new world
health care reform

Healing the System
Facing down fear of change, compromise difficulties, and risks of stressing the already fragile system, the government is challenged to deliver a “sensible hybrid” that provides good care resulting in high satisfaction rates for medical personnel and patients alike. In this interview, Dr. Sidna Tulledge-Scheitel discusses her hopes and concerns, putting the spotlight on human dignity.

by Suzanne Tanzi

The task of health care reform looms large, with 48 million uninsured, expenses escalating well beyond the current 16% GNP, impending Medicare bankruptcy, and the decline of insurance provisions from employers, not to mention the widely variant quality of care and the USA’s number one ranking in the “avoidable deaths” category. This is the situation President Obama’s reform is attempting to face. Dr. Sidna Tulledge-Scheitel has worked as a primary care general internist at Mayo Clinic in Rochester since 1988,  a front-line practitioner has treated hundreds of uninsured. She reflects on the necessity and potential of the proposed overhaul of the current system.

What has led to your interest in following health care reform?
I think what woke me up to trying to really judging the situation was the invitation of Fr. Jerry Mahon [a parish priest in Rochester] to speak at the CL Community Day in September, a talk for which I prepared and reflected a lot over many weeks. Being a physician, I have encountered patients who have health insurance with large out-of-pocket responsibilities or no health insurance at all.  This results in the inability to pay for necessary tests and treatments, leading to sometimes devastating outcomes–one of my patients just recently had a forefoot amputation for gangrene because of no insurance.  What happens is that if patients have no health care insurance, they may be denied an office appointment.  However, by law, anyone who presents to an emergency room for assistance must be treated.  This results in addressing the most serious health concerns in the most expensive care venue with no attention to the whole person’s needs (preventive care, immunizations, chronic condition management). And quality of care is variable across the country; news about avoidable deaths in the number one ranked United States compared to the rest of the world is sobering.  
I was just at a medical conference in Boston where the keynote speaker [Stewart Altman, Professor of National Health Policy, Brandeis University] addressed the necessity for reform by saying, “Health care is trying to grow flowers in a toxic environment.” Due to the obvious need to judge and change, I have been disappointed by inaccurate representation of the health care reform going on in Washington.  Fully discerning the issues is critical to contributing to the solution and will help shape this important legislation–being radically pro or con will certainly not help the process.

Why do you think so many people are against the reform?
I think that many people are afraid of loosing something–maybe their current health care benefits, income (even through taxes), or their autonomy. There is acute concern among the senior population, who fear that, when all is said and done, their lives will not be valued as highly and their care management will become even more difficult. There is a lot of fear around the unknown, which is valid, but in the end some trust that we shall all be adequately provided for is necessary. Other concerns include those linked to very sensitive matters, as the remarks by the bishops on abortion remind us. We have to pay attention to these issues. Where we don’t want our fears to be realized, we must take action toward being heard by our government representatives, catalyzing the community to become informed and to speak out.

While the current system is drawing the most attention for its costs, and the containment of these costs, do you think enough emphasis is being placed on quality of care as well, and the “whole person’s care needs”?
The health care reform legislation is currently a work in progress.  The initial federal bills contained very little on improving the quality of care.  Health care quality may improve if payment does not incent delivery of a high volume of services but incents delivery of high value care, with value being defined as quality + service + safety/cost. We don’t want the federal government putting rigid controls on the care process–they can put general infrastructure guidelines in place, but specific controls should be placed a little closer to home where the action is occurring in the various states and locales.

Do you agree that universal insurance is a necessity, and why?
Health care is a basic human right.  Health care insurance should not be dependent on employment or citizenship.  The mystery is present in the face of every person.

What do you mean?
 First of all, it means, as a primary care physician, that I don’t see them as their diseases but as whole persons. This provides me with a greater capacity for patience and compassion. I once heard this termed “digging for gold”–finding the goodness in each person.

Do you think such a reform will transform the way doctors view their own work?
One of the most satisfying aspects of being a physician is the relationship that unfolds between the physician and the patient. It is through this relationship that healing and comfort become a reality.  I am hopeful that any health care reform will preserve these relationships.  Income and risk of litigation may be modified through health care reform. Certainly these changes will influence some health care professional career choices.   

