This book was, based on my meager qualifications, an acceptable (if mediocre) introduction to healthcare delivery in these U.S. of A. I will endeavor to cover its issues as efficiently as possible, but I promise to digress upon the conclusion of my review (available only in the version posted on my weblog).
First, the typos. I mean, seriously. This is a professionally edited and published book used for education in the spheres of healthcare and information technology. There is no reason whatsoever for this book to have as many typographical errors as it does. Throughout the early chapters especially, but with a sudden uptick in the final chapter also, misplaced words, repeated items on the same list, and similar issues pervade the text. The biggest issue with this is not their mere presence, but how obvious they are. No one caught “thir” where the word “third” should have been? Even spell-check can pick up on that. Less egregious, but equally surprising, are the problems in the flow of the prose. This or that paragraph is entirely disjointed from its topic sentence, resulting in a book that is often convoluted and misleading. At one point, Dr. Schulte (a doctor of business administration, not medicine) uses the phrase, “only more than 40%”; while this is a technically accurate phrase, there are so many better ways to say it. Later, she mistyped the same word twice in the same sentence – in different ways. How did her editor not pick up on any of this?
Another issue is the sourcing. Easily one third of this book is quoting something else. In the first three or four chapters, almost every other sentence seems to be a quote from Jonas and Kovner’s “Health Care Delivery in the United States”; given the apparent similarities in content and the obvious similarities in title, I felt compelled to ask myself, why am I not just reading their book? Later, she even quoted the Encyclopedia Britannica; is it just me, or is that only one tiny step above quoting Wikipedia?
After a few chapters, she starts mentioning (almost constantly) the lack of networking among hospitals. Based on my reading of the remainder of the book from this point, this is, in fact, her thesis; I suppose, then, my question is this: Why the heck didn’t she start with that?
Most of my other problems with the book were in its biases. In her introduction, Dr. Schulte expresses a sentiment common among moderns: the past was horrifying, but the present is almost peachy. I will not sit here and advocate that medicine in the 18th century even remotely rivals medicine today in terms of quality, but a simple acknowledgment of its own improvement would not be remiss. After all, progress is on a continuum; it has seen a notably rapid increase in the past two centuries, but that does not mean that anything old is inherently bad. Relatedly, when she discusses the statistics of health problems in the US between 1950 and 2000, she includes on the table the noted increase in cancer, but makes no mention of it, nor any discussion of why – among everything else improving – this alone got worse.
Dr. Schulte also seems to be quite the advocate of genetic manipulation of infants in the womb: “[Biological factors] are composed of heredity and genetics, both of which impact our propensity to succumb to certain diseases. They also affect our physical characteristics, such as whether we are tall or short, blonde or dark haired, and so on. Advances in the science of genetics offer the potential to reshape some of those characteristics through, for example, embryonic gene transplantation” (p21). In her later discussion of genomics, she takes the time to mention the danger of discrimination (based on genetic predispositions to certain diseases, for example, among employers who do not want to pay insurance companies for cancer bills), but she makes no mention whatsoever of the very real danger that we will endeavor to build a better human through those same studies.
Elsewhere, she writes of the “lack of public will to sacrifice and change priorities to achieve the World Health Organization’s definition of the individual human condition” (p13); while not entirely negative, it suggests (in context) that the problem is consistently other people with their bad policies. If society is to change, it takes all of society, not just the “problem” people. At another place, she implies rather blatantly that private schooling is of particularly low quality. In that same vein, she repeatedly advocates placing the government at the forefront of healthcare. She writes of “the increased recognition of the need for government to play a larger role in assuring medical care for the poor” (pp6-7); not, “the increased belief” or “the increased opinion” or “the increased position” – but the increased recognition of the need. Therefore, the need is an objective fact, and people were finally coming around to it. Later, she rather specifically advocates taxation of currently tax-exempt hospitals, unless those hospitals provide strong evidence that community benefit (i.e., free services by those hospitals) equal or surpass the tax exemption.
