Last night, President Obama diagnosed the disease: runaway healthcare inflation. The cure: “We must address the crushing cost of health care.” If we don’t we will never be able to bring down our budget deficit—a deficit that Obama pledges to halve by the end of his first term. As Peter Orszag, the president’s budget director, observed in October: “the nation’s looming fiscal gap . . . is driven primarily by rising health care costs.”
President Obama stressed that we must begin Now. At the same time, he made it clear that he does not have a finished plan in his back pocket: “There are different opinions and ideas about how to achieve reform,” he acknowledged as he called for a summit to begin work on this issue next week. “I suffer no illusions that this will be an easy process,” he added.” It will be hard.”
We need to begin immediately because the road ahead will be long and arduous. Reiterating his commitment to “quality, affordable care for every American,” the president explained that his budget will include a “down payment” on health care reform. I’m inclined to interpret this as a signal that reform will come in stages.
The president added that universal coverage can be paid for “in part by efficiencies in our system that are long overdue.” Making the system more efficient means “rooting out the waste, fraud and abuse” in our Medicare system, the spending on unnecessary and ineffective treatments “that don’t make our seniors any healthier .”
But greater efficiency will provide only “part” of the needed funding. I take the President’s emphasis on the deficit as a sign that he does not plan to finance healthcare reform with deficit spending He leaves the problem of finding the rest of the money to Congress.
In an e-mail, earlier today, HealthBeat reader Brad F. wrote: “We all know the death knell for a congressperson is asking for tax hikes. It is as if Obama is giving them a pass, ie, the commander in chief is saying it is O.K. This is what the "bully pulpit" is all about. Win the people, and the legislators will have to follow. The fact that he is signaling to us, the voters, that congress has to fall in line (as in it is OK to ask more of us in taxes, sacrifice, etc) is the first step in getting things to turn around.”
I agree. In my next post, I’ll be talking about a very recent and very candid Commonwealth Fund report which makes it clear that universal coverage will almost certainly require tax increases.
Maggie:
I’ve looked over the comments on the NY Times site (still waiting for your contribution) and what is interesting is the number of things about health care that people have found that are wrong.
These range from overpriced drugs, to expensive medical education, lack of computerized records, insufficient primary care physicians and nurses, greedy and inefficient insurance companies, excessive treatment especially at end of life and fear of liability.
These are all valid concerns, although one could dispute how much each contributes. What it indicates is that there is a fundamental fault which underlies all of these problems. Its the Gordian Knot problem, we are pulling at threads while the solution is to cut the whole tangle with a single blow.
It seems to me the basic fault is tying profit to health care. If one wants to have a private sector then it has to be heavily regulated as in Germany or Japan. Otherwise one has to move to a government-administered program like Britain’s NHS.
Since the American ideology is that private enterprise and profit is preferred to government administration, I don’t see any comprehensive new plan reducing costs appreciably. We might achieve almost universal coverage, but low cost implies removing the profit motive and that seems unlikely.
Universal health care will require added financial support from the government, since there is no way to get something for nothing.
However, a comprehensive reform of health care in America could reduce overall spending for health care. While businesses and individuals might have to pay more in taxes, if the program was organized properly the increased taxes could be offset by decreased payment for health care to non-government sources.
The adoption of a national board of effective medical practice could save hundreds of billions a year by eliminating health care costs that are not needed and not effective. Adoption of quality assurance systems modeled on the “checklist” approach that Gawande and others have demonstrated could save tens of billions and perhaps even hundreds of billions by eliminating or reducing errors and complications that increase cost and result in deaths and morbidity. Intelligent use of a national electronic record system could eliminate duplication and increase efficiency. Changes in administrative systems could reduce overhead by billions. Appropriate bargaining for drugs and devices could save tens of billions. Universal coverage with low or no co-pays and deductibles could encourage early intervention that could prevent costly hospital and ICU stays and decrease costs related to poor prenatal care. Aggressive “medical home” style management of the big six chronic conditions could reduce costs by appropriate vigilant management to keep patients out of hospital. Stopping people from using ER’s for primary care by getting them placed in true primary care systems could save billions.
It is not unrealistic to adopt a goal of reducing the cost of health care by $400 billion to $800 billion a year through creation of a functional rather than dysfunctional national health system. If that occurs, the added $60 billion to $200 billion a year in taxes needed to create the system, including universal care and the appropriate effectiveness, quality, and price negotiation systems, would be a wise investment.
