This NY Times story on long-distance runners and medical insurers provides a case study on why productive reform of the U.S. health care finance sector so difficult.

As noted many times on this blog, long-distance running is not healthy. Thus, as the article notes, medical insurers are beginning to balk at insuring long-distance runners.

However, the myth that long-distance running is healthy remains firmly implanted in the American psyche. So, the medical insurers – not wanting to be perceived as refusing to cover injuries resulting from supposedly healthy activity – are trying to figure out ways to cover the runners.

And, of course, Obamacare is going to require that insurers cover consumers who engage in injury-causing activities.

Meanwhile, the runners delude themselves that they are engaging in a healthy activity while advocating that insurers essentially provide them insulation (rather than real insurance) from the cost of dealing with the unhealthy effects of their activity.

Don’t get me wrong. Folks should be able to enjoy long-distance running as either exercise or a recreational activity (those are two different things, but that’s for another post). My anecdotal observation is that most runners don’t actually appear to enjoy the activity — the delusion that the benefits of long-distance running outweigh the costs apparently pushes them through the displeasure.

But if folks elect to take the risk of injury from long-distance running, then they should have to bear the cost of at least the non-catastrophic damages resulting from that risk. And insurers should be free to elect not to cover consumers who engage in such risky behavior. Shifting the cost of that risk to insurers (who pass it along to the rest of us) simply encourages runners to avoid confronting the myth that they are engaging in healthy activity.

As the late Milton Friedman was fond of saying, consumers will consume as much health care as they can so long as someone else is paying for it.

One of the numerous inefficiencies of the American health care finance system is that hospitals have been forced to pay high compensation to attract doctors into emergency room care.

The primary reason for this has been that many uninsured and underinsured consumers use the ER for non-emergency medical matters that would be better and more efficiently handled by an internist or family practitioner in their private office. This disturbing trend has been growing for many years and likely will be made even worse by Obamacare.

Turns out that the ER doc-as-primary-care-physician is also having some unintended consequences with regard to patients, as related by an internist/hospitalist friend of mine:

So, I get a call from the ER today – new doc fresh out of the ER training program tells me she has a patient there she wants me to admit for a cardiac workup.

Says that the patient has a history of “heart problems” and that the patient said that she was having chest pain “just like before my bypass.”

So, I go down to the ER – I look at the patient’s chart and note that her primary complaint when she arrived there was fever and vomiting.  I note that her cardiac evaluation so far was normal.  I looked at her EKG – normal.  I pulled up her chest x-ray – normal. And no sign of any telltale median sternotomy wires that are standard post-CABG.  Hmm…

So, I go in to talk to the patient.  She tells me that she has “chest pain,” and epigastric pain, and fever, and chills, and nausea, and vomiting. I examine her and note that there is no CABG scar on her chest.  Hmm….

So, I ask her, “Tell me about your bypass.”

“You mean my gastric bypass?”

Turns out she never has had any heart problems.

Turns out she had a cardiac cath 15 months ago before her gastric surgery – stone cold normal.

Turns out the ER doc stopped listening as soon as she heard “chest pain” and “bypass.”

So, I put her in the hospital to treat her viral gastroenteritis with IV fluids and nausea meds.  And I will sent her home in the morning, feeling all better.

And I take solace in the fact that ER docs are paid at least 50% more than I am.

Well, not really, about the solace thing, that is .  .  .

To make matters worse, in previous times, the ER doctor’s superiors would have castigated her for her stupidity and intellectual laziness.  However, if that were to occur today, each of the doctors criticizing the ER doc would probably be labeled as a “disruptive physician” and referred to a series of sensitivity counseling sessions.

This is not going to turn out well.

As noted in earlier posts here and here — as well as in connection with the final years of Dr. Michael DeBakey — one of the thorniest issues facing reformers of the U.S. health care and health care finance systems is the extraordinary allocation of health care resources to end-of-life care.

This recent Marilynn Marchione/AP article frames the issues well:

Americans increasingly are treated to death, spending more time in hospitals in their final days, trying last-ditch treatments that often buy only weeks of time, and racking up bills that have made medical care a leading cause of bankruptcies.

More than 80 percent of people who die in the United States have a long, progressive illness such as cancer, heart failure or Alzheimer’s disease.

More than 80 percent of such patients say they want to avoid hospitalization and intensive care when they are dying, according to the Dartmouth Atlas Project, which tracks health care trends.

