Costs and Mediocre Outcomes: Are Doctors or the System to Blame?
American system of rugged individualism
Hoover (1874-1964), campaign speech
little systems have their day
have their day and cease to be.
North Tennyson (1809-1892), In Memorium
is the finest thing
seek in all the world’s wide ring,
well can bear his freedom.
thou be wise and bold,
love thy freedom more than gold,
glory follow freedom
Thomas of Strangnas (1443), quoted by Albert Rosenhal, in The Social Programs of Sweden, A Search for Security in a Free Society, 1967
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.
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
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.
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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