As an old time businessman once said to me, “If you want to start giving me quarters for nickels, I’ll do it all day long.”
people won’t pay more unless they have confidence the system is efficient. they don’t now. but efficiency is in the eye of the beholder and will require people to give up services, however irrelevant, they now rely on. that’s a tough sell that’s probably years away.
I am optimistic this time around
Optimism is my own moral imperative
Rick Lippin
I just came across a elderly man on diaysis, now with advanced throat cancer and surgeon feels not good candidate for surgery. NO one talked to this person about his prognosis and posiible choices, he continues to get his dialysis three times a day and his doctors (specialists work at different hospitals) get fee for services. This man can barely get up to go for his appts, has no family support, very depressed, no primary care physician. Something to think about.
During my Health Administration class last night, the professor asked us how many people thought there should be more government intervention in healthcare. I was the only one who raised my hand. Others said “I don’t want to pay for a woman who chooses to have 8 kids”, “Sure people might die on the streets, but sometimes you have to make tough choices”. These are the hospital administrators of tomorrow. We’re in big trouble.
It seems to me the first step in health care reform is to put somebody in charge. The complacent health care industry has been in charge of itself and gone unchecked for far too long. The CDC should be as vigilant towards hospital infections as they are salmonella in cantelope.
Somebody needs to identify universal standards….this is one big barrier to getting effective IT in the patient care delivery system. Doctors don’t want to learn 2 software programs if they have admitting privileges in more than one hospital. There’s no universal…anything…really from diagnosis codes to treatment. I know one advocate who’s been pushing for mandatory jaundice testing for every newborn. That practice has only been adopted by a handful of hospitals. Is anyone familiair with all of GM’s (yes, General Motors) efforts over the years to make hospitals efficient? Well, they put a lot of work into it and really didn’t accomplish any gain over costs. Why? Because the train is too big a wreck even for GM. The Department of Health & Human Services needs to start giving everybody marching orders, and enforce them, plain and simple. There’s no oversight, co-ordination or co-operation, or really much of a mandate for any institution or licensing agency to clean up their act. There’s no leadership. Obama needs to put Don Berwick in charge of all things healthcare, like, yesterday. Give him a badge and everything. I’m serious. You know why Don Berwick needs to be in charge? Nobody can fix this by themselves, but a good leader listens as much as they talk. Berwick’s our man.
While I said earlier that Maggie Mahar is correct in stating that nationalized health care is really nationalized health insurance, I believe that others, including President Obama, refer to universal coverage and health care costs when they really mean nationalized health insurance. The lines are truly blurred when the discussion mixes terms.
As I said earlier, the cost of insurance is merely a factor of the cost of claims. Claims are the charges for services provided doctors, hospitals and other providers, including pharmaceutical, ambulance transportation, hospice, skilled nursing, et al. The insurance company sets a target loss ratio for its pricing. Insurance Premium = Cost of Claims/Loss Ratio (i.e. $1.00/.75 = $1.33). If the cost of claims increases 20% then the insurance premium becomes $1.20/.75 = $1.60. The loss ratio is constant. The price increase is driven by the 20% increase in cost of claims.
Lowering the cost of claims lowers the increase in premiums. Raising the target loss ratio also lowers the increase in premiums. Going to a single payer system does not lower the cost of claims. Going to a single payer system may raise the target loss ratio.
Medicare is at the root of what is inherently wrong with national health care. From the president’s speech, “The president added that universal coverage can be paid for “in part by efficiencies in our system that are long overdue.” Making the system more efficient means “rooting out the waste, fraud and abuse” in our Medicare system, the spending on unnecessary and ineffective treatments “that don’t make our seniors any healthier .””
It has taken 40 years of fraud and waste to declare that it is bad – and what would make nationalized health insurance any more immune from fraud and waste than Medicare is now?
Medicare is the root of medical inflation commencing in LBJ’s Great Society. Prior to Medicare, there was no such thing as major medical insurance. There was only a product called Hospitalization insurance. Doctor’s made house calls and billed directly. Payments were not made by insurance, but directly by the patient with cash or check. Hospitalization insurance paid a specified flat dollar amount of indemnity directly to the insured. The insured then paid the hospital from his own funds. Insurance premiums were far more reasonable prior to Medicare. The cost of claims is the driver of the increases we’ve seen since.
