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Wednesday, October 31, 2012

A sort of apology to hospitals, especially little ones struggling to make ends meet

In my previous post I said that an obvious reason why we over-diagnose serious conditions in patients who are not terribly sick is that this results in higher reimbursement to hospitals, "...and when a hospital does well they get remodels with big fish tanks and fountains and flat screen TVs which makes everybody happy."  This gives the impression that hospitals are evil and money grubbing, which is not true. Many small hospitals can barely make ends meet and are absolutely vital to the economic health of the communities they serve. Over-diagnosing and inflating severity are definitely the wrong way to go about making enough money to survive, but it is the strategy they are using now for lack of a better one. 

It is important to change payment structures so doctors and hospitals don't waste their time and energy doing the equivalent of clipping coupons in order to cover costs. Part of the costs that make it hard to survive are the administrative and documentation burdens that hospitals carry in order to be paid by insurance companies for what they do. Another issue is that some of the very sickest and most expensive patients to treat are folks who can pay little or nothing to defray their costs, and receive most of their care through hospitals and emergency departments. All that said, though, hospitals are businesses and do not necessarily have the same motivations as the health care providers who work in them. If payment to hospitals was based on their ability to keep their communities healthy, rather than for individual services rendered, incentives would not favor exaggerating the severity of illnesses.

Tuesday, October 30, 2012

What is health care like in India, why do Indian doctors come to the US and why are so many patients septic these days?

Lately I've been working in an unfamiliar state in a rural, but not small, hospital, and have been noticing all kinds of curious things. This is not the first time I've noticed these curious things so now I am sure that they mean something.

1. There are a lot of Indian doctors, especially in small towns in the US.

2. Small hospitals outside of major metropolitan areas often find it difficult to hire physicians, even though they pay lots of money.

3. There are many foreign doctors in the US who are not employed as physicians. They often work in hospitals but not as doctors.

4. In many hospitals patients are admitted to the hospital when they are not very sick and then proceed to have scads of tests and procedures done that are really expensive and not particularly helpful.

5. People who are not particularly ill get admitted to hospitals with the diagnosis of SIRS (systemic inflammatory response syndrome) which is a kind of synonym for "sepsis". (When I was training, sepsis was actually a really dangerous condition of which one might reasonably expect to die if not treated aggressively.)

A little more on SIRS. When a person gets really sick due to a life threatening infection, the body turns on all of its resources to kill bacteria. Our temperature goes up, our heart pumps faster, the blood vessels dilate, we breathe faster. Our white blood cells come out to fight and if we are really sick they are consumed in the battle. The 4 criteria for systemic inflammatory response are a high heartrate (over 90), a high or unusually low temperature, a low carbon dioxide level or high respiratory rate and a high or unusually low white blood cell count, especially with immature cells present. If we have two of these we qualify for SIRS. Today I had two patients with SIRS. One was a woman who developed chest pain while barbecuing, came in, belched and it went away. Her tests were all normal except that she had a slightly high white blood count with immature cells and a low temperature. She also felt fine. She was started on heavy duty antibiotics and had a super expensive stress test and went home, grateful for the care she had received, which was actually completely unnecessary. The other one was a man who was chronically ill with hepatitis who had a cough. He was bedridden so when he got to the hospital his heartrate was somewhat elevated and his respiratory rate was up, and because of the hepatitis he had a low white blood count. He was diagnosed with pneumonia and SIRS. I know what pneumonia with sepsis looks like and it is a medical emergency. It is also not what he had. He had a cough and some changes in his vital signs.

So why does everybody and his brother have SIRS now, even if all they have is a cold? Because hospitals get reimbursed according to how sick the patients who are admitted to them are, and hospitals pay our salaries. And when a hospital does well they get remodels with big fish tanks and fountains and flat screen TVs which makes everybody happy. So in another few years when they do studies on survival from SIRS, they will find that we are much better at treating this dread disease than we used to be. Probably because we have better antibiotics. Oh yes, that must be it.

At this hospital where I have been working I met two interesting doctors from India who were not doctors in the US. One was a cardiologist who was working as a computer tech at the hospital, teaching people how to use the computerized health record system. She was planning on doing a residency in the US which is what she will need in order to actually work as a doctor here. She will have more, but very different experience, than the other residents in her program, since she has already done a residency and fellowship training, but she will also have to settle for a probably not excellent training program because, as an Indian trained physician she will not be very competitive. The other was a dialysis and IV tech who was the go-to person when any intravenous catheter was needed. He had finished medical school but never practiced as a doctor in India, but he did own two hospitals there, which his brother was running while he was in the US. He answered several questions I had about medicine in India.

