Wednesday, April 22, 2009

The “Basic Law of Modern Health Care”

Slate recently ran an article in which they noted that the most “radical” health reform (single payer) is also the most fiscally conservative.[1] After showing a graph that indicated health insurance premiums have increased 6 times that of wages between 1999 and 2008. The author, Timothy Noah, notes that “Whatever pay increases the average worker received were wiped out, and then some, by the rapidly growing amounts deducted from his paycheck to cover health insurance. That's assuming he was lucky enough to be among the 59% of the U.S. population that received employment-based health insurance… These calculations don't take into account the rising cost of actually using ever-pricier health coverage. During the same period, deductibles tripled.” Noah goes through a study by the Lewin Group[2] on the cost of care and probable savings from a “public option”, as well as pointing out that the obstacle is in its very savings – the savings will come largely from loss of profit by insurance companies, which will oppose any effort to implement it. Noah concludes “For the true spending hawk, I see no practical alternative to the "socialist" public option.” The New York Times recently had a brief article in which former Democratic house leader Dick Gephardt cautioned that Obama must first enact cost savings reforms in the health care delivery system before anything close to universal or near universal coverage will pass congress.[3]

In a commentary shared with his colleagues in the Association of Departments of Family Medicine (ADFM), Patrick Dowling, MD MPH, Chair of the Department of Family Medicine at UCLA and a leader in health policy, both of these articles are “…tip-toeing around the basic cost problem of the delivery system.” Dr. Dowling goes on:

At some point a person of influence (how about Warren Buffet?) is going to discover The Basic Law of Modern Health Care which is, of course:
“A cost effective high quality health care system for all cannot be achieved without a well trained and numerically adequate primary care physician infrastructure, geographically dispersed according to need, working in concert an addressing biopsychosocial issues with an adequate number of subspecialty consultants dispersed as needed.”

This of course cannot be achieved until one addresses the perverse incentives of how physicians are paid. Since we do not at present have an adequate primary care infrastructure, the situation is only going to get worse as the number of US medical graduates going into Family Medicine or General Internal Medicine continues to slide just as the number of baby boomer patients hit Medicare followed by expanding waist lines and chronic disease, and the huge number of baby boomer doctors retire or expire. Let’s face it: our health care delivery system is basically modeled on the bloated General Motors approach. Providing everyone with a GM truck or car is not going to solve the transportation, energy or global warming issues in this country. As such, even if the political capital existed to pass a single payer in the US today, I would argue it could not be implemented cost effectively because we do not have a sufficient number of primary care physicians, unlike Canada in which 52 % of the physician workforce are family doctors.

We need to get this point across. Perhaps we should rename family medicine as “Honda” or “Costco” because family doctors produce high quality accessible goods at a fair price!

I do not know if it should be called “Honda” or “Costco”, but Slate and Dr. Dowling are absolutely correct in pointing out that the ability of our country to provide cost-effective care depends on two things:
1. Developing a system that controls costs and thus cannot build in outrageous overhead and profits. This is why a universal care system, which we absolutely need, has to have a public “option”, if not (preferably) a completely public single-payer system.
2. Develop the necessary primary care infrastructure to provide high-quality, lower-cost care. This means incentives (or removal of disincentives) for physicans and students to enter primary care.

At the present time, there is a lot of talk, but no action. From Warren Buffett or from our elected leaders, like President Obama. The people support this change, and if the President were to get out front and lead on the issue, the clamor of enthusiasm from the American people would drive the insurance company lobbyists into quick retreat.

[1] Noah T, “Against Consensus: Why the most politically radical health care solution is also the most fiscally conservative,” Slate, April 10, 2009,
[2] Sheils J, Haught R, Staff working paper #4, “The Cost and Coverage Impacts of a Public Plan: Alternative Design Options”, the Lewin Group, Falls Church, VA.
[3] “The caucus – Health care cautions, from one who knows”, NY Times, April 13, 2009,

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