The cost of claims increased at more significant speed when Medicare introduced Usual and Customary charges and payments directly to doctors. Whatever the going rate charged by the doctors and hospitals in the area is what Medicare paid. There was no regard for how much was paid. It was in the providers best interest to ratchet up their prices because the process would simultaneously ratchet up their profit with no governor within Medicare. It is folly to believe that a single payer system will be less filled with abuse and fraud than our current system of nationalized health care.
Assignment of benefits directly from the insured’s carrier to the provider is what has caused lack of access. Doctors, hospitals and providers require assignment and proof of insurance up front. Prior to Medicare, this was never an issue.
Competition is what will drive costs down. I don’t know that doctors and hospitals compete for any single individual’s business. Regulatory barriers need to be removed so that insurers can compete nationwide. ERISA needs to be amended to allow groups to be formed locally and nationwide, but this has already been proposed and passed in the House only to be killed in committee by the Democratic Senate.
The consumer needs to drive the change. I do not see a clamoring to do this. Individuals need to question provider pricing, question their prescribed treatments and the resulting outcomes.
As others have stated above, tax increases will be necessary. I do not believe that the electorate has the appetite for increased taxes. I don’t believe that the cost will provide the perceived benefit for the majority once the tax details are produced. Most Americans perceive nationalized health insurance to mean no cost to me insurance. Raising taxes will wake them up.
Finally, nowhere is Medical Malpractice insurance or Errors & Omissions insurance mentioned in any reform. Why? The trial bar must have some part in it. The cost of malpractice and E&O insurance for doctors, hospitals and other providers is exorbitant. It is also built in to their cost of doing business.
I understand the want by some for a single payer system. Insurance relies on the law of large numbers, so in theory it makes sense. However, two questions must be answered before any plan is adopted. Is it viable? Will it work?
“The consumer needs to drive the change. I do not see a clamoring to do this.” I’ve been listening to this statement for years “the consumer needs to be the driver for change” I hear it from doctors, nurses, patient safety organizations, everywhere. Well, guess what? WE ARE ALL CONSUMERS OF HEALTH CARE whether we’re a physician or truck driver. Further, there’s thousands of us consumers out here, victims of the health care industry and we’ve been clamoring for years.
Y E A R S.
Lisa, perhaps I was not clear enough in my comment about the consumer.
I am not speaking of outcomes or plans of treatment, necessarily. The misuse or overuse of products and services to cover supplier overhead is real and can be deterred by consumer attentiveness and action.
I do not see consumers being vigilant. Rather, I see them placated by the current system dictated by docs/hospitals et al that require insurance and assignment of that insurance as a requisite to engage in patient care. Prior to nationalized health insurance 1.0, Medicare, that was not the case.
Now, in a non-emergency situation, when an insured consumer enters the waiting room or hospital admittance office, they complete the various forms including their assignment of insurance benefits. At that point, the consumer has no vested interest in what their cost of care is or will be. They are content in knowing that insurance will cover everything. See my post on why your insurance premiums are too high. http://www.insuranceinthelight.com/?p=27
Is the discerning consumer looking for ads for various doctors? Are they looking on line? Does the doctor publish their prices or services offered? How many competing offers did the consumer consider? What is the doctor’s track record? What is the track record of competitors? The same can be asked of hospitals, prescriptions and ambulance transportation (the example in my post) and virtually any other component of heath care.
The likely answer to the question above is no? The consumer is not clamoring for nor demanding this information.
Why?
Simple. The insurance company will pay for it.
Doctors, hospitals and other industry participants know this. Nationalized health insurance started all of this, as Maggie Mahar concurs in Money Driven Medicine, in the form of Medicare. Major medical insurance did not exist prior to Medicare.
Prior to Medicare, patients paid docs with their checkbook. They knew the cost. The doctor charges were transparent. Hospitalization insurance paid a fixed amount for each day in the hospital. Insurance payments went from the insurance company to the insured. The hospital billed the patient. The patient paid the bill with their check book in which the insurance money had been deposited. The bill was transparent. The payment was transparent.
I do not see the consumer clamoring to know for what they are paying. They are content knowing that insurance will pay for it.
When insurance doesn’t pay for the charges, we hear doctors say how bad the insurers are at reimbursement and consumers say how the insurance company stuck them with the bill.
