The New York Times' invites a group of medical professors and doctors into their Room for Debate to think through the issue. For the most part, the ideas boil down one big concept: Share more information to avoid unnecessary, even duplicate, treatments. But there are other ideas that could find their way into comprehensive health care reform. Here's a sparknoted version of their biggest ideas.
1) More Sharing, Less Overtreating
Doctors need to share more information on what works. Dartmouth's Elliott Fisher suggests organizing health systems like Grand Junction, Colorado. Atul Gawande made the same point, praising Grand Junction for combining low costs with "some of Medicare's highest quality-of-care scores." Gawande wrote:
The doctors agreed among themselves to a system that paid them a similar fee whether they saw Medicare, Medicaid, or private-insurance patients, so that there would be little incentive to cherry-pick patients. They also agreed ... to meet regularly on small peer-review committees to go over their patient charts together. Problems went down. Quality went up. Then [they created] a community-wide electronic-record system that shared office notes, test results, and hospital data for patients across the area. Again, problems went down. Quality went up.2) Single-Payer All the Way
Don't tinker around the edges with this public option nuttiness, say Steffie Woolhandler and David Himmelstein of Harvard. Just go straight to a single-payer, like Canada, that limits entrepreneurial awards (a good thing?) and cuts down on the bureaucratic paperwork that takes up almost one-third of US health spending. Sure there's not as much profit to go around (Canadian physicians make about half their American counterparts according to this graph), but if everybody is covered, we don't have to spend billions of dollars on patient research to keep people out.
3) Fewer Ridiculous Law Suits
One big slice of the unnecessary health cost pie, says J. James Rohack, is medical suits. Doctors will stop overtreating once they stop fearing the implications of not exhausting every possible option of treatment. That's the result of "defensive medicine" that's only a rational reaction to the looming threat of our ambulance-chasing legal system.
4) Fewer Specialists
We pay doctors more to sew a facial wound than to diagnose a heart
attack, says Liam Nore, a blogger and ER doctor (not simultaneously, we
hope). That's crazy. We've set up an incentive structure that encourages specialists
to make more money from new technologies, which drives costs higher
while skimping on primary care, where preventative measures offer the
most cost-saving. Nore concludes:
Better-compensated primary care specialties would attract more doctors who would be able to spend more time with their patients. They would require fewer expensive diagnostic tests like M.R.I.'s and rely less on specialists. Accordingly, the use of expensive and invasive procedures would decline. Prevention, wellness and chronic disease management would be encouraged: enhancing quality and patient satisfaction, but at a far lower cost.
The whole article is here.
Wow, maybe we'd get better journalists with single-payer, too. Having various publishers compete for talent just isn't working well, and good writers heal the mind just like doctors heal the body, right?
A few questions..
How does going "single-payer all the way" make doctors better?
I assume that specialists are paid more due to supply/demand considerations - that becoming a surgeon is more difficult, takes longer, and costs more than becoming a primary care physician and that, therefore, there are fewer of them. And that the supply for good surgeons is high, since while you may not care if your primary care physician isn't the best in the country, when someone is going to cut you open you want someone who is damn good. Is that wrong? All that said, how do you increase the pay of primary care physicians relative to specialists? What's the magic mechanism for this?
When we finish telling Docs how to get paid can we start on the Lawyers?
There may be other ways, perhaps, of accomplishing the same thing, but one benefit of single payer would be improving administrative efficiency. It's pretty typical for clinicians to have numerous insurance contracts. Each has different requirements for ordering studies or treatments, different drug formularies, etc., and those rules are often a constantly moving target, to boot. Physicians often hire staff to deal mostly or even solely with these sorts of issues. Contrast this to Kaiser or the VA, where dealing with one system means being able to efficient about ordering studies, making referrals, writing prescriptions, and the like. Ideally, this frees up more time to evaluate and educate patients. If nothing else, it makes clinicians happier, because they're doctoring not arguing with insurance companies and filling out yet another form. However popular it is to bash these systems, they have some of the better quality ratings in this country.
It is not just duration of training and supply and demand that influence the salary of specialists. If that were the case, pediatric neurologists and psychiatrists would make far higher salaries than they do. Some specialties have been very successful in lobbying Congress regarding Medicare reimbursement. As goes Medicare, so often go other payors, including private insurers.
Reimbursement incentives are for doing something, too often without consequence if whatever that something happens to be--MRI scan, endoscopy, or even surgery--is inappropriate. There is no real monetary reward for the astute clinician who can determine that such interventions are unnecessary.
As for encouraging students to go into primary care, one issue is salary relative to educational debt. Loan repayment programs for primary care, but not for, say, dermatology or radiology, could help. Lifestyle is another. It's probably fair to say that younger doctors are less enthusiastic about working the kinds of hours that many surgeons, or primary care doctors in physician-shortage areas, work. That is a culture shift for which solutions are less obvious.
