May I tiptoe onto a ledge for a moment?

Some (just-back-from-Europe) thoughts on health care policy, perhaps?

One of the many differences between the European Society of Cardiology (ESC) Congress and a typical American cardiology meeting was the scarcity of healthcare policy sessions at the ESC. That’s hard to explain; perhaps European countries are settled on their own systems and do not wish to — or can’t — influence their neighbors.

It goes without saying that little about healthcare is “settled” here in the US.

On return from Europe, the first article I saw in my local paper reports that 101,000 residents (16%) of my affluent county live without health coverage.

This is a real problem. So is the fact that it has become easy to gloss over this stuff. You get numb to it all. It’s normal, sort of.

Until you get an email like this:

Hi John,

I have a friend in his 60′s with no health insurance experiencing symptoms like great pressure on his chest and can’t get to a doctor because he can’t afford it. Is there a service in Louisville (a public health clinic or something like that) that you know of where he can get looked at by a doctor?

My e-response:

I don’t know. I think. Maybe. He could go to the ER. I could see him for free, but of course, there would be tests–that are not free.

I’ll get back to you.

This stinks, doesn’t it? Not for this particular guy. He got to me; I’ll see to it that this one patient gets cared for.

What about the other 100,999 residents of my county who don’t have a friend who can email a cardiologist?

This got me thinking about how Europeans approach healthcare. I spoke with an Austrian: “We have excellent healthcare … Everybody gets care.”

From a German cardiologist:

“All Germans get health coverage, whether they work or not. The extremely rich can buy ‘extra’ coverage that allows them to get private rooms in the hospital, or to make contracts with eminent professors and the like. We don’t buy private coverage because it’s expensive and the basic plan is enough for us.”

Lest you think everything German runs as perfectly as their trains, there’s this article published recently in the prominent Journal of the American College of Cardiology, showing that Germans also act according to human nature. It turns out that (even in Germany), if you compensate well for procedures, then it is procedures you will get.

I also learned some basics about British healthcare. Citizens are not billed for health services. You can be admitted to the hospital, treated and when discharged the paperwork includes instructions on medical matters, not a bill. The government pays all the medical bills. Wow.

But another British convention goer reminded me that British care isn’t exactly free. Primary care doctors control care. They determine whether a problem warrants further evaluation or referral to a specialist. And these gatekeepers are more than tacitly incented to contain costs. I guess it’s not surprising then that many of the sessions at ESC that centered on cost-effectiveness came from the UK.

I’ll try to distill my feelings about US healthcare reform down to four simple certainties:

• In a country of such great wealth and wisdom, we mustn’t accept a system that doesn’t cover all the people. I mean all the people — not just citizens. To do so is not just sound policy; it’s more than that — it’s the right thing to do.
• Everyone must start seeing (really seeing) the obvious–that healthcare spending isn’t infinite. We, as a people and a medical community, must accept limits. Choosing Wisely applies to both the patient and the doctor. This won’t be easy. It means making a 180-degree turn in current thinking. If we want things to be better, all parties must accept more responsibility.
• Whichever new delivery system is implemented, be it the Affordable Care Act or an alternative, the patient-doctor relationship must be protected above all else. Medical decision-making should not come from an expert panel or third-party payer, but from the patient and doctor.
• On risk. The idea that humans, not machines, practice medicine must be remembered. Humans make mistakes. They sometime fail to diagnose; they sometimes fail to perform perfect surgeries; they sometimes make real-time decisions that they wouldn’t have made in hindsight. The new US healthcare system must do better at accepting the humanness of its professionals.

John Mandrola is a cardiologist who blogs at Dr John M.