When it comes to healthcare reform, a former industry executive says we should be wary of top-down, Washington-driven reform that produces more bureaucracy, less freedom of choice, and higher costs.
In previous installments in this series of blog posts, I asked what the Patient Protection and Affordable Care Act (PPACA) and ObamaCare are going to do about the rising cost healthcare and whether reducing physician income will be a necessary part of cost control. In this post, I ask “What have we really learned from healthcare reform?”
Here’s what a colleague, the former CEO of a large PPO/HMO, has to say:
With respect to the big healthcare issues (coverage, quality, and financing) and the operational issues (supply and composition of physicians, medical training, role of non-physician providers, evidence-based medicine, provider contracting and reimbursement, medical malpractice, individual and family behavior/lifestyle [think diet, drugs, STD, and teenage pregnancy rates] and associated public health expenses, insurance reforms of various sorts, etc), I've concluded that we've learned many of the key lessons. Now it's a matter of developing the honesty, courage, and will to implement that which works and discard that which doesn't.
As to the President's plan, I'm skeptical. I look at other well-intentioned, large-scale initiatives that have come out of Washington in the last 40 years and the results are not encouraging. Let's take public education, for example. Education, certainly in the public sphere, is now largely controlled or profoundly influenced by Washington. You tell me if the American people are getting value for their money. Pick your metric and compare the performance of American students with those from other countries, particularly in math and science and you will find us wanting. Even in reading and language skills, the situation is not encouraging. Why? Well, for one thing, the NEA and the AFT exert control over instruction in our schools and the combination of tenure and seniority result in the perpetuation of mediocrity and the discouragement of initiative.
I think we'll see similar issues emerge with the President's healthcare plan. Social engineering and political back scratching will trump quality care and objective governance. And while it is certain that greater governmental involvement will move the nation towards nominal universal coverage, that progress will prove to be a cruel mirage.
Those who are expecting the Promised Land will be greatly disappointed. Rather than the Land of Milk and Honey, they will likely find themselves in a Byzantine bureaucratic slough with many of the worst characteristics of the British and Canadian systems -- universal coverage and universal queuing.
Your colleague who used a comparison with Cuba to show what is possible with greatly reduced resources has not visited the same Cuba I have been to. And I would be very cautious when using statistics produced by the Cuban government or cited by international bodies using these statistics to demonstrate how good things are there. Given your facility with numbers and experience as a physician serving various "distressed" communities, especially where the "distress" is largely self-inflicted, you know that when one drills down through the data, the picture in the US reveals much more that is good than you'd likely find in Cuba. Can we learn things from the Cuban experience? I'm sure we can. But what we can learn from the healthcare delivery system of a command economy (I'm being kind in my description) is probably not something that most of the American people would choose to use. But, as I hope you remember, I'm always open to new information, new ideas and new approaches to old problems, regardless of the source.
Finally, what about managed care? (Dare I say the dreaded "H" word -- HMO?) What a sad life cycle we've witnessed! The system we knew and to which we devoted years of our lives has been largely effective on most if not all of the metrics used from the beginning to the present. It emerged from a feeble obscurity in the 1970s and early '80s, grew to a robust young maturity in the '90s, and evolved by learning many of the lessons and incorporating the best practices that emerged along the way. But then, things changed. As managed care became "corporatized," it began to lose its friends in high places. Astute politicians went from championing HMOs to being strident critics, no doubt reflecting the attitudes of the new crop of staff people who pulled their strings and wrote their speeches. HMOs became the butt of jokes from Hollywood and other sectors of the entertainment community.
When I first heard a critical, expletive-powered vilification of HMOs by Helen Hunt's character in As Good as It Gets, and the audiences cheering, I knew we were in trouble. HMOs and managed care wasted much good will on corporate greed and excess. We committed the fatal error of permitting ourselves to be described by our enemies on all fronts -- left and right. Little of the good work and daily care provided by thousands of physicians and other healthcare providers was evident to the public. All they saw and read were endless stories about arbitrary denials of care and the antics of corporate fat cats. Where was the pushback by Karen Ignani and the many other official "spokespeople" of the managed care industry?
Meanwhile, away from the limelight, we find excellent examples of managed care that can and should serve as models. Whether we look at Kaiser Permanente, the Keystone Health, or hundreds of other plans, the template is there and should be followed. Bottom line: healthcare reform without managed care will not succeed clinically or economically. Top-down "reforms" promulgated in Washington under the President's plan will produce a Ministry of Health Model with outcomes equivalent to the results we find far too often in public education. I hate to keep flogging this horse, but I urge you to do a thought experiment: Let your mind go back to the 1970s. President Carter, in a sop to the NEA and other teacher unions, created the Department of Education. Now move forward -- decade-by-decade. More than thirty years have passed and note the metastatic growth of the educational bureaucracies at all levels and the input of hundreds of billions of dollars spent to "help the children and improve education." The dollar inputs have been massive, yet the results have been discouraging. You tell me if we've gotten good value for our investments.
This is what I fear will happen with healthcare in the United States. Only this time, the system will probably not have 30+ years to demonstrate that the "reforms" don't work. The fiscal profligacy by the federal government and most of the very large states will likely derail these well-intentioned initiatives sooner rather than later. We will run out of money and then we'll have…what? I'll let you fill in the answer.