realize that the population I see are the ones not taking care of themselves, by inducing illness on their own watch and feeding off the system that is required to care for their irresponsibility.
4. Young and Chronic Substance Abuse. Most commonly alcohol. These folks never have insurance. Only if they have drank themselves half to death do they get on disability. They are frequent fliers. Waiting lists for free treatment are a mile long. The are uninsurable. They suck the system dry with their cirrhosis, intubations to protect their airway and seizures from alcohol withdrawal.
5. Young and Institutionalized. These are usually folks who live in state or community facilities with profound mental retardation, genetic mutations, diseases or traumatic injury early in life, requiring full medical support. They frequently come in with aspiration pneumonia or seizures or infections. They are always covered by the Medicaid program. Interestingly, I don't see too many older institutionalized patients. They must pass away at earlier ages.
   
6. Young Prisoners. Often related infections. Or hepatitis C. Frequently they fake symptoms as a way to get out of prison. But I've cared for a few new onset disease such as diabetes. They always have private insurance, paid for by the great state of Happy.
7. Illegal Aliens. Almost always admitted for new onset diabetes or infections. Rarely for anything else. They never have insurance.
8. Young American Indians. Almost always admitted for alcohol related complications, or gallbladder attacks. Always. Unless they are on Medicaid, they are always uninsured
9. Homeless. Not much to say. I did actually have a homeless patient once that had insurance. I think that was an anomaly.
   
10. Middle Aged and Healthy. Almost always insured. They hold down a job. Are productive members of society. I rarely see these folks. But when I do, they get treated and get better. They get single event disease that resolve.
11. Middle Aged and Chronic Lifestyle Related Disease. This is a growing population of obese men and women who come in with new onset diabetes, and all the complications that come from that. They do not exercise. They do hold a job and generally they have insurance. They are the smokers, the food addicts, the exercise phobia patients. The are the ones with heart attacks, COPD, strokes all showing up years before their time. They lead unhealthy lifestyles and have no desire to change. They are perfectly happy leading their lives and having their insurance pay for all the complications. They do not change their ways after life altering health events. If they didn't already have insurance, they would be uninsurable.
    
12. Middle Aged and Bad Luck/Genetic Disease. These are the folks who did everything right. Exercised, ate right, worked hard. And they still find themselves battling chronic illness. Cancer, genetic disease with all the fancy names, viral induced disease. They generally have insurance too, but if they don't, they often find themselves on disability and on the government plans. They are very expensive to manage. If they didn't already have insurance, they would be uninsurable.
13. Middle Aged Mental Illness. I don't see a lot of this. It's either the really young or the really old that come into the hospital for this.
14. Old and Healthy. This is usually grandma who takes no medications except for the 12 vitamins and supplements she consumes after reading magazine after magazine. They try and avoid doctors. When I see the old and healthy in the hospital, it's almost always for a self limited issue like flu, or dizziness, or passing out. They are old and healthy for a reason. They took care of their temples all their lives, and they get to enjoy finishing strong.
    
15. Old and Sick. People with multiple chronic medical conditions. Frequently end stage disease from years of hard living lifestyles. Smoking, sedentary, obesity. They frequently have the combination of COPD, HTN, DM, hypercholesterolemia, CAD, AFib. They are horribly expensive to manage. They require multiple labs, xrays and specialists to evaluate. They receive fragmented care from multiple specialists each practicing within the confines of their own cocoon of training. These patients often don't have a clue how to participate in their own health care decisions. They are frequently prescribed polypharmacy. They probably miss mulitiple doses of medications a week. They are in and out of the hospital all the time. They include people who continue to abuse their temples with lifestyle choices in spite of their extensive disease. They also include those who gave up their vices but the damage is irreversible. These are your massive cost centers. Your frequent hospital users and abusers. These are the people who are getting their money's worth in health care expenditures. They are, in essence rewarded for their poor choices, with unlimited access to all the best care someone elses money can buy. The hospital is like their second home.
16. Really Old And Sick. These are the nursing home patients. Those with advanced dementia. Who are bed bound. Who have limited quality of life. Who cannot contribute to their own health care decisions. They languish day in and day out requiring others to perform all their activities for them. To wipe them. To feed them. To push them around in their wheelchair. These are the rolling corpses. The folks who should under no circumstances be admitted to a hospital. No matter how sick they are. These are folks who have lived their lives and are now simply waiting to die. Folks, who under humane parameters would be allowed to pass away peacefully in the presence of family and friends. In the nursing home, no where near a hospital. These are the folks who come in with advanced everything, chronic multiorgan end stage disease and whom we as a nation are expected to provide heroic measures at all costs. These are the folks that are killing our ability to provide affordable health care for all. Some call it cruel to deny health care to the rolling corpses. I call it dying with dignity.

What we have in America is a horribly skewed financial obligation for a few, being spread on the backs of the masses. We have 50% of our population spending 3% of our health care dollars, and 5% of our population spending 50%. As a country we have to ask ourselves what is important. I don't believe for a second that providing universal access in the form of government funded universal health care will somehow create a vast empire of cost savings. What it will do is continue to increase the costs and of regulation and inefficiencies required of us to get paid. We need to get third parties out of the equation, not all inclusive. And you do that by paying your doctor and hospital directly. And getting the rules and regulations of insurance out of the equation. And getting the bloated bureaucracy out of the equation. For that, read on...