Health Care on TV More Real than
By Edward D. Miller, M.D.
or a physician who has spent his entire professional life in the staid environs of academic medical centers, itís been a bit of a jolt to read columns by television critics comparing a series about my institution to "Survivor" and "Big Brother." Last year, when ABC-TV news executives convinced me to allow them extraordinary access to film "Hopkins 24/7," a six-part, prime-time series, I hadnít even heard of the other reality shows that would make Johns Hopkins part of this summerís popular genre. But I was disturbed enough by the unreal, irrational, "through the looking glass" world of health care in this country that I believed some good must come from allowing the public an unvarnished view of the problems constantly confronting our patients and our staff, from struggling with HMOs to patching up the victims of inner city drug wars.
Other than to insist on ironclad protection for patient privacy, Hopkins had no control over what ABC chose to focus on and no right of review. Fortunately or unfortunately, the problems we confront were so obvious to the producers that they couldnít overlook them. My hope is that those advising the candidates on their health care policies also are watching. It might help them to realize that their focus on Medicare and prescription benefits for the elderly is just a fix around the edges of the health care crisisónot the entire answer.
The series offers, for instance, a candid view of a young patient in pain, her family, physicians and clerks struggling to determine what tests her insurance will cover. Can she have a CT scan at Hopkins, will she need to go across town or return to her home state? The producers told us they saw this scenario over and over. They could hardly miss it, because the extent to which insurance companies have been inserted between the physician and the patient is unconscionable.
Letís agree that managed care organizations do a good job of providing preventive careóimmunizations, check-ups, standardized diagnostic testsóto the young and healthy. But when it comes to dealing with any serious medical problem, we must get them out of the decision-making process. Their interference doesnít improve care, and it doesnít save money. With all the hoops and justifications required by most managed care organizations, we say that "it takes a village" of back-office people to deal with each patient. At least 30 percent of every health care dollar now is spent on administrative costs, not on actual care.
A series of steps might remedy this situation: If the government covered the costs of catastrophic care for all ages, managed care organizations would have some protection from loss and thus less reason to try to limit their cash flow through harassing practices. (At the very least, there should be standardized forms, rather than the proliferation of different formats demanded by each company, that creates a paperwork nightmare and inevitable errors.) And just as there should be catastrophic coverage, the government should provide a broader safety net for basic coverage that addresses the issue of the 45 million uninsured in this country. Allowing individuals, rather than employers, to select and stay with a plan would eliminate the risk of losing insurance when losing or changing a job. Without addressing this issue, weíre just cost shifting and putting off the inevitable day when critically ill people arrive in our emergency rooms, at the point when they canít be turned away.
Thereís already one group of patients for whom we donít need to obtain permission from insurers before initiating treatment. The cameraís eye captured the gruesome results of Baltimoreís drug wars. During the past year, close to 400 shooting victims were brought to our ED. What a waste!
Our new, energetic, young mayor has been pleading for more drug treatment money. As the situation now stands, treatment programs could handle more addicts, but those most in need rarely have the insurance or the money to pay. The few free programs have long waiting lists, so at the moment when addicts are ready to kick the habit, theyíre often rebuffed. Social workers in our emergency room spend hours on the phone trying, unsuccessfully, to find placements for these people. Meanwhile, prisons have become warehouses for addicts, who often are released, still addicted, to end up in our ER, shot up or with AIDS contracted through an IV drug habit.
Whatís wrong with this picture? If a fraction of the money that goes into treating hundreds of these shooting victims and AIDS patients went into free, aggressive treatment programs, society and the health of our cities would be well-served.
Hopkins 24/7 demonstrates our indefatigable advocacy on behalf of patients. I now hope political candidates understand that the medical profession would like to work with them in developing the cure for this nationís systemic health care problems, as well.