Saturday, October 25, 2008

U.S. health care system, physician culture - Paradoxes abd Tensions Facing American Physicians

Despite the ideals and wishful thinking, the government’s job is not to provide full employment and wealth, and it can’t provide them anyway. The aging population will make the system unaffordable. It is already unaffordable.

John Naisbitt, Mindset, 2006

Uncover and work with paradox and tension. Do not shy away from them as if they were unnatural.

Edgeware, Insights from Complexity Science for Health Care Leaders, 1998

As long as advocates of a government-driven versus a market-driven care compete for political supremacy, American physicians will experience natural paradoxes and tensions.

This is inevitable. One cannot have a free, choice-filled, autonomous health system with access to the latest technologies and vast uniform social welfare programs covering all with restrictions at the same time.

The barriers to the former are uneven quality, high costs, and more uninsured; the barriers to the later are high taxes, limited freedoms, less innovation, slow productivity, and restrictive practices. The contest between government and market approaches to health care inevitably produces paradoxes and tensions for American physicians.

Paradox #1 - Other developed nations have better health statistics than the U.S. – longer lives, less infant mortality, and fewer deaths that might have been prevented through medical care.

The U.S. culture differs from that of other countries. We demand greater access to high technologies, have a more heterogeneous population, are a vast continental with sharp regional differences, experience more violence and accidental deaths, and have more obesity and diabetes than other developed countries. Some of this is due to the vibrant vitality of our exceptionalism, some to excesses and freedoms of U.S. culture. Most of these statistics are beyond the control of health professionals What is often overlooked is that Medical care accounts for only about 15% of the health of any nation. The rest rests with its culture.

Paradox #2 - U.S. physicians have higher incomes than physicians of other nations.

This is true, and there are reasons for the differences. U.S. physicians must subsidize their education through college, medical school, residencies, and beyond, which is not the case in most other nations. The typical medical school graduate in the U.S. is $150,000 in debt, which often reaches $300, 000 for married medical couples. Also due to the litigious proclivities, U.S. physicians must endure high malpractice liability costs. Practice expenses are also greater in America. These factors aren’t necessary desirable, but what is, and U.S. physicians’ higher pay is partly illusionary when these factors are taken into account.

Paradox #3 - In the U.S., medical progress and new technologies account for about 70% of health inflation.

The paradox here is that the U.S. people demand quick access to the fruits of technological progress, often for elective life-style procedures such as joint replacements and cosmetic procedures. Furthermore, in many diagnostic workups and procedures, advanced technologies – X-ray imaging and heart bypass and stents – have become the accepted and expected standard of care. Finally, practitioners offering high tech care have higher incomes and better life styles than generalists offering cognitive advice.

Paradox #4 - Many mandatory or universal coverage advocates believe Medicare payments should be the gold standard for reimbursement.

This is already the case in certain sections of the country. Unfortunately, this leveling of rates creates paradoxes and tensions. Medicare payments and sister Medicaid payments are usually far below those of private payers. This fact may cause physicians to cease accepting new public-paid patients or may drive physicians out of practice, precipitating an access crisis.

Paradox #5 - There is a yearning for a return of Marcus Welby- like care, for more compassionate physicians, and for a return to more coordinated and comprehensive and less costly care in ”medical homes.”

This yearning is understandable and desirable, but faces barriers: 1) a specialty dominated health system with 2 of 3 doctors being specialists; 2) payment differentials between specialists and generalists; 3) current special interests – hospitals, high tech specialists, health plans, device manufacturers – who profit from the status quo. In addition, there is a renewal among medical school educators for an emphasis of a liberal arts education with a refocus on narrative medicine, listening more closely to patient stories.

Paradox #6 - Doctors are being told they should tell patients exactly what they are doing, including telling them when they are prescribing placebos.

A fine idea in a perfect world of symmetrical information equally shares by patients and doctors. But not practical, desirable, or even advisable in the real world. Studies show 30% to 40% of patients unwittingly received placebos improve. Telling patients you are prescribing placebos will offend many patients, and signal to them you are not taking them seriously or labeling them as hypochondriacs.

Paradox # 7 - The government should establish a Medical Advisory Commission “with teeth” with a specific payment schedule created by Congress.

A bad idea, certain to drive more doctors, who cherish their autonomy, out of practice and to discourage more bright young people from entering the profession. A Center for Medical and Health Effectiveness is also being proposed. Most drugs are approved for “average” patients, but the whole thesis of “personalized medications are that individual patients, depending on their genomic makeup, may respond differently to the same drug. Congressional mandates telling doctors what to do and prescribe might have the effect of reducing doctors to mere medical technicians, devoid of independent thought.

Paradox #8 - Policy makers are fond of proclaiming that the system should be stripped of “perverse incentives” by “aligning” incentives of hospitals and doctors.

This is another way of saying hospitals and medical staffs should be “integrated.” This in unlikely to happen except in large health enterprises with salaried doctors. The truth is that the gap between the hospital “admonisher,” ie. those in executive suite, and practicing doctors on the ground are widening. The gap grows because of control issues and competition for the health care dollar between hospitals and doctors.

Paradox #9 - Politically it easy and safe to say that health care ought to be a “right” and that mandated universal care ought to be the norm for our society...

But it a quite another thing to implement because of the diverse desires of patients and doctors, distrust of government, the trend towards decentralized rather than centralization, and the smothering effect of government mandates on innovation.

Paradox #10 - The partisan divide between those who say medicine is a “Science” rather than an “Art, ” who advocate “group” or “team” care rather than solo or small practice care, and those who push for government-based care rather than market-based care will continue to pose paradoxes and tensions for doctors.

Those who say medicine is a “Science” rather than an “Alert’ claim practices can be” rationalized” through information technologies, including pay-for-performance program, best practice guidelines, application of Health 2.0 algorithms, elimination of waste and duplication, and widespread collection of data through EMRs, and regulation and discipline of practices using the data. This belief system poses dilemmas for doctors who think of themselves and patients as individuals with freedom to practice and choose as they please.

There are those who fervently believe large group practices with salaried caregivers acting as teams, acting upon best practice data at their fingertips, and following group-agreed upon rules will rule. This may be, but many physicians prefer to practice autonomously following their instincts and experience. These large practices are gaining traction but still comprise less than 15% of practicing physicians.

What ultimately evolves will likely be incremental for the simple reason that the incoming president will face a budget deficit of over $1 trillion. If Barack Obama is elected, which seems probably at the moment, this deficit will be constraining for his policies which are projected to cost $4.3 trillion over the next nine years and to project 171 new federal programs.

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