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Epiphanies and the human side of health care policy

From the January ACP-ASIM Observer, copyright 2002 by the American College of Physicians-American Society of Internal Medicine.

By William J. Hall, FACP

In a Dec. 4 Annals of Internal Medicine article drawing parallels between the thought processes of creative writers and physicians, Abraham C. Verghese, FACP, described how we physicians, especially internists, become involved in the "stories of our patients' lives." While at times we are mere observers, he said, we more often serve as active participants, especially in bringing these stories to a closure, or what he calls "epiphany."

I would like to share a story I heard recently at a chapter meeting that illustrates that concept. A colleague I was talking to has been the primary care provider for a husband and wife. For more than 25 years, since the couple entered middle age, she has provided preventive and acute care for both patients.

As the couple grew older, the husband expressed increasing concern about his ability to care for his wife. She was showing progressive signs of dementia, while he was suffering from arthritis, pain and declining vision.

The physician had long stopped billing co-pays, was making frequent house calls, was revising medication lists and had her office handling most of the paperwork for home services. Despite these efforts, however, the ever-rising costs of prescription medications and home services quickly put a major dent in the couple's modest budget.

The story's epiphany occurred suddenly and unexpectedly. One day, after carefully arranging their affairs and providing written explanations, the husband shot his wife dead, then took his own life.

My colleague realized that this course of action was heavily influenced by concerns about declining health, particularly the fear that they would not have the financial resources to continue dealing with health issues.

Perhaps this is where the analogies between the storyteller and the internist pale. Such an epiphany makes for good storytelling, but very tragic medicine.

The case for access

Stories like this put a human face on abstract concepts such as access, prescription drug benefits and Medicare reform. While this case is extreme, I hear equally tragic stories about the effects of the fragmented health care system everywhere I go.

Older Americans aren't the only ones suffering. Younger people with no insurance have equally tragic stories to tell, whether it's breast and colon cancer diagnosed at inoperable stages, raging diabetes or the lives of newborns cut short by a lack of prenatal care.

We are trying to do something about this. The College's position has been clear and immutable: We advocate universal access to meaningful health care for all Americans.

No other organization in health care has done more than the College on this issue. Last November, the College took yet another step forward with the release of a draft of a new policy paper, "Achieving Affordable Health Insurance Coverage within Seven Years: A Discussion Paper for Public Comment from America's Internists." Pending final revisions, the paper should be published in April 2002 and distributed nationwide.

This latest overview of the access issue outlines a clear timetable to provide access to affordable health care coverage by 2009. The paper proposes a pluralistic approach to financing and delivering health care by extending programs like Medicaid, the State Children's Health Insurance Program and existing health plans. The paper will guide College and hopefully national policy for the next seven years.

We have reason to be optimistic that we can achieve real progress during this time. Since Sept. 11 and the subsequent threats of bioterrorism, Americans have been reminded of the importance of having a consistent and trusting relationship with a knowledgeable primary care physician. The legislative and judicial branches of our national government were among the first cohorts to reach this conclusion, when many offices closed and government functions ceased because of threats of bioterrorism.

Suddenly, health care public policy priorities are getting more serious consideration. Recent surveys, for example, showed that by the middle of last October, Americans had become much more concerned about a range of chronic diseases such as cancer, heart disease, diabetes, elevated blood pressure and respiratory conditions.

We have all had a wake-up call regarding the fragility of life and the high value of a functioning health care system. We therefore have an unprecedented opportunity to move forward with our legislative agenda.

Setting priorities

Even now, however, we need to begin thinking of further priorities beyond achieving conventional health coverage for all Americans. I would like to suggest a few.

We internists appreciate more than most physicians that the looming crisis in health care goes beyond affordable access to acute medical services. We know that the real trouble ahead lies in caring for chronically ill patients, the "bread and butter" of internal medicine. Access to the best-trained internist is a laudable goal, but no matter how accessible and skilled we may be, a fragmented health system will undo all of our talent and goodwill.

We need to establish the principle that time—the best diagnostic and therapeutic tool to manage chronically ill patients—is the least available commodity under conventional health insurance. The time we spend on cognitive services must be just as valued as the number of sutures performed by surgeons-and it must be fairly compensated.

We also need mechanisms to allow internists to perform executive functions, such as directing and coordinating the myriad services the chronically ill need.

Will the day ever come when Americans will not be forced to make terrible choices because of a fragmented health care system, as in my colleague's example? I hope so, but the struggle to improve the health care system will never be finished.

The shape of that future, however, is very much in the hands of internists and the College as we strive for better epiphanies in the stories of our patients' lives. There are many ways that all of us can participate in this agenda.

Learn about the College's proposals to bring about universal access by reading the seven-year plan online at www.acponline.org/hpp/seq_plan01.pdf. Armed with knowledge of the College's strategy, this is the time to talk to your representatives and senators. Grassroots advocacy is by far the most effective means of influencing our legislators. For more information on how you can get involved, go to www.acponline.org/advocacy/.

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