Keeping paid claims low is in the interest of the insurer on behalf of the remainder of their policyholders who pay the premiums that pays the claimant’s bill.
Nationalizing the insurance premium payments to the federal government is not, in my mind, the answer.
As for outcomes and efficient and proper care, that, in my opinion, has nothing to do with insurance, but is a function of the doctor, hospital and other providers.
The problem I see is that the advocates of single payer, nationalized insurance cannot divorce the prescription and management of care from the money. This is why Maggie’s book holds so much relevance.
I started typing in caps to highlight my comments, not to sound like I’m yelling, there was just so much I had a response to…
“The misuse or overuse of products and services to cover supplier overhead is real and can be deterred by consumer attentiveness and action. I do not see consumers being vigilant.” Then you need to open your eyes. I was very vigilant about my husbands care, products, medications, procedures, I was asking plenty of questions and we weren’t paying for a single thing . An anonymous insurance company was, I reported what I felt were unneccesary or bogus charges to the insurance company rep. She blew me off, regularly, the insurance company could care less. But, I never stopped reporting to her. Insurance companies don’t care about vigilant consumers or medical bills, they just continue to pass the cost along and THAT’S part of the problem we have today.
“Rather, I see them placated by the current system” YOU’RE CONFUSING THIS WITH TRUST. WE’RE NOT PLACATED, WE TRUST THEM. OOOOPS
dictated by docs/hospitals et al that require insurance and assignment of that insurance as a requisite to engage in patient care. Prior to nationalized health insurance 1.0, Medicare, that was not the case.
Now, in a non-emergency situation, when an insured consumer enters the waiting room or hospital admittance office, they complete the various forms including their assignment of insurance benefits. At that point, the consumer has no vested interest in what their cost of care is or will be. YOU ARE WRONG They are content in knowing that insurance will cover everything. WRONG AGAIN, EVEN WITH INSURANCE WE GET THIRD PARTY BILLINGS AND CHARGES OVER AND ABOVE WHAT SHOULD HAVE BEEN COVERED BY INSURANCE COVERAGE See my post on why your insurance premiums are too high. http://www.insuranceinthelight.com/?p=27
Is the discerning consumer looking for ads for various doctors? WHAT ADS? THE ADS TELLING US THEY DO MORE CARPAL TUNNEL SURGERY THAN ANYONE ELSE IN TOWN? IT’S ALL PR, ADS ARE NOT EFFECTIVE RESEARCH TOOLS FOR CONSUMERS Are they looking on line? YES, FOR WHAT LIMITED INFORMATION IS AVAILABLE FROM OUR STATE MEDICAL BOARDS Does the doctor publish their prices or services offered? NOT REALLY IN THIS COUNTRY EVERYTHING IN HEALTH CARE AND THE CARE DELIVERY SYSTEM IS TOP SECRET How many competing offers did the consumer consider? I THINK WE CALL OFFERS 2ND AND 3RD OPINIONS, WHICH WE GET WHEN OUR INSURANCE COMPANY ALLOWS IT What is the doctor’s track record? GIVE CONSUMERS A RELIABLE SOURCE FOR THIS INFORMATION AND THEY WILL USE IT, THIS IS JUST ONE OF MANY ISSUES WE’VE BEEN CLAMOURING ABOUT FOR Y E A R S What is the track record of competitors? SAME COMMENT AS ABOVE The same can be asked of hospitals, prescriptions and ambulance transportation (the example in my post) and virtually any other component of heath care. YOU ARE CORRECT, THERE IS NO RELIABLE SOURCE FOR CONSUMERS, SOME OF THE RESULTS OF OUR CLAMOURING OVER THE YEARS IS JCAHO WAS GIVEN A VOTE OF NO CONFIDENCE BY CONGRESS AND WILL NO LONGER BE THE ACCREDIATION AGENCY FOR CMS… CONSUMER REPORTS IS NOW STARTING TO RATE HOSPITALS AS A RESULT OF ALL OUR CLAMOURING, MAGGIE EVEN DID A BLOG ABOUT THIS. I CAN’T READ ANYMORE, I APPRECIATE YOUR POSTS BUT YOU’VE GOT ME GOOD AND WORKED UP NOW.
