Sunday, June 27, 2010

How and Where U.S. Physicians and the U.S. Health System Go from Here

The health care bill’s passage sets a framework for reform. It will roll out over the next 10 years. How it goes and where it stops no one knows. It will require multiple mid-course corrections and compromises. It may result in the political transformation of American medicine and the remaking of a vast industry. It may even slow the momentum towards higher costs. By 2020, the health system will consume 20% and $4.5 trillion of the GNP. I’ve been wondering: how do we go from here to there.

Given lack of national physician leadership, how do U.S. physicians become more visible and credible in the reform effort?

Physicians feel marginalized in the reform effort. They think of themselves are political playthings and afterthoughts. The physicians’ main problem, rarely articulated, is that every single social task of importance is entrusted to large organizations run by politicians or managers. Only about 15% of doctors belong to the AMA, and physicians have lost trust in the ability of the AMA to get things done – such as tort reform and getting paid by Medicare. One path being pursued by the Physicians Foundation, a nonprofit organization representing physicians in state medical associations, is educating the public and politicians to the consequences of reform- primary care shortages, lack of physician access, long waiting lines, rationing, invasion of privacy, clinical decision making by bureaucrats and technocrats. Yet the only organization big enough to address society-wide problems is CMS (Centers for Medicare and Medicaid). It covers 100 million Americans, soon to be many, many more. For government, the answer is paying doctors and hospital less, rationalizing (read that as rationing) care for high-ticket items, and making the system more “efficient” and “equitable” through collaborative “systems” of care. The more likely solutions are moving the age of Medicare entry to 70, charging middle class and wealthy Americans more through means testing, and allowing those who can pay to privately contract with physicians.

How does the U.S, cope with the “success” of the system, namely the flocking of U.S. citizens to specialists for first-time care, consumers’ reliance on high-tech life-style fixes (joint replacements, cardiac stents, cataracts), and dependence on third party payment?

It is a very difficult to take back what has been given for “free”(Medicare and Medicaid coverage) or” nearly free” (Americans pay 12% for “out-of-pocket” for care). This problem afflicts the publishing industry. It is going broke because of “free” Internet access. Like the publishing industry, the medical industry needs a new business model. One answer may be the Google approach, namely, have the advertisers pay for the number of hits or visits to a site. This model is being pioneered by Practice Fusion, Inc, an EMR company that offers doctors “free” EMRS by having vendors to physicians advertise.

And how does one steer Americans away from specialists, who have the expertise to perform wonders? After all, we are a country who admires “experts” with the expertise to fix our health problems, many brought about by our bad own health problems, which have lead to obesity, diabetes, cardiovascular disease, and cancer. Keep this in mind. Patients rejected the managed care “gatekeeper” concept. They feel perfectly capable of using the Internet, now in 70% of U.S. households, of picking their own specialist. Perhaps medical homes, integrated multispecialty groups, patients and doctors acting as partners to choosing the right course of action, accountable care organizations, operating on a budget to care for Medicare patients and offering bonuses for “savings ” to doctors and hospitals are alternatives for direct specialty care.

• How do you convince people that market-forces – retail clinics, tax-free health savings accounts with high deductibles and money left in retirement accounts, and physicians and hospitals competing for business - are the way to go?

Given the current political administration – with its almost visceral disdain for businesses, large and small, its trashing of anything related to health that relies on “profit,” and its unshakable beliefs that it knows what is good for the people rather than what people choose for themselves - “market forces” are a hard sell. This set of political attitudes may change. Recent polls indicate two-thirds of Americans oppose Obamacare, 60% do not “connect” with the President’s beliefs, and two of every three American now consider themselves more “conservative” than “liberal,” But the President’s decision to “sell” his health plan to the American public before November may succeed. Given his golden tongue, he may yet convince us his benevolent good intentions outweigh the adverse consequences of the health bill.

Maybe, just maybe, the political transformation of American medicine will re-make the vast health care industry. This will not occur overnight. It is simply too difficult for a left-of-center president to govern a right-of-center country and to wean its citizens from a culture of individualism to a culture of collectivism.


Michael Kirsch, M.D. said...

The AMA is similar to the American labor movement, groups that formerly had power and influence. The AMA has lost it's way. Who do they represent? There's a reason that most physicians are not members.

HaynesBE said...

How can anyone determine whether or not care by specialists is more or less efficient than primary care? Without free market prices which actually reflect supply and demand, there is no way to calculate REAL cost/benefits. At this point, it's all a matter of rationalistic calculations based on the arbitrary prices of the CMS.