In fairness, I will admit that she mellows a bit in later pages. She gives faith-based hospitals a fair shake and positive support (in spite of her comments, mentioned above, about taxing currently tax-exempt hospitals), and provides fair treatment of midwifery (a rare thing among healthcare professionals). Eventually, she really does begin to focus on real issues with healthcare delivery, especially the quality thereof.
All things considered, it’s not a terrible book, but there is a lot of room for improvement. It’s a little slow at times, but it covers the highlights, which is what an introductory book is supposed to do.
And now for my digressions.
Dr. Schulte’s praise of government involvement in healthcare is juxtaposed (unbeknownst to her, apparently) with her appraisal of the implementation of Prospective Payment and the Stark Laws. In short, these two issues are perfect examples of politicians passing healthcare laws, assuming that one thing would happen, when in fact something totally different happened (thereby making them precursors to the Affordable Care Act). When Medicare started the Prospective Payment system (using Diagnosis-Related Groups, or DRGs, to determine how much money will be reimbursed to the healthcare provider), they expected to cut down on rising hospital costs. In reality, healthcare saw a sudden shift from the inpatient world to the ambulatory world (which, at the time, was not subject to the Prospective Payment system) and, simultaneously, hospitals stopped providing essential medical services (because they were paid for the diagnosis, not for the services, meaning that doing less got them paid more), which resulted in significantly lower quality of care for patients. The Stark Laws were a more reasonable assessment of the situation, but they, too, had an unanticipated consequence. These laws compelled doctors to have no financial stake in the clinics or hospitals to which they referred patients (since they would otherwise get financial benefits by referring them to those places). As a result, however, these laws proved a major barrier to the implementation of electronic health records, because without financial arrangements between hospitals and doctors, the EHR cannot meet several of the requirements of Meaningful Use (and makes medical practice and billing that much more complicated besides).
And the Affordable Care Act is the most recent instance of bad policy-making with unintended side effects, all because politicians fail to understand the way real people think. One of the requirements of the Affordable Care Act is that any employee who works more than 29 hours is to be offered benefits by his employer. Clearly, this is meant to increase the number of insured people among the population. The actual result, of course, is that employers everywhere cut their part-time employees’ hours, so they wouldn’t have to provide benefits. This leads to decreased income, which means fewer taxes paid by these people, and decreased spending (and also fewer taxes)… which harms the economy. This might decrease unemployment, since these companies now need to employ more people with fewer hours, but none of those employees are paid enough to buy their own insurance, which will cause problems once the individual mandate comes into effect. Even if Health Insurance Exchanges make insurance available for cheaper, there are going to be plenty of people who still can’t afford it – not because they’re unemployed and qualify for Medicaid, but because they are employed, but the ACA forced their employers to cut back their hours. Jobs are hard enough to find as-is – folks are not going to be able to find a second job so that they can afford health insurance. Honestly, this seems pretty intuitive to me – did no one at Congress or the White House think of this?
Digression number 2: The more I read of this book, the more I got the impression that very few people in the healthcare industry actually have real concern for the whole patient. This is notable, first of all, in the general lack of moral and spiritual considerations in healthcare, but also in the apathy toward financial hardship. Perhaps these are the result of the drilled-down focus of specialists on their tiny segment of health, or maybe it’s the perceived divorce between science and faith, or the general obsession with monetary gain superceding the whole notion of the Hippocratic oath. That oath, by the way, is inherently charitable and dedicated to the health of the patient, regardless of identity or ability to pay. This whole impression is reinforced by an article I read recently, at the New Yorker (but don’t let that color your opinion of it too much), which discusses in some detail the challenges facing healthcare today, especially in a financial sense. I don’t agree with everything the author there purports and suggests, but it does bring me back around to an opinion which is at once radical and traditional, simultaneously considerate and wildly despised: Doctors, like teachers, preachers, and politicians, should work for nothing more than room, board, and debt remittance. If you’re in one of these positions, and making money is more important to you than taking care of people, then you’re in the wrong profession.