Wednesday, June 30, 2010

Never More, Never Mind: Contempt for U.S. Health System and Private Practice

Among policy makers, government officials, and the media, there is no other word for their attitude towards the U.S. health system in general and private physicians in particular. That word is “contempt.”

You hear the same message again and again. The U.S. is first in costs, and last or next to last in efficiency, equity, access, outcomes, infant mortality, longevity.

Don’t take my word for this “progressive” bias. The liberal Commonwealth Fund last week announced in its latest “Mirror, Mirror” study that the U.S. ranked last or next to last among seven industrialized nations in every health care category. Read these headlines.

Reuters: "U.S. scores dead last again in healthcare study"

Los Angeles Times:
"U.S. is No. 1 in a key area of healthcare. Guess which one ...
NPR: "US Spends The Most On Health Care, Yet Gets Least"

The Week: "US health care system: Worst in the world?"

The underlying message in most of these articles is: “Don’t trust individual private doctors. They are in this for the money. They do more than less for cash. If only if we could get the U.S. government, like other countries, to rein them in, provide them oversight, dictate what they can and cannot do, and treat them as government employees, results would improve and costs would drop.”


Never more should we trust doctors to practice autonomously, using their knowledge of the patient and clinical judgment . Instead, we should trust government, using comparative data bases and statistical averages to determine what is to be done.

Never mind that the typical physician has had 10 to 15 years of intensive education and training after high school, or that he or she finished near the top of their class. Or that most are motivated to help people and cure their illnesses.

Never more should we allow doctors to practice solo or small groups. No physician, practicing alone or with a few others has the encyclopedic knowledge to know everything about everything. That can only come from practicing in a larger group with access to multiple resources.

Never mind that 30% to 40% of doctors practice solo or in two person groups, and that 80% are in groups of 6 or less. Never mind that practically every physician has Internet access, and that most clinical problems are mundane and require only common sense and knowledge gained from face to face confrontation.

Never more should we allow doctors to practice without electronic medical records . These records contain the data that allow us to judge their performance, to pay them appropriately and to permit them to practice having access to evidence based best practices.

Never mind that 80% or so of doctors have not invested in EHRs because electronic systems are often expensive, unworkable, clinically useless, slow productivity, are either unreadable or hard to interrupt, and don’t connect to other systems. Never mind that doctors are not trained to be data entry clerks, and make ends meet by seeing patients rather than documenting every detail of the encounter.

Never more should we allow doctors to be paid on a fee-for-service basis, like lawyers, accountants, other professionals, and independent tradesman. We should place them on salary, removing the incentives to do more, and putting them on budgets where managerial oversight can be exercised.

Never mind that ending fee-for-service requires 3rd party oversight, with administrative overheads of 15% to 30%, depending on the size of the bureaucracy or health plan. And never mind that most doctors’ fees are already set, directly and indirectly, by Medicare and the Reimbursement Update Committee (RUC).

Never more should commercialism or market forces, or God Forbid, profit be allowed to pervade the sacred halls of medicine. Health plans should be outlawed, care should be offered gratis, and doctors should not be allowed to practice or profit from activities outside benevolent government systems. Those at the top know what’s good for those at the bottom, whether doctors or patients know it or not.

Never mind there is no health system in the world where patients do not go outside the system to get the care they need. Never mind that medical tourism is exploding around the globe. Never mind that most medical innovation comes from the private sector, and from the bottom-up, rather than government. Never mind that most patients, given their choice, would rather be treated by a private doctor they trust, rather than a doctor paid by the government working in a Medicaid or other government clinic.

Never more should the U.S. try to stand alone as a unique health system. It should try to emulate other countries, where government is the only or dominant payer. In all these countries, citizens should come to expect equality of care for all classes, in all regions of a given country, with rationing if necessary.

Never mind that the U.S, health system has evolved since World War II into a mixed employer-government-based system and central-government and state governed system and into a vast medical-industrial complex, and into the largest single employer in the nation. Never mind that the U.S. is a vast continental nation with marked regional differences. Never mind that our high-tech system is the wonder of the world and the training ground for many of the world’s specialists. Never mind that the expectations of our citizens and our culture differs from that of other countries. Never mind that our citizens have come to expect advanced imaging, routine cataracts, coronary stents, open-heart surgery, and joint replacements as the standard of care. Never mind that we have some of the world’s best outcomes for heart attacks, strokes, and cancer. Never mind that the health care “product” of the U.S. differs from the rest of the world, with its immediate access to high tech and specialty care, and with most of the 250 million Americans with coverage satisfied with the care they get and trust their doctors.

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