The film has a fairly simple basic message: The American health care system is a mess. But solutions, at least partial solutions, are there for the taking.
Part of the film focuses on the payment and delivery of health care – what those of us who write about this a lot may think of as the Dartmouth Atlas message. The fee-for-service system rewards quantity over quality and encourages all sorts of stuff to be done that doesn’t make a lot of sense and isn’t necessarily right for the patients. A part of the film looks at the – related – issue of designing a health care system around people who are sick, rather than emphasizing investment in keeping people well; Dean Ornish, Andrew Weil and Wayne Jonas all appear. We know a fair amount about keeping people well. But that’s not what our system primarily pays for.
The filmmakers, Heineman and Froemke, whose interest in the health care system was stirred when they made a film a few years ago on Alzheimer’s disease, spent more than three years on this project. The more they learned about the health system, the more astonished they became at the scope of its flaws.
“We have worse outcomes but we’re spending twice as much as other nations, “ Heineman said. And despite all that money, we don’t have a “patient-centered preventive and safe system.” The system, as he put it, is “high-tech over high-touch.”
The filmmakers weren’t alone. “We found out that no one in the medical profession is happy” about much of American medicine, they said. Doctors who want to do primary care, or who want to have a more “whole patient” approach even as a specialist, encounter all sorts of barriers. “It’s the spending structure,” Froemke said. “Medicine became a for-profit industry; we lost our moral compass.”
The film has its share of experts, some of whom like Donald Berwick, M.D., will be (I hope!) familiar to health journalists. But the heart of the film, as Froemke put it, is the stories it tells about ordinary – or maybe not so ordinary—patients and doctors.Three stories in particular stood out for me:
♦ Erin Martin, a primary care doctor in an underfunded Oregon clinic who is pressed to see so many patients that she can’t give them the time they need – including the time to just listen. (It’s a bit of an aside, but I particularly liked the scene where she called the mental health crisis line to get help for a suicidal patient, only to be told that the crisis worker was out to lunch.) She is so frustrated that she is considering leaving medicine.
♦ Yvonne Osborne, a Midwestern woman who developed heart disease in her mid-30s and went from surgery to surgery, procedure to procedure – $1.5 million of cardiac care. But until she found her way to the Mayo Clinic, none of her doctors had ever thought about what would help make her well, not just about where to place the next stent.
♦ Sgt. Robert Yates, a self-described tough southern boy, flown home from Afghanistan torn apart body and soul, with a shopping bag full of 32 drugs that didn’t heal either. His experiences in the military health care system was the most moving for me – and the one I learned the most from in the film.
For those of us who write about health care extensively some of this will be familiar. We can even find things to quibble with. For instance, much of the film is framed as a critique of for-profit fee-for-service medicine – but some of the illustrations they relied on were nonprofit and not fee-for-service. For instance, the story of Osborne’s heart care does epitomize the problems with fee-for-service, procedure-oriented for-profit medicine. And the solution was Mayo – not a traditional fee-for-service approach. At Mayo her physicians are salaried, primary care is emphasized and the cardiology team takes the time not to do procedures but to get her other illnesses (including diabetes) under control and help her with lifestyle changes – AKA wellness – that may help her live longer and better with her heart condition. (The Mayo model represents the integrated delivery system – an ACO if you will – that the Affordable Care Act encourages as an antidote to the flaws of fee-for-service and overtreatment.)
But the other two stories were different. Martin was at an Oregon clinic that – as best as I could understand from her description – wasn’t procedure-oriented fee-for-service but capitated. She was paid per patient, not paid based on what she did for that patient. In fact it was more like a medical home (another models encouraged by the Affordable Care Act.) The problem there wasn’t how she was paid – but how much she was paid. Or more accurately, how little. Of course, if we spend less on procedures that patients don’t need we’d have more to pay for the services that patients do need – including doctors, such as Martin, who listen and try to keep their patients well.
Similarly, the problems in the military – overprescribing in particular – aren’t the rotten fruits of fee-for-service. It, too, is a more integrated system. But while the doctors and medics are saving lives on the battlefield that would not have been saved in earlier wars, they have clearly been prescribing insane amounts of mind-numbing drugs, at least in the cases of injured military personnel highlighted by the film. The film’s most poignant moments, for me, were watching Yates, skeptical and suffering, go through acupuncture and meditation, along with his physical rehabilitation. As mindfulness replaced mind-numbing, he threw away all those drugs. He also threw away – well, I don’t want to ruin his ending for you. For me, it was the most emotionally powerful scene in the movie.
Despite the quibbles, I liked this quite a bit and it’s worth seeing. Parts will not be new for those of you immersed in health care — but you aren’t the target audience, and even the more experienced “been there, wrote that” health reporters will find plenty to learn and enjoy. You can download it or find where to see it on the website (which also has viewer reaction, stories, and supplementary materials). Perhaps you can still catch a screening at a med school – because that’s what Heineman regards as the target audience. “They’re idealistic, they’re the future; we want to reach out to them,” he told me. “The point is to provide and instigate conversations.”