Monday, June 27, 2011

What I Have Learned about Health Reform, Then 1989, Now 2011

June 27, 2011 - In 1989, as editor of Minnesota Medicine, I was writing a great deal about the corporate transformation of medicine, which was part of my book And Who Shall Care for the Sick? (Media Medicus, 1988).

The book was a warning shot across the bow about a future shortage of primary care physicians.

As part of the process of writing about managed care, the first big wave of health reform, I was reading the works of Winston Churchill, who you may recall, warned of socialism as stifling innovation and dampening economic prosperity.

Yesterday, I came across a book Blood, Toil, Tears and Sweat: The Speeches of Winston Churchill (Houghton Mifflin Company, 1989). On the back fly leaf of the book, I had written notes of an editorial I was pondering “What I Have Learned.”

For the purposes of this blog, I thought it might be useful to revisit those notes in light of what has happened since.

Here are a few of my notes written for physicians, followed by what I think now.

Note One - If you do anything, do it within the confines of an organization. It takes organizations to make you strong. Society and payers are demanding order and consistency. This will be done within a management context, set forth by government and private managers, and it will compare results within various regions of the country.

Comment on Note One - If anything, this demand for “order and consistency” has multiplied. It is the basis for the health reform law, which essentially, is a federal command and control blueprint for organizing, regulating, and managing actions of independent doctors and hospitals.

Note Two - Medicine is neither a public service or a business. It is both and neither function can be ignored.

Comment on Note Two – Medical services are unique in that politically they are considered a “right,” yet they require business “profits” to function. They are not “free” but when considered so, engender demands that inevitably outstrip resources.

Note Three - Management is not enough, but neither is professional expertise and specialism. Blind setting of limits to control access to specialists to curtail demand seldom works, and so does owning of primary care doctors and their networks to serve as “gatekeepers” to specialists.

Comment on Note Three - As a method to control costs, HMOs and PPOs, using utilization controls and primary care gatekeepers, worked temporarily, but lost favor when doctors and patients alike revolted and demanded straight access to specialists and procedures they offered. It is unlikely the present reform plan will work very well either, for consumer demand to access to what is perceived to be the “best,” i.e., specialist and high-tech care, will persist in an aging population when one is sick or when one seeks treatment to restore full life-style functions.

Note Four - Heaping scorn on physicians or ignoring their solutions on how to fix problems of system is dangerous. Most doctors are entrepreneurial in spirit. Reducing physicians to salaried employees in large organizations runs risks of inducing a civil servant mentality, of stifling innovation, of reducing incentives for talented people to enter medicine as a profession, of creating monopoly organizations that limit access, and compounding the physician shortage.

Comment on Note Four - This is precisely what is happening. The health reform law is exaggerating the doctor shortage. The doctor shortage, particularly among primary care physicians, is spreading; morale among physicians is at a low ebb; and physicians in droves are opting for a 40 hour work week with benefits as an alternative to private practice. The health reform law, and the current government attempt to send “mystery shoppers” to pose as patients to see why doctors don’t accept patients in government programs will only worsen physician shortages (Robert Pear, “U.S. Plans Stealth Survey on Access to Doctors,” New York Times, June 27, 2011). Blaming physicians for flawed government policies is not an effective way to promoted professionalism among physicians or to solve government-induced health system problems.

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