In India there are private hospitals, which are entirely funded out of pocket, and there are government hospitals, which will serve anyone who can't afford to pay. Most people prefer private hospitals because the care is better and the hours are better and because they are actually pretty inexpensive. "If you need a coronary artery bypass," my friend said, "and you have $2000, we can get you one." They buy medical equipment from China, where it is cheaper than in the US. He bought an EKG machine for $1700 that he priced in the US at $17,000. This allows him to provide services for costs that regular people can afford.

So why do Indian doctors want to come to the US, then? It sounds like things work pretty well there. Actually things don't work very well there, from many different perspectives. Infant and maternal mortality rates are very high. Emergency care is extremely poor, even in big cities. Here we pride ourselves on getting peoples' heart attacks and strokes treated within an hour, which saves people from long term disability. We have well trained paramedics and EMTs who can rescue people in the field who have accidents or injuries. This kind of care is rarely available in India. And then, of course, there is the money.

Doctors in the US can make a lot of money. Huffington Post had an article that looked at the best paying jobs in the US, and doctors and surgeons were at the top of the list. The doctors who make the most are in varying fields, some of which might be considered the dirty jobs that nobody in their right mind wants to do. Some of these dirty jobs are in the field of internal medicine, my chosen specialty. Internists often go on to specialize in hospital medicine and nephrology (kidneys) which are jobs that put one in the position of always treating patients who are pretty sick and having terrible hours. Hospital medicine is usually in 12-14 hour shifts during which one must see a crew of up to (or even more than) 20 patients, all of whom could, conceivably, need the doctor at the same time. Nephrology involves knowing the sickest of patients, folks whose kidneys no longer work, who have dialysis 3 times a week, which they don't love, and which is the nephrologist's bread and butter. It is not at all uncommon to see a large proportion of hospitalists and nephrologists who are graduates of foreign medical schools, especially Indian ones.

Doctors in the US have to put up over a quarter of a million dollars just to go through medical school, and since a fair portion of this for US trained docs is funded by loans, early in a doctor's career quite a bit of salary goes into paying off loans. In India, though, tuition and fees at a medical school are nominal. The medical education system is run by the government, or so says a friend who trained there, and many (though not all) of the schools are excellent. Education is in English, so Indian doctors do not have much of a language barrier once they have finished school. How very very tempting to come here, repeat a little medical training and then make more in a year than you could in 10 or 20 years in India. But why the US? Certainly other countries also pay doctors huge amounts of money. Well, actually, no.  Although some articles looking at cost of living and such say that the US is right in line with other developed countries, I don't entirely buy that. Our absolute salaries are definitely higher, and a person can live on very little money in the US if they put their minds to it. A doctor practicing long hours can eat at the hospital for next to nothing, sleep and shower there, and some do, especially foreign medical graduates, who are probably supporting whole extended families on their very generous paychecks.

So here's how it goes, how the little mysteries arrange themselves.  America loves medicine (gross generalization, but based in truth.) We pay our doctors really well (except primary care, because it's sexier to cut people open and save them from the jaws of death than keep them from getting sick in the first place.) We have to be paid really well because medical education is really long, hard and expensive. Hospitals are becoming the pocketbooks for the American healthcare dollar. They
pay us really well because otherwise we would refuse to work for them. They get us to admit lots of really not very sick patients in order to stay in the black and we cooperate because they pay our generous salaries. Patients get procedures that they don't need and become convinced that they are really sick and really depend upon the medical profession or they will certainly die (of sepsis.) Foreign physicians come here because the pay is so good that it is worth working in hospitals that are in the middle of nowhere after journeying far from the land they love.

What is the actual problem, though? We are wasting our time and energy treating patients who are not sick and convincing insurance companies that they are sick. This is bad for everybody. Some of it may be driven by fear of being sued, but more, I think now, is driven by money. We have such wonderful technology now for treating truly sick and salvageable people, but we waste it on people for whom it is not appropriate. It is not a problem that we have lots of foreign doctors (other than the issue of stealing them from their generally underserved countries.) They have interesting perspectives and skill sets and they take care of patients in rural areas and in unloved specialties. The fact, though, that foreign doctors are flocking to our shores may mean we are paying doctors too much money.

