Terrorism's Ripple Effect

Our family has experienced a "ripple effect" from this year's attack. My son's girl friend was stranded in Chicago, so he drove to Denver to meet her half way. On the way home his transmission blew out in a small southern Colorado town. The car was towed, and he had to spend time away from home and work.

My youngest daughter has a dear friend who lives in a northern New Jersey area that is a bedroom community for people working in Manhattan. Nearly every family in her area lost a family member in the attack. These repercussions far away from "ground zero" are what I would call the "ripple effect."

How does this terrorist attack on the other side of the country affect the practice of medicine in California? I do not know all of the ramifications, nor does anyone, yet. I do predict repercussions for us in California. These will not allow us to practice "business as usual."

For one thing, the discussions and concerns about bioterrorism seem to be in the news continuously. Anthrax has escalated into a terrorist scare. Pictures of plague and smallpox victims appear on the Internet to familiarize practitioners with what would otherwise be exotic diseases of no importance. County health departments say they are not ready to deal with the effects of a terrorist attack.

There may also be financial repercussions that affect physicians even more. Recession is a very real threat, if not already underway. Money will be diverted from other projects to the war on terrorism, so less will be available for worthy projects. Too often, medicine is ignored as soon as a "crisis" develops elsewhere. Look at the energy crisis in California earlier this year. Yes, this year! Seems long ago, doesn't it?

How much money will the fight on terrorism take? How deep will the next recession be? Health care premiums are climbing, and medical group insolvencies are spreading. Health plans are pulling out of the Medicare market in certain areas. All of this financial uncertainty may lead to much less money available for medical care. If the financial hemorrhage continues, will we in medicine be asked to cut back on services we offer patients? How do we cut back on services already mandated by state or federal regulations?

I do not have the answer to these tough questions. I would welcome others' input. One concept, though, that warrants consideration is the concept of triage of services according to value. It is basically the Oregon Health Care Proposal instituted for a different reason. Oregon, as you remember, did not have enough money in its state health care budget, and so gave priority to services it would pay for based upon a value scheme. Pediatric immunizations were high on the list and covered, while liver transplants were not. At one point, there was talk of this system going nationwide, but it was quite controversial and did not spread.

If health care shifts so the patient controls more of the health care dollars, and there are fewer and fewer dollars available, then our patients will begin asking us a very crucial question: "Doc, what really matters?" Are we prepared to answer that question? Much of what we do now is out of force of habit, and concern about malpractice or that rare disease that could potentially occur. None of these practices is inherently bad. However, we may have created some cushion in our health care spending. We now desperately need to re-examine what is important in medicine.

If we don't, then politicians will decide where the money is to be spent in medicine. Unfortunately, doctors are too often unwilling to state that a service or test is not absolutely necessary. However, we physicians are in the best position to decide what is important.

I may be more sensitive than most to what happened on September 11. I would like to see physicians and legislators in California come to the plate - physicians by providing excellent advice on priorities in health care, and legislators by changing rules and regulations to accommodate these priorities.

"Business as usual" may not be a viable option.

robert.midgley@kp.org