Sunday, August 21, 2011

What's Missing In This System?

I have two friends who have told me their own hair raising personal story of being on the last plane out of Ruanda at the height of the collapse of the Ruandan Society in the horrific tribal massacres in 1994. They worked with Medicins sans Frontiers and with the refugee camps that were necessary because of the tribal warfare. The collapse of Ruandan society has been discussed endlessly, it occurred after country experienced a century of colonial tribal manipulation under first German Rule and the becoming a Belgian colony after the First World War. In 1964, Ruanda became independent, but the friction of tribal rivalry which had been exploited by the Belgians came to an ugly head 30 years later with a massacre that totaled over 1 million victims.
In the after math, the country was traumatized and economically devastated. Ruanda was never a rich place. There is no real mineral wealth, no oil, no gold, no uranium. The society is based on farming and agricultural exports are the basis of the economy. I learned about Ruanda because I was interested in fish and actually bred Ruandan Rift Lake Chiclids as a hobby. After the massacres, I was actually a source for the breeding stock in New York City and sold these fascinating mouth breeders to a few pet stores in lower Manhattan.
But the massacres occurred 17 years ago and since then, a traumatized land has begun to heal and deal with the problems that created the horror. In the wake, they have become one of the most progressive nations in Africa, creating a new agricultural and ecological tourism based economy.
The government has embarked on one of the most ambitious health care systems in the world. Te logic is that a healthy population is a productive population and in the last 15 years, the life expectancy of the average Ruandan has doubled! 
The cost to a Ruandan for health care? $2.00 a year. 97% of the population is insured by this program, the ones opting out are only those who do not trust western health care....
A good example is the 150 bed Butaro "Harvard Quality" hospital in a city that previously had no medical facilities at all.
The 150-bed Butaro hospital was built in only two years at a cost of R40-million. (The cost of a comparable hospital in the U.S. would be 225-300 million USD). The physical structure itself is designed to scrub the air twelve times per hour to reduce risk of airborne infection. Here, that requires multi-million dollar machines. The Butaro hospital has advanced laboratory facilities, telemedicine capability, and a fully functional, user-friendly electronic records system.
In a country where the annual per capita income was $510 in 2009, patients get as high quality medical care as we get here in the richest nation on earth. But wait - their care is better! Why? Because it cost a tiny fraction of what health care costs us here.
What is missing from the new hospital in Butaro? Answer: things that waste money, such as unnecessary duplication and the #1 dollar waster in U.S. healthcare: a massively bloated bureaucracy needed to support a costly and harmful regulatory machine.  
Let's qualify that, because, though the administrative system wastes so much money, the real burden is on the consumer, who pays for the bloated vampiric insurance agencies and their advertising budgets, the lobbyists, the over-billing, the salaries of the Health Care CEO's. This is the monster that has become the dysfunctional American Health Care System. It's the best in the world, they say, but only if you can afford it. Most Americans can't. It is the inherent flawed American Health Care System, which cannot be reformed with out first destroying it. This is why Obama's attempts at reform are so easy for his opponents to throw mud at. They don't have to be concerned with reforming a corrupt system which they profit from and enable. 
Before 2010, the U.S. healthcare bureaucracy consumed almost 40% of healthcare expenditures. That is right: 40% of all U.S. healthcare dollars never touch a patient. With passage of PPAHCA (disingenuously named Patient Protection and Affordable Health Care Act), that number could approach 50%. Even Everett Dirksen would consider throwing away one trillion dollars a year wasting "real money."
You really need to experience healthcare from the inside to appreciate fully how and how much the U.S. healthcare ‘system' wastes dollars and frustrates providers. Most of that daily waste is missing from Rwanda.
Doctors in Rwanda can communicate with each other without fear that HIPAA looking over their shoulders hoping to find them "out of compliance" and pull their licenses.
Hospitals in Rwanda do not waste time and money preparing for a Review by the Joint Commission (JC). They do not have to hide their doorstops on take down the books on top shelves. If the JC reviewers find doorstops or anything within 18 inches on the ceiling tiles in doctors' offices, they can close the hospital because those infractions will place them "out of compliance."
Nurses in Rwanda can spend time with patients, time that American nurses must waste in repeated annual training modules about security upgrades, ethics infractions, theoretical biohazards, and the next set of regulations that must be followed to the letter.
Nurses in Rwanda can use the infection prevention checklist without filing a research protocol with the FDA.
In Rwanda, restocking hospital supplies does not require multiple committee meetings, forms in quadruplicate, and pre-approval by legal counsel.
In Rwanda, research to find better ways to treat patients does not require 87 different steps*, each involving multiple committee meetings, thousands of man-hours and billions of red tape dollars.
*The number 87 was not picked at random. Dr. David Dilts at Vanderbilt reported in a 2006 article that number of different steps are mandated when going from an idea to actually starting a clinical research project. 

One more thing that is missing in Rwanda: Federal organizational charts. Go online and look at the organizational charts for the NIH or the FDA. Then recognize that every box represents a whole agency with its own organizational chart, and each box in a box represents hundreds of bureaucrats, thousands of regulations to oversee, billions of dollars to consume, and thousands of providers to hound right out of health care.

To your right is displayed an organizational chart for the Healthcare ‘Reform' Act (PPAHCA). Are you surprised that it will cost only a trillion or so dollars? This too is missing from Rwandan healthcare.

For some inexplicable reason, the U.S. Public thinks that healthcare regulations are free or at least that they do not have to pay for them. In fact, the Federal healthcare bureaucracy is the leading cause of dollar wastage in the U.S.  Those are dollars they do not need to waste in Rwanda.
But then again, another  part of the Rwandan system is preventative care. That is not a part of the American approach. Money spent on prevention is money 10 times saved on treatment. That might be the biggest factor of what is fact it is more of what is really missing in American Health care....
If patients in Rwanda can get high quality care without regulations ‘protecting' them, why are we throwing away trillions of dollars a year on healthcare regulations and bureaucracy, money that we do not have?
The real question perhaps is how can a system be reformed that is so inherently flawed in the first place?
Does America have to experience a public health trauma on the level of Rwanda's to wake up to the fact that things just don't work. In my opinion, America is suffering from an ongoing Health Care disaster that we have become inured to. the scope of the disaster is increasing on a slow but steady incremental basis. Obama has tried to deal with it, but the insurance companies, the health care lobbies, the drug companies and the inherent evolved bureaucracy make it impossible to really make a meaningful change...
Will it take a Health Care Holocaust?


mud_rake said...

What is missing in the system? Hmm. I'll take a stab at this one. How about: insurance agents, TV commercials, over-billing, health care CEO's, large corporate headquarters, legislative lobbyists, checks to campaign coffers...

microdot said...


microdot said...

Mudrake, I re edited my piece because I was too blown away by the information I had dug up about the costs of Health care from an administrative view point. I almost missed the real focus of what I wanted to say. Thank you for your comment, I almost think I should make you co author of this piece!

J.O.B. said...

Very good piece, I will be looking forward to you e-mail.

But as far as this piece- Does the fact that Ruanda can do this just show the waste in "income" that The U.S. government has grown acustomed to? How is this so hard here?