Second thoughts about my ranting:
In addition to the apology, above, to hospitals which are trying to make enough to survive, I realize that I have also been somewhat misleading to patients who may be reading this and have been admitted to the hospital. There are still plenty of patients admitted to the hospital for very good reasons. There is no actual shortage of really sick people, truly and dangerously sick people. But there are more not-very-sick people in certain hospitals than would be ideal, and once admitted, such not-very sick people can stay there for a long time. (An old adage says "no reason to admit means to reason to discharge.") The culture of a hospital and the population it serves determines how many of the patients inside are really sick. Some hospitals are at capacity for the population they serve, and simply cannot admit patients who don't really need to be taken care of in a hospital. Inflating the severity of illness in documentation is common even in these high acuity hospitals in order to get stingier payers, like Medicare or Medicaid, to pull their weight. These two entities pay far less than private insurers and usually require much more specific documentation. They will pay our hospitals more if we, for instance, document "hypokalemia" when the patient's potassium level is a little low, but if we say "the potassium is a little low" that won't count. So we end up making long lists of little picayune things that are wrong using big Latin derived words which makes a patient appear to be horrendously complex and gravely ill. Right now I could probably give myself a list of dire sounding diagnoses if I really put my mind to it (I'm thinking rhinorrhea, actinic keratoses, menopausal syndrome, shift work sleep disorder, presbyopia, irritable bowel syndrome, female pattern alopecia, chondromalacia of the medial femoral condyle, bunion deformity) though I'm actually vigorously healthy. Just going through this exercise makes me want to start thinking about buying a prepaid funeral policy. I will continue to assert that inflating diagnoses and severity is wrong, but it is based in our perverse payment system, not a result of individual greed or dishonesty. 

Saturday, October 27, 2012

Balancing the budget: how exactly will we eventually pay for health care?

This week the American Medical News featured an article with the disturbing title, "Massive health job losses expected if Medicare sequester prevails." I wasn't entirely sure what a "sequester" was, since I thought it was a verb. Sequestration, I thought, was the noun. (I hear a loud knock. It must be the grammar police.) The story, as I understand it, is that when our government decided to pull together and raise the debt ceiling, they also passed the Budget Control Act, which was intended to reduce the deficit by $1.2 trillion by 2021. This was to be achieved by a bipartisan Joint Select Committee on Deficit Reduction, which would make well considered cuts in funding for various projects. They were unable to come up with a plan that they could agree upon (imagine that) and so automatic across the board spending cuts are mandated to go into effect in 2013, excluding only a few programs, such as childrens' health and disaster funding, and capping yearly cuts to sensitive programs such as Medicare to 2% per year. These funding cuts are called "sequesters."

This sounds so very familiar. Several years ago Congress passed the "sustainable growth rate" formula which mandated that medicare costs would rise only as fast as inflation. Up until recently Medicare costs continued to outpace inflation, and so yearly congress must legally cut Medicare payments, across the board, but then at the last minute they don't. Doctors and patients say that the program will surely not survive since across the board cuts mean that as well as cutting the numbers of unnecessary procedures and devices that are used, we must also cut payments to primary care docs, who already receive far less than they are willing to accept in payment for office visits. Applying the SGR is then delayed, again, by a last minute agreement. Congress does this at least yearly.

Across the board cuts are a bad idea, yes they are. Some parts of programs need to be cut and others need to be grown in order to make systems more efficient. Good primary care more than pays for itself in saved hospital costs (I'm making this fact up entirely out of reason and good sense. There are no studies that exactly address this question.) If payments to hospitals shrink, it should be via improved health of populations who then will need less hospital care. But across the board cuts don't allow for this. So, one might imagine, the specter of across the board cuts would be very effective in making us come to a consensus on how we could control expenditures so that such cuts would never become necessary. It clearly has not been an adequate deterrent. Doctors and others in the field of health care continue to allow their piece of the financial resource pie to grow, to the detriment of all kinds of things.

Nobody, it seems, wants to be seen to cut money that goes to programs when doing so would anger a significant portion of the voting population. And lawmakers don't really understand that there are huge areas of unpopular inefficiencies whose elimination would be mostly painless. They don't know this because they are rarely in the thick of medical care, either as caregivers, health care providers or patients. Those who know about inefficiencies are too busy to speak up or are not likely to be heard by lawmakers.