The likely answer to the question above is no? The consumer is not clamoring for nor demanding this information. YES WE DAMN SURE HAVE BEEN, SCOTT, SEE MY COMMENTS ABOVE THE CMS HOSPITAL COMPARE SITE IS ALSO A RESULT OF OUR CLAMOURING. THE WORLD HAS ALREADY STARTED CHANGING AS A RESULT OF CONSUMER CLAMOR.
Thanks for the comments–
I’ll be back later to reply. . .
Hi everyone–
(Robert, Pat S., Dr. Rick, Jim, Ray, Mike C, Lisa, Scott
Somehow, I missed this thread and never came back to reply–]
Robert,
Over use of advanced medical technology really is what makes our heatlhcare so ecpensive.
Of course, that is all tied up with people seeking profits.
But if we change the way we pay hospitals and doctors, and start hiking co-pays (and reducing fees) for technologies that are only marginally more effective (if that), we begin to really cut costs.
We need to get rid of fee-for-service and pay for value to patient, not outcome.
Since we know too many hospital beds drives overtreatment, we need to put a cap on hospital construction–and close some hospitals.
In other words, we need to clamp down on the profiteering.
Other countries have done this by regulating the private sector–we could do.
Pat S.–
I agree with what you say.
Let me just add: if we provide good care for the tens of millions of Americans who are uninsured or underinsured, and provide good care for the people on Medicaid who now receive sub-par care (because we pay Medicaid providers so little) and
devote more money to public health–that will
cost more.
In addition, funding comparative effectivness reserach and IT will cost money.
At the same time, there is much waste in the system, many dollars to be saved.
Bottom line, I think we could utlimately offer good care to anyone for about 16 percent of GDP (what we are spending now)
And, I think we could make sure that health care spending doeson’t grow any faster than GDP.
In real dollars, we would be spending more. But as a share of the eocnomy, we would be spending the same amount, while providing better care for many more people.
Finally, we will need tax increases to provide the seed money for IT, etc, and to cover us for the five to ten years or so that it takes to begin to realize big savings by
squeezing out waste.
And these probably are not temporary tax increases–we’ll need to continue to fund public health (something we are not doing now) do the comparative reserach and improve health It. . .
Jim– it is a tough sell.
But Obama uses the bully pulpit well, telling Americans that the time has come to put childish things away . . .
Over the next 8 years, I’m hopeful that he can make a real change in how we think about healthcare.
Dr. Rick– I agree, now is the time for optimism as a moral imperative.
Ray– Thank you. Such a very, very sad story, but repeated in our hospitals all of the time.
The legislation that made dialysis so lucrative has done so much harm. I remember reading a non-fiction book titled “Momma Might Be Better Off Dead.”
If we had more palliative care, a palliative care team might protect a patient like this from whoever put him on dialysis . . .
Mike C.–
Wow. As you say, if these are the hospital administrators of tomorrow, we are in big trouble.
I would love to see more nurses become hospital administors (the nature of their job means that the successful ones are good managers) and fewer MBAs.
Lisa– yes, we do need someone in charge–someone who is a leader.
I agree that Berwick would be excellent, but probably too passionate for Washington, and too eloquent. You have to speak in short sentences and stick to a limited vocabulary when speaking to many of our Congressmen.
Scott–
Yes, when Medicare legislation was passed LBJ made a major mistake in giving doctors essentially a blank check to charge waht they wanted to charge in the form of “usual and customary charges.”
Do you know why he made that mistake? Because he thought that as more and more doctors came out of medical school (and they were beginning to stream out of med schools)
COMPETITION WOULD BRING PRICES DOWN.
Guess what? It didn’t.
Why not? Because the consumer looking for healthcare is a patient–i.e. a sick person. (The lion’s share of healthcare dollars are spent when someone is seriously ill and seeing specialists.)
And a sick person is not a bargain hunter. Even if he/she has a 20 percent co-pay out of her own pocket,
she does not want the cheapest doctor taking care of her husband–or herself. She wants the “best” doctor.
And most Americans believe that what is most expensive must be best. They may then decide that, when it comes to a lap-top, “I don’t need the best. I just use it for e-mail.
But when it comes to their heatlh–and again most dollars are spent when people are sick– they don’t want the least expensive care.
Moreover, while I might be able to make a fairly savvy decision about which lap-top offers the “best” value for my money, I simply don’t know enough about medicine to know which doctor is offering the right diagnosis and prescribing the “best” possible treatment.
