Still More Healthcare Reform

September 18, 2009

With some assurance of positive change, people might be more willing to cooperate in the healthcare reform debate. But life isn't like that. However, keep in mind that shining a light into dark corners usually helps.

As we left Frostbite Falls last time, we acknowledged that our futures as taxpayers, patients and doctors are in play in Congress. There is a generally agreed upon need to rationalize healthcare, particularly it's perceived high cost, inefficiency and exclusivity. And it is clear that the free market alone has not, and cannot, solve some of these problems. I pointed to cost drivers such as employer involvement in obtaining insurance, a lack of physician training in business basics, the defects of paper medical records, the toxic malpractice environment, and the straw man of science and technology advancement. At least the last factor does yield eventual cost savings and health improvement, our basic goals.

And what about some low-hanging fruit such as having one national, standard, simple superbill/insurance form? This instead of the Babel of forms that exist requiring battalions of secretaries and software to struggle with, leading to endless delays and more needless expense.

And everyone, except the insurance companies, agrees that there should be no denial of benefits for preexisting illness, or for changing employment.

I wrote earlier of a relatively cheap federal program that might pay the entire bill for medical training, which would better balance both the number and location of various specialties on a more need-based basis. In exchange, the doctor opting for finishing training debt-free would "repay" by giving a couple of (paid) years of national service. It would also take some pressure off docs to go into higher paying procedure-based specialties just to pay back their large debts.

We can further incent docs to go into the underserved, desired cognitive specialties (read: lower cost to the system) by shifting some increased portion of the fee pot to them.

Another biggie that is getting what seems to me only lip service is prevention. If, for the sake of argument, we agree that about half of what makes us sick and kills us is at least in part our own doing, we should be making a lot more fuss about it in a coordinated national way. As in a big budget to encourage and reward people to stop smoking, lose weight, exercise daily, put on their seat belts, deal with our ostrich attitudes about alcohol, drugs, etc. I've heard all the same excuses from my patients that you've heard from yours, but we need to get everyone on board and make this a cultural effort, not just a medical one. Really. An ounce of prevention is a lot of money, morbidity, and mortality saved.

Now, I am going to throw out three ideas that are considerably more debatable. First, I have had the privilege of employing many PAs and FNPs over the years and they do an excellent job. And I, as a primary care doc, realize full well that I am overtrained for what I am called upon to do most of the time. These other professionals are cheaper and quicker to train. And we might be looking at the sudden infusion of some 40 million previously uninsured Americans into the market. Who is going to see them? Primary care docs are already impacted. We'll always need some narrowly-focused specialists, but are primary care docs dinosaurs that economics will exterminate over time in lieu of PAs and FNPs?

The next two ideas are linked: the replacement or unification of many insurance companies with a single payor and the elimination of fee-for-service. “Heresy! Socialized Medicine!” But think about it. Salaried docs do not drive costs the way fee-for-service docs do. Look at the many successful examples around the country. Yes, they have their own issues—economic, organizational and so on—but you have to say that fee-for-service is a major cost driver.

It is asking a lot for the thin blue line of medical ethics and pre-approval clerks to hold back basic human nature for docs to rationalize doing more when it is reimbursed, even if it is presumably well intentioned. And "evidence-based best practices" are too much of a constantly moving target to hang your restraint hat upon. And that's if every doc even knew about these "standards," let alone agreed on them. And they (and we) don't.

I was almost shocked recently when a group of docs that I hang with (a mildly crusty bunch) grudgingly admitted that a single payor program was not only inevitable but desirable. Desirable! Maybe they are all finally just burned out. After all, the gradual, unplanned, and uncontrolled decline in our long-cherished autonomy (and therefore stature) might have gotten to be too much. And single payor systems like Medicare and the VA "work." Just like hospitals, the best system for healthcare could be non-profit to eliminate the huge cost driver that focusing upon the margin instead of the mission brings. The mission should be the driver.

It seems the thorniest issue for all Americans is that we are sailing into uncharted waters here. If there were some assurance that such changes would, in fact, be more cost effective and help more people and do so more efficiently, we might be more willing to cooperate. But life isn't like that. And we also know that the success of any venture, business or medical, is in the control of details. Aye, there's the rub, to steal a line.

Time's up again and the only thing that I am sure of after all of this is that this debate itself has got to, eventually, help. Shining a light into dark corners usually does.