— from S. John Gorton —
In 1939, at the onset of WW2, my father was a practicing doctor and surgeon in Birmingham (UK) and had been appointed head of medical services for the city as it prepared for The Battle of Britain. So, I have been an interested observer of healthcare issues since childhood, and have maintained a keen interest in them since coming to live full time on Orcas Island.
My working life was spent participating in the remarkable evolution of electronics since WW2 and then through the growth of digital data processing systems. Today such systems perform amazing feats of data acquisition, manipulation, and presentation to end users. But, of course, as such systems grow more and more capable, their complexity, and cost, also grows.
It has always been difficult to provide good healthcare in a rural environment – a high proportion of residents are older and no longer working, and inflation drives down the value of their savings. They suffer from a variety of age related complaints and are not very mobile – often house-bound. And, they are spread about the country side. Thus providing services is less efficient, and so more expensive than in the city. The working environment is less attractive for the medical provider, particularly younger professionals. Our doctor’s surgeries on Orcas have many years of first-hand experience with these problems.
Today, good comprehensive health care is becoming ever more expensive – both for the modern doctor’s tools and the information systems that support them. The only practical way to deal with this problem is to gather ever larger groups of Patients into integrated groups using modern data processing equipment and facilities.
Such technology can provide information – gathered, sorted, and presented in tailored form for optimum use on a previously unimagined basis and, with the incredible advantage of providing the Caregivers with visibility over the results of treating vastly increased pools of patients. This is already creating a “medical revolution!” that is only in its infancy. But for us “doughty Orcas islanders” it opens the door to a medical care system of the future at a price we can afford.
Orcas Islanders would surely be advised to make the change sooner while they have some degree of influence over its introduction and “grow with it.
Lucky for us, we have those in our community who are seizing the chance to bring this about. As they hack through the jungles of bureaucracy and local politics, they deserve our appreciation and our utmost support.
Mr Gorton,
I most curious about your perspective not only due to your personal and logical connection to and interest in the subject matter, but because of how well you relay the medical challenges of the elderly in rural settings in so few words. It portrays a reality that demands a workable answer.
May I ask if you believe the PHD ballot measure will address this need in particular and if so, will it do so successfully?
If so (and if you would be so kind enough to share more of your thinking), can you speak to this with a bit more detail?
Ensuring adequate medical treatment and care for both children and the elderly, in my mind, are very defining factors of where a society is on its evolutionary path.
I’m interested in understanding how this can be accomplished. After all, we’re either already there or heading to that stage in life. If for no other reason, self-interest and/or empathy kick in and have us all wondering how to get from a certain annual stipend ($ to be taxed per the ballot) to affordable quality care on Orcas Island.
Do you have any concerns about the practicalities of a PHD approach? Do you have any specific recommendations or requests relating to the pending ballot. I’ve come to understand that Lopez Island presently has a PHD in effect. Do we know how it has worked for them given their smaller population and would it be rational to compare their demographics and needs with Orcas for purposes of comparison?
Thanks sincerely for your letter.
Oops, left out the “am” (second word)
As a physician in a small state, we face the same problems described on Orcas. I would love to share your enthusiasm for technology to be our savior, but alas it is technology that has greatly increased costs of healthcare w/o commensurate improvements in quality, better outcomes, or patient satisfaction. My experience over the last 34 years is that patients want face time with an empathic physician who listens, diagnoses, and then shares treatment options and decisions with the patient, who has the ultimate say in her/his own care. Technology will never do that.
Dr Kaye,
I couldn’t agree more. I see technology as a “tool” to be placed at the service of an actual physician (not to replace him or her). To date, I’ve not found anything as satisfactory as a personal relationship established over time between a doctor and one in need of care.
The trend (beta testing) in larger population centers is to downgrade (degrade) the doctor/patient relationship altogether. In NYC, the State’s “Oscar” program is based on there not being a primary care physician. For each instance where care is sought the person in need accesses a limited supply of doctors based on location, specialty and particular illness; he/she essentially sees a new doctor with each occurrence.
By eliminating the “necessary” referral system, the burden of diagnosing need is placed on the would-be patient.