There is so much ambiguity in medicine that even many doctors disagree on what is best.
And I am better at doing medical reserach than most people.
So all I know is whether I like the doctor, whether I like his staff, whether I like his office.
And doctors know that. So many specialists “compete” by renting or buying nice offices in very good neighborhoods, hiring attractive pleasant staff (paying them a little more)and being as pleasant as they know how to be. They also buy cutting edge equipment for their offices so that they can run tests without sending the patients elsehwere. (Economically, this makes no sense–a small practice does not enjoy the economies of scale that a large lab or hospital would. But patients like the convenience, and if doctors charge enough, they can make a nice profit even while using the equipment 30% of the time.
AGain, even when patients have co-pays, they don’t question the expense of the tests or the number of tests because, when it comes to their health, they don’t want to cut corners.
(And, as Lisa says in the comment above yours, these days, patients do have hefty co-pays and deductibles –even under Medicare. (Under Medicare, for example, if you have outpatient surgery, you pay 20 percent–n addition to your annual premium. )
Scott– in reponse to your second comment.
Also, Scott you write: “Prior to Medicare, patients paid docs with their checkbook. They knew the cost. The doctor charges were transparent.”
This is absolutely not true. Where did you get this idea? (And by the way, back in the 1950s, most middle-class famlies didn’t have check books. )
You need to read a history of medicine in the U.S.–the best one is “The Social Transformation of American Medicine.” It won a Pulitzer in 1982.
If you read some history, will find out that, prior to Medicare, doctors routinely charged different patients different amounts for the same treatment–depending on how wealthy they were.
Doctors provided a great deal of charity care back them. I can remember a doctor coming out of the house next door (where he had made a house call) carrying a pan of baklava–that was all the family good afford to pay.
Middle-class families paid a few dollars–mabye $5.
Meanwhile, the wealthy patinet paid $20. The wealthy subsidized the poor tne poor and the middle-class.
And one one knew what the doctor charged other people. The system was far from transparent.
As for consumers gong on line looking for price lists . ..
If your wife had breast cancer, would you go online to find the doctor offering the best “deal”–or would you want the best surgeon.
And how, exactly, would you know you is best???
The office, the equipemnt etc., adds to the doctor’s overhead–and so he charges patients more.
Reserach shows that in cities like Manhattan or Boston, where many doctors are “competing” prices go up, not down. This is because, as they vy for patients, the doctors spend more and more on the office, the equipiment. The fiercer the competition, the higher the prices.
All of this has been well-documented in journals like “Health Affairs” –I also write about it in my book (MOney-Driven Medicine– clean used copies are available at a very low price on Amazon.)
Most also try to practice the best possible medicine that they can. But they realize that, unless a doctor is clearly incompetent, patients don’t know the difference.
Even if your aunt dies while seeing a particular doctor, you have no idea whether another doctor could have saved her.
Lisa —
Much of what you say is true–except the part about needing clear information about a doctor’s “track record.”
As I keep explaning it is impossible to measure the quality of an individual doctor–or a small group of doctors–
a few non-compliant or seriously ill patients can
tip the scale, making him look bad.
If you try to measure quality of individual doctors, you simply encourage them to avoid hard cases and poor (often not compliant) patients.
At the extreme of “bad” doctors there is information– For instance, one should be able to find out how often a doctor has been sued, and how often he has either settled or been found guilty of malpractice.
A very small percentage of all doctors account for the vast majoirty of settlements and payments. I’m talking about docs who have been sued –and paid– 10 times in 8 years. This is a red flag.
But this is also extremely rare.
Patients and consumers cannot control the quality of care that doctors deliver. Hospitals, and state medical boards have to do that. We need better laws protecting doctors and nurses who report on incompetent doctor (right now, it’s too easy for him to sue them). And we need state medical boards to really police their own.
Doctors–and nurses–know who the bad doctors are. Often, they are very, very popular with patients. Totally charming. They expend their energy on being sociable when they should be concentrating on detials,the patient’s medical history, using checklists, making sure they don’t make errors.
Sometimes, the best doctors are pretty serious people.
Lisa– I’m not suggesting that cosumers shouldn’t also report what appears to be bad medical care–but most consumers just don’t have enough knowledge of medicine.
Should that procedure have hurt so much? Maybe it was necessary. . .The nurses know–at least the good ones do.