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Ideas and Opinions |

Boston Medicine, Before and After FREE

Deborah Cotton, MD, MPH
[+] Article and Author Information

This article was published at www.annals.org on 30 April 2013.


From the American College of Physicians, Philadelphia, Pennsylvania.

Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-1009.

Author Contributions: Conception and design: D. Cotton.

Drafting of the article: D. Cotton.

Final approval of the article: D. Cotton.


Ann Intern Med. 2013;159(2):145. doi:10.7326/0003-4819-159-2-201307160-00650
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The Boston health care war had really stepped up at the end of winter. The hospitals were competing furiously for us to be their patients. Their ads boasted: “Individual Care/Global Impact,” “Human First,” “Exceptional Care Without Exception,” “World-Class Care Where You Live,” and “Everything Possible.” They told us we should choose them because they were big, because they were small, because they transplanted faces, or knew our neighborhoods, or performed true miracles every day, or were closing in on cancer, or did not see age as anything but opportunity, or shared our roots, or respected our values.

The insurers all wanted to cover our lives. They offered a vast array of networks, tiers, deductibles, mail order prescriptions, or access to our favorite pharmacy. They would let us pay extra to keep our primary care providers, or give us a list of others just as good while putting money in our pockets. They motivated us with rewards if we would eat less, move more, stop smoking, start meditating.

The health policy experts were writing articles and blogs. They were back from stints in Washington and ready to try out their ideas, here where there was Obamacare before Obamacare. They told us small practices would disappear. They said that electronic records were The Answer. They promised the miracle of telemedicine, how 50 patients in 5 ICUs could all be followed by 1 critical care doctor at a console in a strip mall.

The Guilds were arguing. The doctors said the nurse practitioners were not competent to provide care alone. The nurses said they had proof they could, and at far less cost. The doctors dreamt of how many relative value units they were generating and usually came up short. The nurses slept fitfully, facing another shift with ever greater patient-to-staff ratios.

The legislators were meeting. The Other Hospitals told them that the Famous Hospitals were getting far more money from insurers for the very same service with the very same outcomes that they provided. The Famous Hospitals said their patients were sicker in ways the policy experts could not yet measure, that they needed more money to do the ground-breaking research, to provide money-losing services no one else would. The legislators said costs better go down. The Mayor and Governor cautioned us that health care was the number-one industry in our whole state, the ultimate Job Creators. Better be careful.

Through all this, the hospital CEOs were trimming budgets and investing warily and most of all hoping they had captured their institutions as well as possible in 4 or fewer words in an ad.

And then it was a Perfect Spring Day and the Marathon was in full swing. The runners ran under banners with the logos of the hospitals and insurers, in shirts with their slogans, drinking from cups with their names. Many of the runners were nurses. Many of the runners were doctors. Many were EMTs and health policy experts and insurance executives and legislators and some were even hospital CEOs. Because running is good. It helps you live better. It helps you live longer. And that, of course, was the whole point.

When the finish line exploded, the nurses and doctors and EMTs all ran to help and we could not tell them apart if we tried. The ambulances filled up with the maimed and shaken, and the EMTs managed to get to the Famous Hospitals and the Other Hospitals so that none was overwhelmed. All of the hospitals performed nobly, and nobody who got to any of them died. As far as we heard, no one asked about the injureds’ networks or tier plans. The surgeons never said how many relative value units they generated with each amputation. The CEOs ignored HIPAA, and picked up the phone to call each other so that frantic families could find loved ones. And in the emergency rooms and critical care units, instead of video-rounding, real doctors and real nurses touched and embraced the patients, and everyone seemed to remember that most of all.

The next day the newspapers and the talking heads and the government leaders all said that Boston would never be the same, would be stronger, would be better, and I hoped they were right. Though not in the ways they were talking about.

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