Friday, October 11, 2013

High Costs and Mediocre Outcomes: Are Doctors or the System to Blame?
The American system of rugged individualism
Herbert Hoover (1874-1964),  campaign speech ,  1928

Our little systems have their day
They have their day and cease to be.
Alfred North Tennyson (1809-1892), In Memorium

Freedom is the finest thing
We seek in all the world’s wide ring,
Who well can bear his freedom.
Wouldst thou be wise and bold,
Then love thy freedom more than gold,
For glory follow freedom
Bishop Thomas of Strangnas (1443), quoted by Albert Rosenhal, in The Social Programs of Sweden, A Search for  Security in a Free Society, 1967
Are doctors or the system to blame for high costs and poor outcomes?  

It’s a question that’s been festering below the surface of health reform since its inception .  
The lack of a rational system  and health system thinking as the root of the problem has its champions.  George Halvorson of Kaiser and other big health system are examples.    So are the academic publications  in business and medicine, like the Harvard Business Review and the New England Journal of Medicine.    So too are policy wonks and makers, policy makers and staffs in the national capitol, who wrote  and designed the unreadable and  unread Affordable Care Act.  To these thinkers,  it's a top-down thing.
If Only
The reasoning goes like this. 
If only we did away with incentives for personal gain on the part of physicians by doing away with fee-for-service and put physicians on salary  in coordinated teams and rewarded gains in population health and adherence to evidence-based guidelines and systematically engaged patients to prevent disease and improve health,    costs would go down and outcomes would improve.
If only we listened to the experts and managers seeking the common good rather than the individual good,   prevention and wellness would reign among the general population. 
If only we would reward physicians for quality through pay-for-performance programs  all would be well.
This all sounds rational.  Unfortunately,  pay-for-performance programs, on the whole,  have mixed reviews.   They  have not consistently  improved results or lowered costs.  Nor have they changed physician behaviors.
Medical students continued to pick specialties over primary care because of prestige, better incomes, and balanced life styles;  they are more likely to use facilities they own rather than those owned by  health systems; and hospitals are more likely to expand profitable product lines rather than money-losing lines.  
And to compound the  problem,   physicians are more likely to treat the suffering of patients  and provide the best promise of care for the patient who sits at the desk or examining table across from them regardless of what’s best for the organization.   Furthermore,  they seek ways to pay off their medical school debts and to increase their productivity rather to advance the cause of the “system. The caregivers seem more anxious to please the patients and reduce suffering and foster hopes  rather than receive performance bonuses,
Tweet:    Who’s to blame for high costs and mediocre results of  U.S, health system.  It’s a dilemma:  system control vs individual doctor freedom.




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