Sunday, August 5, 2007

Market Reforms - Health Care Choice – U.S. Health Care’s “Wild Card”

Choice is the right, power, and chance to choose. It’s freedom. It’s also variation – the bane of those who preach “zero variation” in human behavior and human services.

This is America, and we vary as a people.

Choice lets patients choose one doctor – or many doctors. Some say multiple doctors are bad. It’s best, they argue, for each patient to have one medical “home.”

This is America, not the United Kingdom, where patients must go through a family physician.

Here people have choices from whom to seek care. Managed care failed when it tried to route patients through gatekeepers. Medicare patients now average seeing six doctors yearly. Patients with multiple diseases average 11 doctors, mostly specialists, often unknown to each other. This is bad, critics say. Choices ought to be few, and each patient should have one record, shared by all doctors.

This is America, and some say a personal health record violates privacy and invites job discrimination.

People can choose to go to one doctor, or to groups. In groups, advocates say, doctors can confer with one other, work as teams, provide multiple options, coordinate care, and offer one-stop care. For first visits, however, 90% of patients still choose solo or small groups for first visits. It’s about neighborhoods, word of mouth, and personal referrals.

This is America, and patients can choose solo practitioners or groups.

In America, people can choose to be uninsured or uninsured. Some have no choice. They can’t afford premiums. But two-thirds of those without coverage work. Some choose not be insured. Being young and healthy, they may see no need for insurance. In Massachusetts officials claim insurance is an obligation, not a choice, but many uninsured, given a choice of paying or not paying, prefer not to pay,

This is America, and people can make irrational choices.

Some say a free marketplace offers more choices, better quality, and lower costs. Doctors, it’s hoped, will compete openly on costs and quality.. “Transparency” will make it clear in advance what things cost. Costs will drop for all care, as they have for cosmetic and laser eye procedures.

This is American capitalism at work, and markets will decide.

Government and corporations seek to correct bad habits by banning smoking in public places and at work, raising “sin” taxes, forcing food vendors to post nutritional labels on their products, and banning trans-fats.

This is America, and people can pick their poisons.

Doctors have choices, too. They can choose to be paid fee-for-service or on salaries, practice in solo or in large groups, or in hospitals or academic institutions.

This is America, and doctors can choose where they want to work and how they want to be paid.

Doctors can choose to see patients – or not to see them. With a scheduled decline in Medicare payments of 10% next year, nearly 30% of doctors say they will choose not to see new Medicare patients. As many as 50% of doctors don’t accept Medicaid patients. Doctors say they have no choice. Medicare and Medicaid payments don’t cover overhead.

This is America, and doctors can choose whether to accept patients to stay in business.

Doctors have a choice whether to invest in EMRs. Only 15 to 18% do. Some say EMRs are the electronic Holy Grail. EMRs will improve care, patient safety, and efficiency. Doctors say EMRs cost too much, invade privacy, and are good for government and health plans, not for doctors and patients.

This is America, and doctors can choose to reject information systems.

Doctors can choose to follow clinical guidelines, which may standardize and improve care, and end variation. Only 50% of doctors choose to meet all indicators.

This is America, and doctors can choose to follow their own judgments.

More than 80% choose to practice as specialists. Specialists have more respect and earn more money. A final year medical resident survey indicates <1% will choose to practice n towns of 10,000 to 25,000, 4% in towns of 5.000 to 50,000, and 81% will choose to practice in cities of 100,000 or more.

This is America, and doctors can choose what specialties to enter and where to live.

Doctors can choose what drugs to prescribe. With drug formularies, and government and health plans policing brand name use and identifying “outliers, ” choices are narrowing. Some patients are asking doctors to dispense cheaper drugs. Everybody is looking for more bang for their buck, an inevitability in an inflationary health cost environment.

This is America, and doctors can still pick which drugs to prescribe.

Critics say doctors work in a “cottage industry,” meaning they vary in their practices, resist standards, and practice individually, using their own clinical judgment. Doctors counter by saying government and health plans have no business “practicing medicine.”

This is America, and some doctors still think of their “cottage” as their “castle”

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