Most doctors of repute find this trend very disturbing. It’s being beta-tested and promises to become a cost cutting strategy that de-prioritizes human healthcare in favor of lowering healthcare costs— of course, at the expense of “health” itself.
It’s begun in earnest in exchange programs where there’s heavy subsidization present- translation: trying it out on the voiceless poor who struggle to articulate their dissatisfaction. It’s only a matter of time before this model makes its way to mid-size and smaller cities nation-wide (if it proves cost effective and minimally meets the definition of healthcare).
The trend for technology to replace human labor like medical doctors (and doctors of juris prudence via the ethereum blockchain protocol with so-called smart contracts—though this will fail for complex legal matters) is well underway cross-sectionally in most areas of industry.
Arguments showing the computational leap-frogging of machines capable of exponentially augmenting their ability to “learn” (compute/ computational scaling) faster with each passing year is juxtaposed next to the human brain that hasn’t noticably increased in computational capacity in the last 100 years— so the reasoning goes.
Not only is the above corollary superficial, it is linear rationale in its naïveté and fails to understand the still vastly unknown capacity of the human brain.
But this is the thinking in hi-texh circles of those who likely specialized too early in their undergraduate studies and thus lack a deepr underatanding of the human equation in all of its dimensions.
This thinking along with social platforms and augmented /virtual reality platforms “soon to be on dispaly at a store near you” indirectly contribute to a desensitization and dehumanization of “human” society.
There are dots here that connect much of this together with the evolution of medicine and healthcare which is unfortunately being swept up and placed into these new modalities under the guise of better technology = a better quality life (truly, it’s not cherry picking the dots to support one’s thesis)
It seems one of the errors / failures to comprehend more deeply is that there is an irresistible temptation to confuse a tool for its user, or to see them both as interchangeable, for now, only to be wholly replaced over time— as our latest generations enter onto life’s stage without the context of what came before and therefore will lack the ability and data to compare and contrast.
One can’t help but see the inevitability of these trends as populations explode and automation improves at alarming rates…and all for what? Productivity? Profit Margins? Minds untethered and ungrounded are left to “abstract without a human context” and, if left unchecked, lead us blindly into oblivion.
But I digress (though it’s these trends that are the real driving forces) —-back to healthcare on Orcas Island and how best to implement (for now at least) the meaningful delivery of quality care on a consistent and timely basis?
I’m delighted to read Dr. Kaye’s informed assessment of technology’s impact on “favorable outcomes”.
Whoa I just heard that UW does Not accept Kaiser insurance, true? I’m in favor of PHD yes, not at all sure about UW, & if true no Kaiser, well…is that a problem for 100s of people? Wonder what the candidates have to say—here on OI
Susan, when I looked at UW’s website it does list Kaiser but seems to hint at limitations… it’s not clear if this means all of Kaiser’s health insurance policies —also, the list might not be updated. Better to call Kaiser and UW directly.
Here’s what I see at UW -Medical’s website:
Commercial Health Insurance Plans
Aetna
Boeing BlueCross BlueShield of Illinois
BridgeSpan Health
CIGNA
First Choice Health Network
Kaiser Foundation Health Plan of WA fka Group Health (HMO plans require permission from Kaiser FHP before services can be provided)
LifeWise Health Plan of WA
Multiplan
Premera Blue Cross
Regence Blue Shield
Uniform Medical Plan administered by Regence BlueShield
UnitedHealthcare
Government Programs
Washington Apple Health (Managed Medicaid plans)
Amerigroup
Coordinated Care
Community Health Plan of Washington (specialty care only)
Molina Healthcare of Washington
United Healthcare Community Plan
Washington Health Benefit Exchange
Indian Health Services
Washington State Medicaid
Medicare – Original Part A and Part B
Medicare Advantage
Aetna
Amerigroup
Community Health Plan of Washington (specialty care only)
Kaiser Foundation Health Plan of WA fka Group Health (specialty care only)
Molina Healthcare
Premera Blue Cross
Regence Blue Advantage HMO
UnitedHealthcare
Please note that many sureds depend on the credit obviously to be able to afford coverage.
Per our insurance agent Kaiser is currently the only carrier offering individual policies in San Juan County – residents have no other choice.
Group policies, Medicaid (Applecare) and Medicare supplemental policies are better supported, but choices are limited. At an earlier OIMC informational meeting UW stated specifically that they would accept Kaiser, which does not have a facility here, the inference being that Kaiser is expected to authorize out of network providers and might have to defend a denial of service.
Phil,
Isn’t it the doctor or treating facility that decides whether to take X insurance or not?
I can see the following risk, however:
UW says we’ll take it but if they exceed Kaiser’s contract payment rates then the insured is stuck with the underpayment difference or applies for the center’s hardship / forgiveness program to zero out or further reduce the remaining balance due?
Definitely not a starting strategy for setting up Orcas Healthcare system. If a patient qualifies for medicaid he/she should obtain the benefit from the State so that the hospital isn’t left with losses after losses. UW or anyone else cant operate if losses are the norm and not the exception. Whatever we implement it should be viable.
Further, if UW is considered an out of contract provider, that’s tantamount to saying UW doesn’t take Kaiser and will treat the patient as a self-pay account.
However to say you take Kaiser should be equivalent to saying you have a worked-out relationship with Kaiser and have agreed to contract rates— that is, if you want to avoid misleading the receiving end.
Very good points Chris, that underscore the ongoing confusion / collapse of private sector insurance plans which ultimately may lead to a single payer (Future Care). But that hasn’t happened yet, so we have to deal with the here and now.
My point is that individuals in our county who are not indigent or have no group access currently have have only one commercial insurance option (Kaiser – Group Health). So for the PHD to meet public access expectations the commission must require providers to accept Kaiser (or whatever may be commercially available) or forego PHD (tax)funding. The greater challenge may be for Kaiser to authorize primary care from providers outside of their network. If that’s a problem the resolution may rest in Olympia.
To tax someone then deny them service because of insurance variances that they can’t control is unacceptable! As a consumer I believe our community must insist, and the responses I’ve seen from candidates infers general agreement, that the commission not contractors, must be in charge of our tax dollars. The commission has no obligation to UW, OIMC or any other vendor. Their obligation is to deliver viable, cost effective and accessible primary and urgent healthcare to all members of our community (4,600+ residents) and our visitors, within the constraints of PHD funding, fees for service and charitable giving. At least that’s the tenor of what I’ve read so far.
Phil,
Also good points that beg the question if our scale will create the leverage necessary to do the job?
At the end of the day, rising costs experienced by the providing facilities make viability a never ending challenge which more often than not is unmet (hence your “Future Care” option down the road).
Having said that, has anyone done the math to confirm that our projected “working funds” are capable of bringing potential providers into compliance for the residents’ needs? It may very well be that this endeavor does just what you fear: “tax someone then deny them service because of variances that they can’t control…”
A concern I have is that we perhaps not take on such a large effort to replace what doesn’t work with another option that also doesn’t work. That seems like a net loss for the islands’ taxpayers and residents alike.
So far, I don’t see anything novel in any of these approaches that addresses the declining healthcare choices available to island residents. Perhaps some magical mixture of our unique demographics will make it work but there seems to be a lot riding on importing a mini-healthcare system to the Island wherein we attempt to customize it using on our relatively small financial base and purchasing power.
Living with “what is” is often the more prudent option until something truly better comes along. Every time you move in quick sand you sink faster. We need an “intervening” idea; something that “interrupts” what hasn’t worked up to now; that changes the formula/metrics and objectively demonstrates how an HPD (or another option not now on the table) would be both financially viable and beneficial to residents now and into the medium term (for the next 5-10 years at least).
We need to interrupt this failed system, not perpetuate it at additional cost and liability to island residents. Otherwise, we’re perhaps wiser to make do with what we have until a real solution materializes.
Just a thought.
Very well said Chris!
I agree completely, the challenge for our community is to think outside the box and craft a sustainable approach. But the need to provide interim healthcare is real, equally challenging and more immediate. So how to proceed? Create a PHD with commissioner’s charged with sustaining “what is” while providing a framework to take us beyond existing templates? Or do nothing as “what is” collapses and our neighbors and families are hurt?
Those questions, along with our ability to pay, come before us in April.