All Fall Down
by Rosalind Kaplan, MD
I am reading The Hospital by Brian Alexander and trying not to cry. For anyone who hasn't heard of this book, it's not a written version of a soap opera, not a melodrama, and in fact not fiction. That's why I want to cry--because Alexander, a seasoned journalist at the Atlantic has written a true and accurate account of the demise of a community hospital in a small town of Ohio that encapsulates the failure of medical care in the United States. The hospital's woes are only the tip of the iceberg, as we follow the stories of members of the community it serves, people who work, who tried to believe in the 'American Dream', and found themselves, instead, in a healthcare nightmare.
It's not that I didn't know what the book exposes. I knew. I knew that a huge sector of this country can't make ends meet with the wages they are paid, even when they work themselves into the ground. I knew that health insurance had become so expensive that the 'choice' to remain uninsured is not a choice at all for lots of folks, and a single ER visit or the need for a high-tech medical test can tip someone in a tenuous financial situation into dire straits. I knew that much of the money flowing through healthcare systems was not being spent directly, or even indirectly, on patient care. I knew that private equity owned hospitals and physician practices and nursing homes, just like they owned real estate and consumer products, and that their concern was whether their holdings made money or not. After all, living in Philadelphia, I'd watched Hahnemann Hospital, topple in 2019 under private equity ownership, leaving patients without physicians and without a healthcare 'home' and leaving doctors without jobs, and medical trainees without training programs.
So if I knew all that, why is this book tugging at me, making me sad and angry and frankly EMBARASSED that I am part of the American system, or rather sick care system, since we generally don't do all that much to preserve health in this country; it's sickness that makes money, not prevention or wellness? I guess it's the intensity of The Hospital, the financial and political and personal details of this town and this hospital and the people who work there and need the services the place can provide. The people who really don't have a clue how any of the medical machine works --or doesn't.
Maybe it's also that, on the day I was just getting into the meat of the book, I worked an urgent care shift in a site located in an impoverished area of Philadelphia, a site where most of our patients are people of color, and where resources are scarce. One of the patients I saw was a gentleman in his seventies (I'll call him Mr. Smith) who came in because of uncontrolled hypertension.
Mr. Smith had been prescribed two blood pressure medications by his primary care doctor about a year ago, and had a blood pressure cuff at home, which he used to check his pressure several times a week. All was well until five or six months ago, when he needed a refill of one of the meds, and was unable to reach his doctor. He left messages on a machine at the doctors' office, but nobody called him back. He thought it was because of the pandemic; he tried to be patient, but after a few weeks, he walked to the doctor's office, hoping to find someone in. What he found instead was a letter on the door saying that his doctor, a solo practitioner, had died unexpectedly. A list of other primary care doctors was attached.
Mr. Smith called every office on the list, but not a single one was willing to schedule a new patient appointment for a patient with the discounted Medicare HMO that Mr. Smith had chosen. He called the large health system closest to his home, and was put on a waiting list. Another health system gave him an appointment more than 6 months away. Meanwhile, his blood pressure cuff broke and he could not afford a new one. He knew that his high blood pressure could cause longterm damage to kidneys and heart and blood vessels, but he tried not to think about it, and succeeded most of the time because he felt fine, and he figured he'd just wait for the August appointment.
Then a friend who had a blood pressure cuff encouraged him to use it to check his status, and his BP was sky-high, 200/100. He checked it two more times over the next two weeks, and it stayed sky-high. The day he came into urgent care, it was 240/130, too high for us to treat in an outpatient setting, especially since he had developed a bad headache. I had to send him to the ER.
I checked in on Mr. Smith a few days later. He'd been admitted to the hospital, treated and released. He'd had blood tests, and EKG's and a CT scan of his head, a renal consult, intravenous blood pressure medications. He didn't yet know how much he would owe for copays on his medicare HMO. Worse yet, they'd given him a one month supply of medication, and told him that he MUST have a primary care visit within a month (though in reality, it should have been within a week, to make sure he was doing well at home). But they didn't get him an appointment. They just gave him numbers to call. I told him that if he couldn't get an appointment, he should call the hospital and ask for help. And that he could always come in to see us, as a stop-gap, if he needed help, but that an ongoing relationship with a doctor was much preferable to urgent care visits, given the situation.
Mr. Smith and I could have been characters in Alexander's book, if he replaced the small town in Ohio with the big city of Philadelphia. Because this kind of scenario, and many other equally or more alarming situations, happen all over the country, in cities and suburbs and rural towns, every day.
Of course, I don't have an answer as to how we are going to fix this. It's wound up in so many deeply ingrained problems from racism to hourly wage jobs that don't provide insurance, to huge disparities in reimbursement between procedural specialties and primary care, to inflated medication prices to the greed and lack of caring of the medical industrial complex to the idea that America is about individualism rather than the common good. But in the wake of a pandemic, it seems pretty insane to say that health care is a privilege rather than a right. Maybe we could just start there.