Monday, March 2, 2009

Obama, Doctors, and Health Reform - Prospects for Obama Reform

I'm in heat - the heat of composition. I'm in the throes of producing a book, Obama, Doctors, and Health Reform, with a subtitle of The Health System, From Top-Down to Bottom-Up, As Seen Through Lens of Complexity. The books essential message is: Obama has bitten off more than he can chew and will be reduced to taking small bites.

Here is the tentative foreword,

President Barack Obama has vowed to overhaul the U.S. health care system and to spend more than $1 trillion over the next ten years while doing it. He seeks to lower costs, expand access, increase efficiencies, and cut spending.

I would place odds for sweeping reform at 20/80 in his first term, and odds for immediate incremental changes such as coverage for children, stem cell financing, funding for electronic records, and extension of unemployment benefits to Medicaid as slam dunks.

I expect other issues now being debated and demonstrated at Medicare – such as pay-for-performance, competitive bidding for Medicare Advantage plans, government negotiating of drug prices, medical home expansion, bundling of hospital-physician bills, creating integrated groups, coordinating care, forming a Federal Health Board, creating a Comparative Outcome Institute, and mandatory use of EMRs as a condition for payment – to make slow, uneven, and unpredictable progress with a few setbacks.

Otherwise, the debts incurred by the economic stimuli and the staggering federal deficit ( $1.75 trillion for 2010) will be too steep a hill to climb for those who crave universal coverage or single-payer in the near term.

I do not see how Obama in the next few years can create 3.5 million jobs, redesign the entire health system, save the auto industry, reinvent the energy sector, revitalize the banks, and reform education – with one bold swipe of his political magic wand.

The bold strategy and breathtaking scope of Obama’s health plan became apparent when he unveiled his budget plan on February 26 Obama would use current political power his first 100 days to set in motion a 10 year plan culminating in near universal coverage.

He would set aside $634 billion as a “down payment” for a plan eventually costing over $1 trillion. Half the money would come from higher taxes and lower deductions on those making over $250,000; the other half from Medicare and Medicaid cuts with the biggest hits coming from hospitals, doctors, health plans, drug companies, and home health agencies.

The Obama plan would “tighten” payment to doctors. Translated, this may mean lowering payments to specialists and compelling them to participate with hospitals in “bundled” payments for such high ticket procedures as hip and knee replacements and cardiac stent and bypass.

However, the budget sets aside $330 million for loan repayments and other support for primary care doctors who practice in doctor short areas. For doctors, the budget proposal has a big positive aspect. It protects doctors against across-the-board Medicare budget cuts based on the SRG (Sustained Rate Growth) formula.

How one at the same time covers more Americans while slashing costs eludes me. Expanding coverage always costs more. It goes by the name of the entitlement syndrome, which means cutting costs is the improbable meeting the impossible.

I only know one thing- and it’s a big thing. It will be impossible to superimpose a single-payer system on the current system – and to save money in the process. In the jargon of today, the infrastructure must be changed before we impose a new suprastructure.

I wish the President the best. The present state of affairs – unhappy patients, unhappy doctors, soaring costs, and 15% uninsured – cannot last. At least that’s what we keep saying. Health costs, mainly Medicare and Medicaid, consume 25% of the federal budget, and more cost rises are on the way and are unsustainable.

President Obama faces four towering obstacles to reform. I call them the four “Cs.”

Culture, American style, abhors the word “rationing.” Our culture cherishes unlimited choice, quick access to the latest and best in medical “cures,” and lifestyle restoring technologies.

Complexity, American health care is a whirling Rubik’s Cube, with millions of interrelated moving parts, institutions, and people, each with own agenda and axes to grind.

Costs, Obama says prevention, electronic medical records, and paying only for what works, as established through comparative research, will save billions of dollars, yet little evidence exists that these measures work.

Consequences, of curtailing health costs, may be worse than the cure, because health care institutions and private practices in many communities are the biggest and only growing employer in town. Collectively, health care has a profoundly positive economic impact and cannot be dismantled quickly – if at all.

Given these truths and consequences, I offer in this book my observations, gleaned in part from my writings, in part from conversations with health care people on the ground, and in part from public discourse in the media.

Someone once said books about Lincoln, doctors, and dogs always sell well, so the perfect book would be Lincoln’s Doctor’s Dog. This observation partially accounts for my title, Obama, Doctors, and Health Reform. President Obama admires President Lincoln; doctors are still doctors, not yet replaced by nurse practitioners and physician assistants; and politically, until now, sweeping health reform has always been a political dog. But not under President Obama. Health reform is coming – ready or not.

A concluding note to members of the general public with courage enough to tackle this book. Health reform is complex because it involves the expectations of our culture. Everyone of us will need health care at some point in our lives; everyone will expect the best American medicine has to offer; everyone, directly out of our pocketbooks, or indirectly thorugh government and employers will have to pay for it.

Health reform is like a duck. It quacks and glides above but paddles furiously below.

• Health reform can be viewed from top-down, from policymakers and politicians point of view. The interests of policymakers, sometimes dismissed as wonks or gurus, are generally directed towards developing an all-purpose system that glides smoothly along the surface with primary physicians, with modern day Marcus Welbys working as teams. delivering more effective, efficient, and affordable services; public and private entities working in tandem to prevent chronic disease through prevention; all making sure that what we pay for works through comparative effectiveness research.

• Or you can look at it from below, where hospitals, patients, doctors, and big suppliers, like health plans drug companies, businesses are paddling furiously to adapt and adopt to government-imposed policies, as the Obama administration rewrites the rules, decreasing pay to hospitals and doctors and health plans and drug companies, while promising to expand coverage through Medicare and Medicaid.

We’re all part of the same duck, joined at the junction of water and sky. Perhaps this book will help observers understand that political idealism meets clinical realities at the interface of water and hot air, and it is there maybe we can keep the health system from becoming a dead duck.

As you read this book, keep in mind two fundamental differences between physicians and those who would fundamentally transform the system.

• Physicians are trained and accultured to treat and cure disease and to alleviate pain. That is what they are trained and paid to do, and they are not as confident as those who have never been in the clinical trenches that they can change unhealthy patient behavior once patients leave the office or the hospital.

• Policymakers, on the other hand, tend to think that prevention should automatically be part of the physicians’ “toolbox, “ and that care should be coordinated across the entire health spectrum from womb to tomb, but physicians should not necessarily be paid for time spent in discussing prevention or in coordinating care outside their realm.

Have a good read – and even a little fun – despite the gravity of the subject matter, the depth of the recession, and the scope of President Obama’s ambitions

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