Sunday, May 31, 2009

Physician shortage, effect of culture, physician culture - The Baby and The Bathwater

As a doctor, it continues to be amazing to me how the bulk of the Washington-New York-Boston medical and political establishment has gone to war against doctors.

The establishment includes the following: The New York Times, the New England Journal of Medicine, Health Affairs, a wide assortment of policy wonks, the Obama administration, Peter Orzag of the Office of Management and Budget, Senators Kennedy and Baucus, Representatives Waxman and Stark, Karen Davis of the Commonwealth Fund, Dr. Donald Berwick of the Institute of Health Care Improvement. Dr. Fisher of the Dartmouth Group, and Obama’s Boston-based health policy advisors.
The establishment’s message is: as the most visible symbol of the current “broken” health care system, doctors are at fault, and all will be well if only we as a nation can,

• Put into place a public plan closely resembling Medicare and Medicaid to pay doctors less at CMS rates.

• Install EHRs and a Comparative Effectiveness Institute to guide hapless doctors along the path of moral righteousness and what works and doesn’t work.

• Drop fees into a government homogenization blender to bring down costs of high spending regions to low spending regions.

• Use data to erase differences between the most expensive doctors and hospitals to the least expensive doctors and hospitals.

What this assault on doctors fails to mention is, establishment policies will,

• Alienate doctors, causing fewer to enter the profession and more to leave.

• Worsen the doctor shortage, making a mockery of providing more access to the uninsured.

• Create already lengthening waiting lines for doctor appointments, as is occurring Massachusetts.

• Drive more hospitals and doctors out of business as Medicare rates are extended to the private sector.

• Cause more doctors to go underground into concierge or cash only practices, or above ground into nonclinical positions.

• Stifle private innovations with more regulations.

• Substitute bureaucratic judgment for independent clinical judgment.

• Limit choice of doctors, hospitals, and health plans.

Now it may be the political establishment will come up with replacements for independent doctors - physician assistants, nurse practitioners or nurse doctors, foreign-trained doctors, or mega-groups with clinical teams with a doctor here or there.

But until then, I am willing to bet most members of the political and policy-making establishment will seek out a private physician while they are ill while they are trying to answer public’s questions: Where have all the doctors gone? Why can’t I have a private doctor? Why can’t I have access to the very best medical technologies? Why can’t medicine be the way it used to be?

In the end, somehow we must have a vibrant physician community and affordable care for more. This ideal situation will require balance with trade-offs between private and public interests. The health system can't provide it all - collective equality and individual choice. There should be equal opportunity - but results will not be equal for all.

No comments: