A guy calls me out of the blue. I don’t know him from Adam. He got my number from a friend. He’s having a problem with healthcare.
He can’t get his FLMA form filled out. He’s a patient of a community health center but he hasn’t been seen there since the pandemic started. His regular doctor left that community health center, so he has no doctor.
He had a couple of episodes of bad diarrhea and belly pain, which went away on their own.
He works in Boston, for an airline, and he called out twice. The airline has a no-tolerance-for-missed-work policy, and, as he tells the story, he doesn’t have any sick days. When he calls out the second time, about two months after the first time, HR tells him he needs to get an FMLA form filled out or he’s going to get fired. The Family Medical Leave Act (FMLA) lets employed people take unpaid time off from work without getting fired if they have an ill family member or a chronic disease that will make them miss work repeatedly.
He didn’t want to get fired, so he called the health center, and they got him in to see one of their urgent care folks. The Physician’s Assistant (PA) who sees him says yes, it sounds like gastroenteritis or irritable bowel syndrome, and gives him some medicine.
Great, the guy says, but I’m better. What I really need is for you to fill out my FLMA form. Oh no, the PA says. I can’t fill out your FLMA form. Only your regular doctor can do that. But I don’t have a regular doctor, the guy says. My regular doctor left. Sorry, the PA says. I only work here once a week, and only your regular doctor can fill out the form. And so, the guy leaves, desperate, and starts calling everyone he knows to keep from losing his job through no fault of his own.
There’s no point in telling you how we unwound this mess. Let me just say it took me about six hours on the phone to get it fixed, and I have advanced degrees, used to run the Rhode Island Department of Health (DOH), and know or used to know most people in health care and health policy in Rhode Island. The long and winding road to get this little thing fixed took us through the DOH, the Rhode Island Attorney General’s Office, the CEO of a health plan, and lots of other people. Finally, we got it figured out. Which is the good news.
The bad news is that this kind of Catch-22, this kind of impossible situation for regular people, shows up everywhere in healthcare, and touches on many of the problems in health care we have created for ourselves: health care has become a dumping ground for all sorts of social issues; we don’t have enough primary care doctors; and we have way too many administrators and way too many forms that don’t accomplish anything.
Think of how health care gets used as a dumping ground for all sorts of social issues for which no one else has solutions. This guy’s employer wanted to make it hard for employees to be sick or miss work, so they used a form meant for something else (for people who have a chronic illness or an ill family member and need to be out of work repeatedly).
When police departments figured out that the incidence of death from alcohol withdrawal is ten percent, they started transferring every intoxicated person out of the “old drunk tanks” to hospital emergency departments, instead of asking us to create adequate treatment for people with substance use disorder, overwhelming emergency departments.
When we stopped building public housing and produced hundreds of thousands of homeless Americans, we started asking medical practices to screen for homeless needs and food insecurity instead of building affordable safe and healthy housing, and subsidizing farmers’ markets in every community to provide all Americans with fresh fruits and vegetables.
Now think about how we have too few primary care doctors. If we had enough, those we have wouldn’t burn out and leave, and this poor guy could have seen his own doctor without a problem. Think about the waits in Emergency Departments, which in Rhode Island are among the longest in the U, S, a problem we made for ourselves by inaction.
Now think of all those forms. The back-to-school notes, which schools require because they don’t trust parents to be truthful; the 11-page Medicare Home Health Certification and Plan of Care form required for people getting home health, which must be filled out every two months. Eleven pages. No one understands it, not the doctors who fill it out, and not the home health nurses whose computers fill out most of it. I doubt anyone at Medicare understands it. There’s a form to help poor people from getting their electric or gas service turned off in winter and there are workers’ comp forms.
And then there are the obscure mommy-may-I forms and processes from insurance companies – may the doctor who went to medical school and residency pretty please order a CT scan or MRI for someone with a head or back injury or abdominal pain, may I pretty please order this medication for someone with diabetes who might die if they don’t get it, and so forth.
Thirty-seven percent of all healthcare dollars are now spent on administrators or administrative employees, who get paid to think up all these forms and processes.
We have met the enemy, and it is us. Much of the mess in health care is there because there is too much money in it, and too many people use health care to solve the problems we ourselves created.
Want to fix homelessness? Build housing. Want people to come to work every day? Treat them well and pay them fairly. Want to prevent intoxication and drug overdose death? Create after school programs and community centers where people can spend time together and play sports or learn, and make sure there is treatment on demand for everyone who develops alcoholism or substance use disorder anyway. Want to save money on pharmaceuticals? Build exercise programs and subsidize fresh fruits and vegetables so people stay in shape, and that will prevent diabetes, high blood pressure, stroke and heart disease that is responsible for many of our health care costs.
Rudolph Virchow, a pioneer in the development of scientific medicine in the 1850s, called physicians “the natural attorneys of the poor,” because physicians see and treat the diseases caused by man’s inhumanity to man. Medicine, in 2023, has now been reduced to a sewage system for social waste and political dysfunction. Medicine and healthcare collect all the social problems that we create together — but are too lazy or distracted as a people to fix.
We could fix all this if we wanted to. It’s crazy that we don’t.