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From Russia with love

April 2010

I generally do not write autobiographical blogs. That’s because despite my title’s reference to James Bond, no one would confuse my day-to-day existence to anything remotely out of a 007 movie. But this entry skirts my usual rule, as I have just done something interesting: I spent a fascinating four days in St. Petersburg, Russia.

I was at an art history conference courtesy of my wife who is a university professor. The conference was sponsored by Gazprom, the country’s major energy company.I know nothing about art–or, for that matter, history–but an offer to go gratis to Russia, with help from a company that had revenue last year of almost a $100 billion was well worth it. I now believe I am the only hospitalist who has ever been vetted by the KSB, formerly the KGB, which I needed to be admitted to the Boris Yeltsin Library. Needless to say, the whole experience was unforgettable.

Immediately before I jetted off to the former Soviet Union, the health care reform bill was signed into law, so it was on my mind as I set down in a foreign country on another continent. Some would have us believe that as a result of this new law, our heath care system is about to be completely socialized, so what better to investigate while abroad than how socialized medicine is working for the Russians?

To kick off my intrepid reporting, I first familiarized myself with a few local traditions to better blend in. Fortunately for me, one such custom stipulated that vodka–and only vodka–was to be consumed after a toast had been made and then downed in one swig. Another local habit: Smoking cigarettes as if they were oxygen delivery devices, a local predilection I was, happily, able to avoid.

As if vodka were a truth serum, I got an earful of reality about Russian health care. If you need basic care, and by that I do mean very basic care, everyone has access. If your health care needs are more complicated, be prepared to wait a long time or be willing to pay much more money out of pocket than most can afford.

The other option is to find healthcare in another country–again, an option available to only a select few. But Russia is an extreme example of socialized medicine gone bad, and the demise of its health care system has more to do with the country’s political history than it does with the basic tenets and structures of socialized care.

As this was an international conference, I had a chance to speak to people from many different countries, including Germany, France and England. Most of these Western Europeans were generally happy with their health care system, but all complained of longer wait times and difficulties with getting subspecialty care, at least when compared to how our current American system works. They also noted that those with money were able to move ahead in the line, hardly a surprise no matter which the nation or particular political system.

Well, where are we left by my brief and wholly unscientific investigation–one probably more hindered than helped by the fact that my field research took place during social hours, in the company of the aforementioned vodka and drunk by me in the name of international camaraderie? Allowing for the assumption that more nationalized care will mean more restrictions on expensive treatments, should we be afraid, very afraid? Or not?

The answer is … maybe. Of course, while it is clear that reform will lead to more socialized medicine, we were indisputably heading in that direction anyway. Just look at the recent MGMA data I read (while downing caviar) that demonstrates the following: for the first time more doctors are now employed as opposed to owning a private practice. For the purposes of discussion, let’s call these docs the “proletariat” for large tax-exempt non-profits, almost all of which are employed by companies that depend on the government for their existence. On the demand side, the employer benefit of health insurance is collapsing for many, even if they still have a job. I know few hospitalists who don’t have countless stories about how no insurance or poor insurance has devastated patients and their families, both financially and emotionally.

So, what is my read of reform? It is a positive step toward two important goals. First, as has been said for many years by many people, health care is a right and not a commodity. Health care reform seems poised to further this idea in both ideology and practice. Second, we must attempt to have a mature and rational dialogue on how best to ration care that is of limited benefit. Maybe, hopefully, somehow this will start to happen through evidence-based medicine driven through EMR and proper incentives.

Of course, none of this will happen overnight. And perhaps we will see many revisions of the current reform before true progress is made. But something had to be done before our system collapses under its own weight–overloaded, bankrupt systems tend to do that (cue Soviet national anthem here).

On the off chance that any Russians are reading this blog, I wish to thank them for their overwhelming hospitality. And all tongue-in-cheek aside: my sincere condolences for the inexplicable terrorist attack that occurred on the day that we left.