How feasible is total coverage in terms of support facilities and personnel?
Providing universal health care insurance is only a part of the solution that allows for universal health care access.  It is projected that by 2020 an additional 40,000 primary care providers will be required.  Access to health care is highly variable across the United States.  In general, rural areas are experiencing health care provider shortages already. Massachusetts, touted as a health care model, has been successful in providing health care insurance for 98% of their residents; however, there is an inadequate number of primary care providers, which has resulted in increased emergency room visits.  

On November 7th,  the House of Representatives passed H.R. 3962, the Affordable Health Care for America Act, by a vote of 220-215, leaving the Senate running to catch up while mired in financial concerns and abortion language. Are there major internal obstacles to a comprehensive package, and how realistic do you think President Obama’s year-end deadline is?
One of the biggest obstacles will be compromise between the committees. There are many different approaches and priorities still flying around. Some have said that the final bill will probably look more like the Senate bill, which has been influenced by the Massachusetts system, but there is no way to know that for sure. What we need to settle on is a high value, coordinated care payment reform proposal, using shared electronic (IT) medical records–infrastructure guidelines that are used across the board so that information can be shared with discretion and efficiency. This latter will be another great challenge for the future of the process.
 As for the year-end deadline, I feel we should emphasize that it is a journey and not something to rush. The journey started long before Obama and there has been a lot of progress in the past decade.

What does the USCCB offer to this challenge and do you think they have a voice in this debate?
The United States Catholic Bishops are strong supporters of a health care reform.  They support the provision of universal health care insurance and view health care as a basic right.  They support the expansion of public programs (Medicaid and Medicare) and government subsidized premiums for those who can’t afford to pay the full premium.  They support providing health care insurance for immigrants.  They do not support direct or indirect funding of abortions.  Indirect funding of abortions can result from the government’s Insurance Exchanges offering health plans that cover abortions. The bishops also support preventing discrimination against any individual or organization that refuses to provide, pay for, provide coverage of, or referrals for abortions.  The USCCB continues to participate in the formation of this legislation through a wide array of communication means. While the  bishops are supportive, and they seem hopeful that some aspects of the current plans may work, their reservations are valid and need answers, particularly  those concerning the value of every life, including the unborn and the undocumented, and the right of health care workers to refuse to perform procedures that go against their conscience. We Catholics have much at stake here. Our role is to participate. The Catholic Church has always been at the origin of the health care needs of the people of this country–20% of all our hospitals were initiated by Catholics. Even my own hospital, Mayo Clinic, originated as St. Mary’s Hospital, begun by Franciscan nuns with the cooperation of the Mayo brothers (Charlie and Will), both doctors.

What are your highest hopes and what do you fear most for this proposed overhaul?
I am hopeful for universal health care insurance payment reform that incents high value care, adequate urban and rural health care access, integration of health care systems that will allow for care coordination coverage of health care services, and provisions to prevent illness.  I am fearful of continued escalation of health care costs, of abortion services being covered by this legislation, and of discrimination against any individual or organization that refuses to provide, pay for, provide coverage of, or refer for abortions. 

All said, do you think we are moving in the direction of the transformation of the human that values each and every person with the right to dignified care?
This is my great hope, that we can stop trying to “grow flowers in a toxic environment.” The status quo has been shaped by what we doctors call the “tyranny of the visit”–everything must be billable and only through the protocol of office visits that are not necessarily the most efficient or inviting means to good care. Since everything is revenue driven, we haven’t the convenience of serving people in their homes, even through electronic consultations and telephone calls (which are nonbillable).
There has to be a kind of sensible hybrid in measuring quality as well as cost, with more attention to good care and high satisfaction rates. I think that people choose to enter this field for noble reasons. Universal healthcare may evolve to address every need person by person, and it may continue to attract the right people for the right reasons while supporting their ideals in such a way that they do not become jaded, they do not have to choose certain specialties to guarantee time with their families, for example.
It is up to each one of us to educate ourselves and stay current on the evolution of the process, contacting our congressmen to let community opinions be known, discussing in churches and other public forums, and really praying that with universal health care will come the even tacit realization that “human nature, by the very fact that it was assumed, not absorbed, in Him, has been raised in us also to a dignity beyond compare” (Paul VI, Gaudium et spes 22).