Monday, June 18, 2007

Blogging, General, - A Medical Blogger’s Self-Afflicted Interview

Q; Good Morning. It’s Monday, June 18. This is your 189th consecutive blog. By now, you must know why you’re doing these blogs. Tell me, are you a left wing or a right wing blogger?

A: I’m neither. I’m a MD Blogger, which means “Medical Doctor Blogger” or “Middle Blogger,” take you pick.

Q: Why do you talk so much about “innovation?”

A: Because you can always do things better, quicker, more conveniently, and cheaper for the benefit of patients. Besides, it’s never too late to innovate.

Q: Why not “consolidation” into one single system covering all?

A: Given the American culture’s desire for freedom of choice to providers, equality of opportunity but not results, distrust of centralized government, dislike of sweeping changes, and access to high tech care without rationing, I don’t think “consolidation” would work. It's been debated for 95 years, and it hasn't worked yet.

Q: Anything else?

A: Well, there’s this myth floating around out there that universal coverage means better care. That’s never been proven to be true. Medicare outcomes are no better for the elderly than they have even been. Federal entitlements like Medicare and Medicaid and child coverage are about financial security, on occasion “safety net” care, but rarely about overall improvement of care.

Q: Any other myths?

A: Yes. That somehow federally-run top-down care will be more even-handed, equitable, and fair to all. As a matter of act, centralized government is a lousy way to distribute resources. Take Medicare. Its payment schedules are so low and convoluted in paying primary care doctors, that primary care is on the verge of collapse. Or take Medicaid, Its payment rates are so low and its bureaucracy so unwieldy, that 40% to 50% of doctors refuse to take Medicaid patients.

Q: Are you suggesting a market-based system might be better?

A: In some ways, yes, because consumers on the ground spending their own money and making their own choices are wiser than federal or state bureaucrats and technocrats.

But suggesting that a market-based system would replace federal reimbursement is a fool’s errand. The government already pays for 46% of care, and as we all know, the sun never sets on federal programs, once established.

Besides, ideologically, one man’s meat is another man’s poison. Advocates of government-care and market-based care will never deviate from their “principles.” In the end, there will have to compromise.

Q: What about lowering costs? That seems to be the main theme of current reformers.

The reformers are right. Lowering costs is the key to reform. “How” is another matter altogether. Retail clinics, which charge less than primary care practices or emergency rooms, are a concrete step in that direction. Other innovations, mostly IT, such as having patients enter their own information through smart cards, personal health records, or debit cards and paying at the point of care – or patient-doctor communication through website, e-visits, or video education – will help. Other suggestions – universal interoperable computer systems, better coordination, obligatory public outcome data publication, regional information sharing, integrated health systems, pay-for-performance - are still largely abstractions.

Q: Are there things we ought to look for as the reform movement begins to play out?

A: Yes, and I would list them this way, but not necessarily in this order.

1.Experiments and compromises with “universal coverage” in Massachusetts, California, Illinois, and Pennsylvania – the big states with lots at stake and the size to see if new systems of care are possible.

2.Chronic-care management of Medicare, Medicare, and health plan populations, through “hands-on,” telephonic, and IT monitoring, of that 10% of the population causing 90% of costs.

3.Innovations in the marketplace – retail clinics, work-site clinics, disease-focused and integrated clinics, and strategically place big MACCs (multispecialty ambulatory care centers).

4.The decentralization activities of “everything-for-everybody” general hospitals, who now consume almost 50% of all health care dollars, and who know they must make moves, many specialty based - to become more productive and cheaper, please increasingly demanding constituencies – the public within their communities, demanding and assertive consumers, and restless specialists seeking more productivity and income, and to make their facilities more pleasant and safer places to be.

A; And the employers – what about them?

Q: They’re a huge factor, and they’re doing many things, -- becoming more active in their business coalitions, shedding and narrowing benefits, shifting costs, setting up wellness and preventive programs, establishing on-site clinics run by salaried physicians, insisting on use of generic drugs, clamping down and managing health care supply chains. A central issue in all of this is how to reduce costs so American businesses can compete globally. Businesses aren’t going to sit idly by and let their profits g down the drain.

A: Finally, what about the doctors?

Q: People tend to stereotype doctors as being of one mindset – compulsive, loyal to each other, oblivious to costs, focused only on themselves, resistant to change. I have never found this to be true. We are more like the “rats” (no disrespect intended because I admire doctors) of Hamelin City,

And out of the houses the rats came tumbling,
Great rats, small rats, lean rats, brawn rats/
Brown rates, black rates, gray rats, tawny rats,
Grave old plodders, gay young friskers.
Fathers, moths, uncles, cousins,
Cocking tails and pricking whiskers,
Families by tens and dozes,
Brothers, sisters, husbands, waves –
Followed the Piper for their lives.

Our Pipers are the patients. In the end, I believe we will do what pleases them, prevents their diseases, improves their health, cures them, and increasingly, costs them less in time, money, and inconvenience. Medicine is rapidly changing. Young doctors don’t think like old doctors. They seek security, stimulation, balanced life styles, and time off for themselves and their families. Doctors are innovating with new drugs, new procedures, new forms of organization, new specialties, new forms of payment, new forms of communication and education. Experimentation and innovation are the orders of the day.

A: Is that all?

Q: Isn’t that enough for now?


Mike said...

Nowhere in your paradigm is there any mention of fraud! So much money is lost to medicare and medicaid fraud. There is also no mention of reducing costs through negotiating drug prices, though I know this is controversial. If concessions are asked of doctors through reduced medicare fees, then certainly Big Pharma and insurance companies can share this burden. After all, we all are aprt of the health care "team", right? (and if you believe that one...)

Richard L. Reece, MD said...

Dear Angry Doctor:

I see you're an internist in New York City, one of the Medicare and Medicaid fraud capitals in the U.S. So I understand your anger.

Still I'm not sure fraud and abuse have much to do with systematically cutting honest doctors' pay by a projected 40% over the next five years. What other profession do you know that would put up with that? Certainly not your lawyer brother.

I'm aware Big Pharma and Big
Insurers have their own set of abuses. But I'm not confident federal regulation and price controls. which are what "negotiated drug prices" are all about, will work. They never have. Nixon failed in 1973 when he "froze" health care prices. He failed

But let's let the Democrats have their way -- and see what happens. I, for one, am not so cynical that I believe fraud, abuse, and greed are the main causes of high health costs. Western capitalism is based on trust and the notion that the market will adjust prices, if, and this is a hell of a big "if," those prices are transparent.