Thursday, August 6, 2009

Doctors, their Patients, and Health Reform


Recently, some of us in the medical profession have seen proposals from medical societies for letters that physicians can send to their patients, asking them to weigh in (with the opinion of the physician, or at least of the medical society, on health reform proposals. I suspect that many of the rest of us, as patients will receive them. The idea that physicians can multiply their level of influence on the policy debate is an interesting and not uncontroversial one; however here I will focus primarily on the content that those letters might take. Any position or letter taken by any large group, such as a medical society, will obviously have members who disagree in part or in whole with its content, but the fact that the medical society is weighing in may be quite influential.

The most important issue is the health of the American people, a very important component of which is access to health care. This means financial access without unreasonable barriers, geographic access, access to a primary care medical home, and access to proven, evidence-based diagnostic and treatment methods. It is also critically important that the cost of "health care" be controlled; I put it in quotes because a large part of that cost is in administrative costs. These costs, which are "waste" in the sense that they do not deliver health care to anyone, include, and are driven by, the enormous profits health insurance companies make, but are far more than that. They are in the huge billing and collecting infrastructures that the insurance companies (to try to not pay) and all providers (to try to get paid) have to have in place. Zero percent of this is from public programs, but the growth in administrators is astonishing (see slide).

The issue is not, should not be, and absolutely cannot be seen to be, protecting the self-interest and incomes of doctors. This is not to say that doctors should not be reimbursed "fairly" for their services; certainly they have to be able to pay their staff and make a living. (Although note, above, that a lot of staff and physician time is spent on trying to get reimbursed!) In addition to any moral or ethical issues -- and it would be nice if physicians, who we ask the American people to trust with their most important assets, their lives and health -- would act, especially as an organized group, morally and ethically, there is the fact that physicians already make more money than most people. It may not always seem so if we live in the richest parts of town and thus compare ourselves to the richest people, but even the poorest paid primary care physicians are in the top few % of income, and many are in the 99+++%. Whether you think you deserve it or not, the typical employed, not to mention unemployed, American is not going to cry for you, and it is amazing that we would even think of asking them to.

Another huge cost driver is the growth of expensive technical procedures. Many of these are important diagnostic and therapeutic advances, and when evidence shows that they are beneficial they should be used, although the cost has to come down. The American people -- forget the government -- need to know that zero percent of any recommendation for a diagnostic or treatment intervention is motivated, even subconsciously, by the potential income it may bring to physicians. We must welcome, embrace, cheer -- and definitely be part of -- efforts to identify which strategies are evidence based, and for what populations, and what the cost benefit ratio is. (As to what ratio is acceptable, that is a different question, but one must be joined. It is NOT ok to say a huge cost to benefit ratio is ok for one person -- me or mine -- and not for another person.)

The basis of every effective health system is primary care, a primary care medical home. People need a doctor who knows them, who can help them work, if needed, with multiple specialists, help them interpret the jargon, help them know when two consultants who seem to the patient to be disagreeing really are not, and how to figure it out when they are. They need a doctor who knows them and their family, and what their health was like before they "fell from the sky" into the hospital, so that s/he can know when they are better. They need a primary care medical home because it is mainly primary care doctors who will be able to practice in rural areas, where 20% of the American people live and 9% of physicians practice -- and decreasing rapidly. Medical students are not entering primary care, and not going to rural areas; some of this may be lifestyle but much of it is financial. Organized medicine needs to take this issue on as its own, demanding policies that encourage a move toward a 50% primary care workforce. Even if it means some decrease in income for some specialists.

One of the letters I have seen uses anti-government scare tactics, which are indefensible. If there are members who do not believe that everyone should have access to the highest quality medical care, we are on different pages; that is a different discussion. Fear mongering of "government bureaucrats" coming between you and your doctor is just that; first of all, there are no such proposals. Secondly, the government bureaucrats could have nothing on the insurance bureaucrats. Let us not lose sight of the fact that the government -- including our congressmen and senators -- is supposed to be responsive to us. I know it may often seem as they are only responding to the biggest contributors (often including organized medicine), but for-profit insurance companies are not even supposed to care about our opinions; they are only obligated to their shareholders. A public option is necessary to ensure that all people are covered. If the insurance companies are confident that they are offering a better product, they should not be afraid of the public option competition. Indeed, it seems they are not so confident, but rather, contrary to the idea that the public sector will have "unfair" advantages, believe that they need the special privileges, "unfair advantages", that would come from hobbling the public sector. And, of course, a public option only saves a small percent of the cost of "non-medicine"; even if half of Americans were in it, we would all need to maintain our billing and collecting infrastructures for the rest.

Scare tactics that alarm our patients are inappropriate, undignified, and inappropriate. The medical profession has done well financially not because they studied hard (there are starving artists and musicians everywhere who study and practice hard) but because people trust them with their lives and health. To take any position other than that which is certain to have the greatest health benefit to all people -- lowest to highest income -- is a violation of that trust and is dishonorable. We are, we have to be, better than that.

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