We Can and Must Do Better!

Guest columnist Dr. Susan Biener Bergman, is a physiatrist in Massachusetts who has been in practice for 31 years and offers a unique perspective on competitive bidding and watching her patients’ health decline and time tested resources slowly disappear. Her call to members of Congress—We can and must do better!

My patients are people with multiple chronic conditions, including paralyzing disease or injuries. I have known some since their original injuries dating back decades. Until recently many were living independently with the help of high and low tech equipment, as well as personal care attendants funded by MA Medicaid or devoted family members working without pay. The rehabilitation model developed in the Spinal Cord Injury Model Systems from the 1970's worked very well, offering people education about their conditions, engagement in preventing complications and a satisfying life.

Creative thinking allowed people with catastrophic injuries and illnesses to live in the community, raise families and work, often at very high level jobs. The right equipment and supplies prevented predictable complications like infections and pressure sores. The key pieces of equipment- properly sized and fitted wheelchairs with controls set to maximize independence and low air loss mattresses to reduce pressure and prevent bedsores seem costly at first, but more than paid for themselves in reduced complications, fewer ER and hospital visits, lower costs and lower patient mortality rates. Over the years as businesspeople and legislators searched for ways to cut burgeoning costs, slowly but surely clinical decision making has shifted from trained clinicians to people with no medical experience and even to algorithms and machines. The results have been disastrous.

While U.S. health care costs skyrocket, small local medical equipment vendors and suppliers are being gobbled up, consolidated and forced out of business. Thousands of jobs have disappeared. Even spending hours on prior authorization paperwork I am no longer able to get my patients wheelchairs that fit, proper urologic and wound care supplies, non-opiate pain medications, appropriate braces and prostheses or even pressure relief mattresses to prevent bedsores. People I have known for years are literally dying. Trusted professionals with years of experience are retiring early or closing their business because they are undercut by large high volume equipment suppliers who can bid low and make up their losses on materials or by cutting staff. In theory competitive bidding works; in practice we get cookie-cutter services of inferior quality that don't fit properly or don't work. People with disabilities feel the effects every day. So do the small brace shops, wheelchair vendors, specialty bed companies and medical supply companies that have served them well for decades. Even doctors are forced to practice corporate medicine- either conform or drop out. There aren't enough doctors to meet the need.

The combined results of efforts to centralize, standardize, automate and digitize health care have left us with a fragmented system run by people whose expertise is in management, not medicine. Laws passed by well meaning legislators are parsed and micromanaged to "maximize efficiency." The system is running on autopilot with little variation or creativity. That's very bad news for people with disabilities and for small businesses. For example, hospital bed vendors have pulled out of the home care market so a person who needs a specialty bed is forced into an institution. Even they have to wait weeks.

People are left high and dry without the tools they need to take care of themselves. Our current health system is not working and costs are higher than ever. We can and must do better.