But on the subject of job losses related to cutting spending on Medicare--yes. That will absolutely happen and there will be economic repercussions. Excess money spent on health care sometimes goes into the pockets of greedy people who already have enough money, but it also supports families, via health care employees who do jobs enmired in inefficiency, such as insurance adjusting and device sales and pharmaceutical advertising. These are homegrown jobs and paychecks often go to local industry and support real live American people pursuing life, liberty and happiness. The inefficiencies of health care sometimes grow our economy, but at the cost of lowering effective take home pay for all insured workers and creating dependent and indebted individuals who are forced by ill health or poor decisions to make use of acute care.

What to do? I would favor some kind of health care industry/government collaboration to make binding decisions regarding where best money can be removed from the Medicare budget. Failure to come to an agreement should not be an option.

Thursday, October 18, 2012

The Ryan Plan and the Affordable Care Act--can market forces improve quality and cost in health care?

In today's New England Journal of Medicine an article by Republican health policy analyst, Gail Wilensky, brought up several excellent points. The article is entitled "The Shortcomings of Obamacare". She points out that the Affordable Care Act does not directly address the forces that have lead to high costs and less than optimal quality in American health care.  She points out that physicians are paid according to a relative value scale that creates perverse incentives to do more procedures regardless of whether they work, and that this has not been addressed by the ACA. She says that if we want to use market forces, putting consumers in a place where they can have an impact on cost and quality of the care they receive, we should look to Paul Ryan's health care proposal.

So I did.

I read the version called "Summary of the Legislation" in a .gov site dedicated to the "Roadmap Plan" that is part of a republican budget. It is much simpler than reading the ACA. Perhaps if it is in the form of an actual bill it will also be 1000 pages, but I doubt it since it covers much less. It appears to be a tax and insurance reform that allows people to pay for health insurance with tax credits, and aims to transition medicare to a voucher system which gives medicare recipients an amount of money equal to the average cost for a year's healthcare on medicare to be used to buy private insurance. The medicare change would not go into effect until 2021.  People would be able to keep their insurance when they changed jobs, and insurance companies could sell coverage across state lines which would improve competition and maybe costs. There were also provisions for income tax reform and for privatization of social security.

The amount of tax credit that a person would receive was less than I pay for my super high deductible plan by a substantial amount, and my family has no health problems. A medicare voucher equal to what medicare pays out per person would come close to buying insurance for a healthy elder but would not approach the cost for someone with multiple medical problems.

But that isn't the big issue with the Ryan Plan. The big issue is what Gail Wilensky said in her article: market forces are not acting to reduce costs and improve quality. There is no way that market forces will do what they do so well as long as people depend on insurance companies to pay their bills. Dr. Wilensky implies that the Ryan Plan will do that, but it won't. With the Ryan Plan people would maybe shop smartly for health insurance, but even that is questionable. Health insurance companies are so good at misrepresenting their product that it would take a genius with nothing else to do to figure out which plan does what and for whom. But even if we were able to find cheaper, better insurance through the magic of the free market, we would still be financially detached from our actual health care. We would still continue to be seduced into more, better, fancier, technologically more advanced care which might but probably would not make us healthier.  This would happen, is happening, because insurance pays for these things, and it is always nice to get as much care as possible after paying a hefty health insurance premium. Doctors would continue to make more money for doing more stuff, but not for better outcomes. At least the Affordable Care Act, in its more than 1000 pages, has some provisions that would create incentives for doctors and hospitals to keep patients healthier.

Dr. Wilensky also says this thing that people say when they talk about what's wrong with our system: she says that it is a big problem that such a large number of people in America are uninsured. That just isn't the issue. The problem is that such a large number of people don't have adequate medical care. Many of these people are insured. Costs have gotten so out hand, due in part to the third party payment by health insurance companies, that the consumer's portion of the cost is still out of reach for many people. They can't afford to go to the doctor or buy the medicines they are prescribed because the out of pocket costs are just too high. There is also a looming primary care shortage which means that, even with money, many people who live outside of the metropolitan areas where doctors are plentiful can't get a good doctor at all.

What I see in hospital practice is that many patients are getting expensive procedures done that really don't work. A patient will get 3 or 4 cardiac stents put into minimally narrowed arteries when they were not really having troubles that couldn't be solved by taking a medicine or improving their lifestyle. These stents cause their own problems, require their own dangerous pills to work, and often cost hundreds of thousands of dollars. People get multiple ablation procedures for heart rhythm disturbances which don't work. People get joint replacements which don't reduce their disability. All of these procedures are life giving and wonderful when used appropriately, but since insurance pays for them and doctors, hospitals and medical device companies make lots of money when they are performed, many more are done than are truly beneficial.