Yet the numbers show that’s not what is happening:

— The average time spent in hospice and palliative care, which stresses comfort and quality of life once an illness is incurable, is falling because people are starting it too late. In 2008, one-third of people who received hospice care had it for a week or less, says the National Hospice and Palliative Care Organization.

— Hospitalizations during the last six months of life are rising: from 1,302 per 1,000 Medicare recipients in 1996 to 1,441 in 2005, Dartmouth reports. Treating chronic illness in the last two years of life gobbles up nearly one-third of all Medicare dollars.

–People are actually now sicker as they die, and some find that treatments become a greater burden than the illness was, said Dr. Ira Byock, director of palliative care at Dartmouth-Hitchcock Medical Center. “Families may push for treatment, but there are worse things than having someone you love die,” he said.

But if your family is facing the prospect of caring for elderly parents in their waning years, don’t miss this extraordinary Katy Butler/NY Times Magazine article on the negative impact that an effective pacemaker had on the quality of her father’s life in the final years of his life:

Until 2001, my two brothers and I — all living in California — assumed that our parents would enjoy long, robust old ages capped by some brief, undefined final illness. Thanks to their own healthful habits and a panoply of medical advances — vaccines, antibiotics, airport defibrillators, 911 networks and the like — they weren’t likely to die prematurely of the pneumonias, influenzas and heart attacks that decimated previous generations. They walked every day. My mother practiced yoga. My father was writing a history of his birthplace, a small South African town.

In short, they were seemingly among the lucky ones for whom the American medical system, despite its fragmentation, inequity and waste, works quite well. Medicare and supplemental insurance paid for their specialists and their trusted Middletown internist, the lean, bespectacled Robert Fales, who, like them, was skeptical of medical overdoing. “I bonded with your parents, and you don’t bond with everybody,” he once told me. “It’s easier to understand someone if they just tell it like it is from their heart and their soul.”

They were also stoics and religious agnostics. They signed living wills and durable power-of-attorney documents for health care. My mother, who watched friends die slowly of cancer, had an underlined copy of the Hemlock Society’s “Final Exit” in her bookcase. Even so, I watched them lose control of their lives to a set of perverse financial incentives — for cardiologists, hospitals and especially the manufacturers of advanced medical devices — skewed to promote maximum treatment. At a point hard to precisely define, they stopped being beneficiaries of the war on sudden death and became its victims.

My family and I have experienced both a sudden death of a still-vibrant parent and a slow one under the painful grip of dementia. There is no question that my mother, a former nurse, did not want to die in the manner that she did. But she did not have that choice.

And that lack of choice is at the root of this vexing problem facing us all.

This earlier post decried the failure of the Obama Administrationís reform of the U.S. health care finance system to address one of the fundamental problems with the system ñ the over-reliance on third-party payor of health care expenses.

Take Medicaid, which is the foundation of Obamacareís insurance-for-all principle. As the Happy Hospitalist explains, Medicaid is a particularly shaky foundation:

Not accepting Medicaid used to be the in thing for primary care.  Only one internist out of thirty in Happy’s town accepts new Medicaid patients.  That’s nothing new.

However, this Medicaid contagion has now spread to subspecialty care. In a first of its kind for Happy’s community, I learned that some subspecialty surgeons are no longer accepting Medicaid for outpatient evaluations.    Cash is king.  If they are forced to care for a Medicaid patient during ER call, they don’t even bill Medicaid for the care.  The hassle factor outweighs the payment received.

Going to the ER does not guarantee you’ll get a hospital admission which would mandate the physician to see you.  If you aren’t sick enough to get admitted, you may get referred back to the subspecialist doctor  from the ER for an outpatient evaluation.  And the  front desk at the office will tell you  they don’t accept Medicaid and will ask for a cash payment up front for a clinic evaluation.  They may be required to see you.  They aren’t required to accept your insurance.

If a Medicaid patient shows up in the clinic as an outpatient referral from a primary care doctor’s office, the patient is told they do not accept Medicaid and cash is necessary for an evaluation.  There is no where for the patient to go, except to the University Hospital 60 miles away.  The surgical clinic doesn’t  offer cab vouchers like Happy’s hospital does.  This is the current reality of Medicaid.  This is ObamaCare’s cure to health care finance reform. 

Medicaid is not a solution. It’s pollution.  Medicaid is an insult to physicians everywhere. [.  .  .]

A nation of disgruntled patients with all the insurance in the world, and no where to go.  Take it up with your Congressman I would say.  They are the ones that destroyed it.

Yes, but everyone will still have health insurance.

For whatever thatís worth.