Thursday, July 8, 2010

How Should Physicians Respond to Reform?

Last month I spoke at a high school reunion on my life as a doctor. The talk produced a standing ovation. Why did it succeed?

I suspect because my talk reviewed our shared experiences, was nonpartisan, contained self-denigrating humor, praised my classmates, and related history lessons learned.

Perhaps I can apply the lessons learned there to here - to how we as physicians can better connect to our primary audience - our patients- and to put Obamacare in its proper perspective.

History Lessons

• That World War II, through such advances as penicillin, sulfonamides, transfusion, life-saving battlefield treatments, and government care of 13 million soldiers, heightened public awareness of the value of regular health care and led to later generous public support for health care research.

• That Medicare and Medicare programs, introduced in 1965, have been wildly popular and wildly financial irresponsible. These entitlement programs now consume over $1 trillion, pay for 50% of health costs, and are the largest single contributor to our soaring national debt. It’s complicated. We cannot live with these programs, and we cannot without them.

• That the structure of these national entitlement programs, our tax code favoring tax deductibility for health benefits for employers, and imposition of third parties between payers, providers, and patients, has fostered high administrative costs and a vast $2.5 trillion medical industrial complex, now taking 17% of GDP, growing fast and uncontrollably , and eating the federal budget alive. We are victims of our success.

• That the treatment and successes of the medical enterprise, notably life-saving and lifestyle-saving half-way technologies - stents, bypasses, cataracts, dialysis, and joint replacements- have created public expectations for further medical wonders that cannot be met. The success of these half-way technologies has led to the cruel illusion that we can extend productive life indefinitely through technologies alone. Instead we need realistic changes in governmental altitudes above and cultural attitudes below.

• That the promises of genomic therapy have yet to be fulfilled and will be unlikely to transform care into an affordable system, even though discovery of the genome dates back to 1962. Genetic engineering and stem cell research is still in its infancy, and its potentials for curing cancer and degenerative diseases are overstated. Personalized knowledge of our genetic make-ups and its applications will not lower costs and will have only marginal effects on the health system.

How Should Physicians Respond?

• That we should conclude reform in some form, namely public-private collaboration, is inescapable. Government now pays for half of health care. Government policies and those of the private sector need “reform,” another name for “innovation.” Large social problems require large organizations and will be entrusted to those organizations, rather than to individuals. This will require fundamental changes of the status quo – reforming Medicare, how we pay and incentivize doctors and hospitals, and limiting and justifying utilization.

• That liberal reform, Massachusetts-style, where the political class has been in command over the last four years, has produced a runaway “train-wreck,” leading to the highest premiums in the nation and the longest waiting times in the nation to see doctors, even though Massachusetts has the highest number of doctors per capita of any state. Replacing the current “train-wreck,” our current system of providing care across the country, with a “train-wreck” engineered by politicians, is no solution at all.

• That certain aspects of our national culture contribute to U.S. health care dysfunction and have limits – runaway expectations of perfect results based on access to technologies, absolute power of Internet-based consumer information to guide patients to good health, good doctors, and good care; comparative metrics in judging doctor performance and patient outcomes, and the belief that casino-style legal oversight will somehow correct doctors abuses.

• That comparing the performance of U.S. health system to other nations is invariably misleading. The U.S. health system is a product of our culture, its affluence, its heterogeneity, its freedoms, its pockets of poverty and violence, its regional variations, its population growth secondary to exploding immigration growth, and the wants and expectations of its peoples, and cannot be reduced to simplistic comparisons.

• That reducing costs will ultimately come down to collaboration between hospitals and specialists, for that is where most current costs now lie. Reducing or stabilizing these costs may come down to bundling fees for common diseases and procedures. It may also come down to patients choosing what and what they will pay for, based on their ability to pay and the necessity of treatment to the rest of society. And, in the long term, it may come down to decentralizing care and making it more ambulatory-based and less-invasive.

• That human life, with or without universal coverage, ends in death - 99% of us will die before we reach 100 no matter what we do. Instead of unrealistic promises for extending life, we should concentrate more on comfort, relief of pain, home care, hospice care, and compassionate primary care, whatever it takes to make our final days more affordable and comfortable in familiar surroundings.

• That there is always room for improvement in medical care, and we doctors should not resist that improvement or measures of that improvement.

. Finally, that we as physicians need to connect more closely with patients and to show we share their economic, physical, and emotional pain. We need to say that blaming physicians for shortfalls of the system is counterproductive. Paying them less and regulating them more will drive current and future doctors out of the system and out of caring for the sick. Universal coverage and universal the access are not the same. Patients without doctors is not a tenable clinical or political solution. In the end, a balance between government and private solutions will be required, rather than more of one and less of the other.

1 comment:

Michael Kirsch, M.D. said...

Richard, I have nothing to add to the above comment.