I would like to see everyone get adequate medical care. Health insurance companies have been in the business of making money for themselves and their shareholders for a very long time. They are not our friends. I don't think most of them have the ability to be repurposed to help channel the truly adequate amount of money we presently spend on health care such that it buys health rather than the commodity of medical services. Community based cooperatives have the potential to do this. Transitioning to this would be slow and maybe painful, but ultimately so very worth it. We need to stop thinking of health insurance companies as the disagreeable but necessary body guard that stands between us and health care related financial ruin, because there are other options.

Tuesday, October 16, 2012

The changing nature of truth, answering questions for a chance to win a free MKSAP subscription and should we now stop using warfarin (mostly) for atrial fibrillation?

I am presently really excited about learning all over again what I thought I knew when I finished my medical education about 25 years ago. Since that time I have become wiser, learning how to do things and what works for patients by practicing medicine and reading literature. I also retain a body of knowledge that I absorbed from my grand old doctor professors at Johns Hopkins which is sacred and dear and not necessarily true.

Just recently in my e-mail I got an invitation from the makers of the MKSAP (the medical knowledge self assessment program which I used in studying for my internal medicine boards) to answer a set of not-ready-for-primetime questions in the various subspecialties, for which I will be rewarded with a chance to get the next MKSAP materials for free. I must answer these questions without using outside materials and the answers from all of the folks who do this will be used to standardize the test.

I took the endocrinology section first and had an answer for each of the questions, based on what has been true over the last 2 decades. I then looked on UpToDate, the online resource that is updated constantly by recognized experts in every field, to find whether I had been right, and yes, sometimes I was right. But the answers I found didn't necessarily even correlate with the multiple choice answers, obviously also written by worlds' experts. So on subjects about which it is critical to do the right thing, it is really not clear what that is.

When I graduated from medical school I knew the right answer to questions that were of the ilk where there might be a right answer. Like "Is chemotherapy helpful for pancreatic cancer?" or "What are the most effective antibiotics for a simple urinary tract infection?" At some unclear moment in time, those and many other answers that I knew were no longer correct.

While cruising UpToDate I chanced upon a page called "Practice Changing UpDates" in which I found that a whole bunch of things that we do are wrong. I always feel warm inside when I find out that something that had seemed unnecessarily painful or expensive or complex is of no value. I wonder, though, how soon these new recommendations will also be wrong and when, perhaps, the previous ones will be right again, or whether the whole thing is a huge oversimplification and everything we've ever done was perhaps right, given the appropriate circumstances.

But a larger issue, for me, is the fact that it is now completely impractical to be an expert in the field of medicine, unless perhaps the field of knowledge to which on aspires to have wisdom is itty bitty. Research is just happening so very fast, communication is nearly instantaneous and discussion amongst the many diverse practitioners who very much have a right to their own educated and experienced opinion is limited. For instance: last night I heard another physician tell a patient that he shouldn't drink so much coffee because he was having heart arrhythmias and the coffee would make it worse. He had heard a cardiologist say this and berate another physician for allowing a patient with a heart attack to have a cup of coffee. Studies show that coffee doesn't cause heart arrhythmias and that it is in general good for people in large quantities, reducing risk of liver disease, diabetes and all sorts of realms of misery. But certainly the studies that purport to show that coffee is of no harm and nearly infinite help are not designed to look at this particular individual's risk from caffeine, which definitely can cause an increase in heart rate (check your own pulse after a strong cup if you are not a habitual drinker.) What is true, then, about coffee, or anything else for that matter?

But all that said, I do think the news from UpToDate as of September 20, 2012 is pretty interesting, if not necessarily true.

Of the clinical pearls in the article, 3 stand out as particularly relevant to my practice. First--people with allergy to eggs CAN get a flu shot, even though it is made with eggs, because there is hardly ever any problem. They should be observed for 30 minutes where there are personnel capable of handling an allergy issue after vaccination, but they can go ahead and be vaccinated. The question of how important vaccination is for healthy adults and children is, of course, not addressed, and is still very controversial.

The second is that UpToDate recommends use of Pradaxa (dabigatran), Xarelto (rivaroxaban) or apixaban for prevention of strokes in patients with atrial fibrillation rather than Coumadin (warfarin.)  I have written several articles about these new drugs which reduce the ability of the blood to clot and do not require monthly blood test monitoring. They are not easily reversible should abnormal bleeding occur, but honestly neither is warfarin, and the risk of bleeding is so much higher with it because of all of its drug and food interactions and its tendency to be taken wrong. The new drugs are more expensive, but with the expense of monitoring and paying for the morbidity from bleeding or clotting when using warfarin, the costs will end up being similar, and much less once there are generic options. There have been studies looking at various possible risks of the new drugs, including more heart attacks with the use of Pradaxa (dabigatran) but the vast magnitude of error related illness with warfarin dwarfs these risks.

And still. After all of my ranting, I am absolutely positive that many patients will still find that warfarin is the best drug for preventing clotting. There are many people whose doses are always perfect and have absolutely no problems, monitor their own blood tests at home without difficulty and the drug is, in fact, cheap. I could go on with pros and cons for a very long time, but I won't.

I would really like to see these new anticoagulants replace most of the injectable anticoagulants such as enoxaparin and dalteparin since this will profoundly change the way we treat patients with artificial heart valves and blood clotting disorders such as pulmonary embolism.

Last on the "Oh, cool. Finally." list is that it is unnecessary to follow liver function tests for people taking statin drugs such as lipitor (atorvastatin), crestor (rosuvastatin) and simvastatin. They are not liver toxic. We thought they were and they aren't. Again, like with the flu shot, the question of whether so many people should be taking these drugs is begged, but at least they don't need to get blood tests all the time. They also don't need to get their cholesterol levels checked all the time if they are on a dose that is stable and works, but that isn't part of the article, just information from long ago that still hasn't made its way into standard medical practice.

Wednesday, October 10, 2012

Back, but still a bit jet lagged: Health care in the Republic of Georgia

The Republic of Georgia is beautiful, welcoming, has great food, ancient and rich culture, is quite inexpensive, and I am now back. The language is fascinatingly complex, with an alphabet that does not resemble ours in any way, and the capital, Tbilisi, has the feeling of a thriving European city, but there is almost no crime and you can see snow capped mountains and farmed fields if you look up or out. I did no doctoring, but did sit down with a now unemployed pediatrician who told me a bit about their health system. I also talked to other Georgians about how they felt about their health care. Georgians are proud of their wine, their music, their architecture, their food and their loyalty, but they are not particularly proud of the quality of their medical care.

In the Soviet era, before independence, health care was entirely state funded and mainly based in hospitals. After the fall of communism, Georgia was torn apart by the sudden dissolution of their economic system and loss of their major trade partner. Health care rapidly deteriorated and most people had no money to cover it.

Government sponsored insurance covers some of the health needs of kids up to age 6 and adults over the age of 60. Families and patients are still responsible for paying for treatment of serious diseases in kids, and I'm not sure about the elderly, but it sounds like they also have to pay out of pocket for serious illnesses. Doctors are not particularly highly respected or highly paid, though they now have about as many years of education as we do in the US. I'm not sure how good that education is, however. A primary care pediatrician may see 15 or 16 patients on a busy day (a light load by US standards) and make a little over $100 a month.  A highly paid surgeon might make as much as $800 a month. Doctors do not make more than the average worker, and some make less. The cost of living is lower than in the US but not correspondingly lower. Some medical care is inexpensive by our standards: an office call for an uninsured patient costs about $15, but that is actually very expensive for a Georgian. The full cost of a surgery, per my pediatrician friend, might be as much as $15,000, which almost nobody can afford. People do die because they can't afford medical care, though hospitals will not refuse to treat the very ill on the basis of inability to pay. Like in the US, there is a safety net for the very sick and the very poor. My pediatrician friend does not know where the money that people pay for medical care goes, but it is not to the doctors.

Dental care, on the other hand, is a good deal. A British friend said he had gone to Georgia for a root canal which cost around $100. The work was excellent, he said. I don't believe there is dental insurance.

Wikipedia tells me that life expectancy is a little over 74 years, which is low by the standards of the more wealthy European countries and their maternal and infant mortality rates are somewhat higher than those countries, though not as bad as the rest of post-soviet Russia. Smoking (over half of the male population smokes) and automobile deaths are public health issues that contribute powerfully to death rates, but there is still a significant amount of preventable and treatable infectious diseases that kill people.

There is no shortage of physicians in Georgia, with about 1 per 200-250 people. But for whatever reason, quality, cost, accessibility, they are not used.

What wisdom can be gleaned from all of this? There are many recipes for not-good health care systems. In Georgia's case, a soviet model of health care delivery, followed by economic collapse and a war plus many doctors without access to basic technology and without high standards of competence predictably has not been successful. Clean water, adequate nutrition and strong communities go a long way towards keeping the health of the country good despite lack of what I would consider to be adequate medical resources.