For Reform to Go Forward....

September 4, 2009
Jeff Kaplan

Are we ready to deal without discrimination with potential genetic endowment or burden, given the great variability in penetrance and expressivity (how genetic diseases are manifest, if at all)?

In the September 2nd edition of JAMA (2009) lies the philosophical underpinning of this blog—"Reforming Healthcare & Managed Care."

The first piece asks is there a future for systems medicine? This term refers to not only genomics, pharmacogenomics, the external environment and behavior, but also "new dimensions of concern" that include cost, privacy, discrimination and justice.

Thus, the authors call for a more comprehensive approach than the bio-psycho-sociological model that I have been writing about, saying that: "Modern medicine often neglects [the more] comprehensive model and treats disease in isolation, without taking into account the dynamic, integrative systems in the human body." They augur for a more holistic approach, one that recognizes the "sociolegal [sic.], ethical, and economic implications."

Howard J. Federoff; Lawrence O. Gostin. "Evolving From Reductionism to Holism: Is There a Future for Systems Medicine?" JAMA. 2009;302(9):994-996.

But, are we ready to deal without discrimination with potential genetic endowment or burden, given the great variability in penetrance and expressivity (how genetic diseases are manifest, if at all)? I certainly do not want the insurance companies to have this information; do you?

The second commentary addresses assessing the appropriateness of care, which is vital to any health care reform proposal or plan. Dr. Brook speaks to the "RAND/University of California Los Angeles (UCLA) Appropriateness Method (RUAM), which is empirical research used to "develop explicit criteria for determining the appropriateness of care. Physicians and patients can use the results from applying this method to make better informed decisions about expensive, elective procedures or diagnostic tests, and the process of developing the criteria will strengthen the clinical evidence base." He, nevertheless, cautions that the only major non-research users of this, essentially, managed care technique, were those in the insurance industry. (And, we all know that their incentives are neither aligned with doctors nor patients.)

Quite naturally, the managed care industry used a carrot and stick approach, alienating "physicians because they felt their clinical autonomy and judgment were threatened."

Have times changed?

Robert H. Brook. "Assessing the Appropriateness of Care—Its Time Has Come." JAMA. 2009;302(9):997-998.

The mighty pen of the practicing physician determines most of the utilization of care

The third commentary discusses the futility of cost shifting and healthcare costs, a shell game if there ever was one. The adage of the balloon applies: if you squeeze it in one place, it pops out elsewhere. Thus, docs, squeezed by reducing their fees, order more visits and procedures. (I do it myself). If you cap (capitate) them, they discourage the same stuff raising questions in the other direction).

Let me be clear, I totally agree with Dr. Fuchs and always have. As he says:

"After adjustment for the higher proportion of specialists and the cost of training, the difference between physician incomes in the United States and other countries is smaller than first appears, but relative to other occupations, US physicians still make more money. Reducing fees is an option that Medicare often tries to exercise, but frequently backs off under political pressure. Moreover, reducing fees does not necessarily reduce expenditures because physicians can respond by recommending more visits and tests. ...."

"The challenge to health reform is to implement systems in which physicians have the information, infrastructure, and incentive to practice cost-effective medicine. In such a system, high-physician income would be of minor importance as long as total spending was under control."

Victor R. Fuchs. "Cost Shifting Does Not Reduce the Cost of Health Care." JAMA. 2009;302(9):999-1000.