The health care debate heats up

On occasion I am brutally honest with patients about their differential diagnosis.  I tell them of several possibilities, but conclude that the most likely is “God Only Knows.”

This has been an active fortnight for news about reforming our health care non-system, highlighted, I suppose, by President Obama’s frank talk with the AMA and the Congressional Budget Office shooting Sen. Edward Kennedy’s plan out of the water.

As of this writing, and for the near future, God Only Knows is the front-runner.

What I look for is honesty about the real challenges.  And, lo and behold, we’re starting to get a little honesty.  

It started with Dr. Atul Gawande’s New Yorker article (see my June 1 blog post), which President Obama made required reading for White House staffers.  Then he mentioned it in his AMA speech. In his punch line, he referred to “…a system of incentives where the more tests and services are provided, the more money we pay. And a lot of people in this room know what I’m talking about.”

Throughout the speech, the president got a lot of nervous applause, and one standing ovation (“You entered this profession to be healers – and that's what our health care system should let you be"), but the line about incentives got stony silence.

If you want a useful and perceptive commentary, read Dr. Abraham Verghese’s article, “The Myth of Prevention,” in the June 20 Wall Street Journal.

If you don’t have access to these articles, or the time to read them, here’s an executive summary of the debate to date:

The CBO decided that Sen. Kennedy’s bill would cost roughly $1 trillion over 10 years, and still leave 37 million Americans without insurance.  That was a big "OOPS!" for congressional Democrats.

Dr. Gawande usefully observed that doctors make a lot more money when they decide to order tests and procedures which make them a lot more money.  He did not have a solution to this problem. The solution I favor, Health Savings Accounts, he dismissed by noting that no one shops for price when chest pain strikes in the middle of the night, which is true. He failed to point out that lots of people shop for price in the course of my routine office practice, which, to be fair, is completely outside his limited experience as a surgeon and author.

Dr. Verghese, an internist and infectious disease specialist, writes:

“Cut, poke, sew, burn, insert, inject, dilate, stent, remove and you get very well paid; if you learn how to do this efficiently, maybe set up your own outpatient center so you can do it to more people in a shorter time (which is what happened when this payment system was put in place in 1989) and you are paid even more. If, however, you are a primary care physician, and if, just like the young doctor who saw my parents yesterday, you spend time getting to know your patients, and are willing to play quarterback when your patient enters the hospital, so that you can herd the consultants and guide the family through a bewildering experience that gets surreal if you are in the intensive care unit, then you may have great personal satisfaction but you will make five to tenfold less than your colleagues in the doing-to disciplines.”

No argument there. But aside from “behavioral things – eat better, lose weight, exercise more, smoke less, wear a seat belt,” he is skeptical about preventive medicine. Primary prevention through the use of statins may not be cost-effective (unless you are careful to use generics when possible); there are lots of technological gimmicks, like CT scans for coronary calcium, which don’t add much except anxiety.  

Dr. Verghese is also skeptical about electronic medical records: “…an electronic medical record (EMR) may or may not save money (it won’t be anywhere as much as is projected) but what it will do is ensure that we doctors, nurses, therapists, particularly in hospitals will be spending more and more time focused on the computer, communicating with each other, ordering and getting tests, buffing and caring for our virtual patient – the iPatient is my term for this phenomenon – while the patient in the bed wonders where everybody is. Having worked exclusively for the last seven years or so in hospitals that have electronic medical records (EMR), I have felt for some time that the patient in the bed has become an icon for the real focus of our attention, the iPatient. Yes, electronic medical records help prevent medication errors and are a blessing in so many ways, but they won’t hold the patient’s hand for you, they won’t explain to the family what is going on.”

He asserts “the single most important fact about health care in America that you or I need to know. ... all of us – doctors, hospitals, pharmacists, drug companies, nurses, home health agencies, and so many others – are drinking at the same trough which happens to hold $2.1 trillion, or 16% of our GDP. Every group who feeds at this trough has its lobbyists and has made contributions to Congressional campaigns to try to keep their spot and their share of the grub. Why not? – it’s hog heaven. But reform cannot happen without cutting costs, without turning people away from the trough and having them eat less. If you do that, you have to be prepared for the buzz saw of protest that dissuaded Roosevelt, defeated Truman’s plan and scuttled Hillary Clinton’s proposal."

Our leaders in the AAFP are, at this moment, trying to shoulder their way into this trough. And I wish them well, I really do, because their ideas are better than the proceduralists’ ideas. In a perfect world their proposals would be enacted. This is not a perfect world.

Meanwhile, I know this from personal experience: If I am given complete control of medical dollars through a full-capitation model, I will make a lot of money, because I practice evidence-based, cost-effective medicine. If I am simply scored against my peers based on costs that pass through my fingers, even if there is no monetary incentive, I will rank high for the same reason.

For around $200 per patient per year, you can have all of my services, including office visits, labs, x-rays, and obstetrics. My Job One, except for delivering babies, is to keep patients out of the hospital. I'm good at it, Dr. Verghese. Prevention works for me.

Based on proposals he has entertained thus far, President Obama is suffering from delusions about what it will take to reduce health care costs. I am not.

What we need is a system in which patients trust their family physicians, internists and pediatricians to direct their care in a cost-effective, patient-centered, wise and humane manner. This system should not interpose itself between me and my patient, and it should not raise questions about my motives. The inevitable and necessary rationing decisions must be made by patients and their families with the advice of their personal physicians, not by insurance companies or government commissions.

Aside from a universal system of Health Savings Accounts with refundable credits for the poor, I am waiting for alternative proposals that meet these criteria.

But this is beyond my pay grade. In the meantime, I’m Making It just fine, and you should be too.

Posted at 10:41AM Jun 27, 2009 by Doug Iliff  |  Comments[3]