It is astonishing that you would mention the VA system as an example of efficient and quality health care. How many working patients would tolerate waiting 6 or more hours to be seen for a routine office appointment? That is not at all unusual at the VA. Plus, the staff know that they get paid the same whether they see 10 patients a day or 50, so guess what happens? The VA is the LEAST efficient place I've ever experienced in medicine. SUre, you can access all the information on the computer system but it isn't prioritized. You might have to weed through 20 dermatology follow-up visits to find the location of a biopsy or to get to the treatment plan.
Loan repayment programs and comprehensive tort reform could even the playing field compared with other countries-how many neurosurgeons in France pay upwards of $200,000 per year on liability insurance alone? But repaying/forgiving debt only to some specialties could create a caste system in medicine-only wealthy med students could afford to go into dermatology or radiology.
No one looks at the risk to the "highly compensated" surgeon either. Should he/she ever get stuck by an instrument and contract Hepatitis B or C then forever forward will he/she need to disclose this to prospective patients. This equals the end of a career. (If you don't think so, consider a scenario where your 10 year old needs surgery and one doctor has hepatitis and another surgeon doesn't. Whom will you choose?)
Yes, many tests are duplicated secondary to a lack of communication, and many more to protect against lawsuits, but to suggest doctors order them to increase reimbursement is ridiculous. If someone comes to a cardiologist or internist with chest pain, the physician is obligated to try to find the cause. He/she didn't manufacture the chest pain in order to increase reimbursement. If someone has a more complicated treatment or diagnosis, then the doctors works much harder to diagnose/treat/or operate. If you pay, say the same amount for any sort of ENT surgery, then "cherry-picking" will be rampant-who wants to spend 8 hours doing a tricky neck dissection (with risk or nerve injury and subsequent lawsuit) versus doing 8 ear tubes?
Don't forget that all those single payer countries have a second-tier system, where patients pay on their own. This is already mostly the case in psychiatry, where more than half don't accept any insurance at all because the administrative hassles are too high and the reimbursements too low.
Finally, the comments on wellness and prevention programs are very well intended but also ridiculous. Seriously, what in medicine is PREVENTATIVE? Ok, vaccines and maybe aspirin. Essentially all other intervention programs are used to DIAGNOSE disease at an earlier state (and perhaps intervene more effectively.) Everything else is lifestyle: exercise regularly, eat a balanced diet, maintain a healthy weight, don't smoke or do drugs, don't overdo sun exposure... Look at Americans; we're fat and lazy and looking for a drive-thru solution so we don't have to miss watching our 5 hours of TV every night while we continuously eat.
Bottom line, you get what you pay for. If you/America wants the best medical care then expect to pay for it.
Bottom line, you get what you pay for. If you/America wants the best medical care then expect to pay for it.
You might want to acquaint yourself with the data regarding VA medical care. They have led the way when it comes to electronic medical records.
Students choose dermatology and radiology for reasons other than salary, which are currently quite high. Those are among the so-called "lifestyle specialties," with less arduous hours than many other specialties. In primary care the hours are long with lower salaries. Surgeons work are well-paid and work long hours. Arguably, what defines a lifestyle specialty is fewer hours (or at least quiet nights on call) and high salaries.
And yes, doctors do run tests and do procedures, not just for fear of litigation, but because that is what the system reimburses. That's the point. The incentives are not to promote good health but to overtreat illness. There is evidence that brief primary care provider intervention helps decrease smoking and excessive alcohol consumption. The current system doesn't pay for that and when primary care doctors have to crank out six patients an hour to make their overhead, education and counseling go right out the window.
We pay more per capita than any other industrialized nation, don't cover 15% of the population (and underinsure a significant proportion as well), and don't get good outcomes compared to peer countries. We are not getting what we pay for.
Doctors really need to WASH THEIR HANDS. Yes, it seems that would be obvious. But what's frightening is the fact that the chances are only 50-50 that the doctor treating you in the hospital has washed her/his hands. The odds are the same as flipping a coin. Well, it's actually worse. According to the National Quality Forum, physician hand-washing compliance rates at hospitals are generally LESS THAN 50 percent.
Hospitals are desperate to get physicians to simply wash their hands and are taking extraordinary means to try and influence them to do just that -- including termination threats and hidden cameras. And now the swine flu is an official pandemic -- guess who is going to help spread it? Ethic Soup blog has a good article on this at:
http://www.ethicsoup.com/2009/01/dont-kill-me-doctor-wash-your-hands.html
EVERY YEAR $17Billion is spent by Americans on UNNECESSARY HEART STINT operations... stints are good only for advanced vascular disease NOT for "chronic stable angina-CSA", BUT America's doctors and hospitals make $17Billion off of CSA operations. The other stint operations are necessary and do work but CSA operations DO NOTHING TO IMPROVE HEALTH!!!
This is just ONE unnecessary procedure that the health industry scrws Americans with... I see no difference with this and Bernie Madoff... these doctors and hospitals should be fined and shut down.
And we wonder why health insurance cost so much... in fact the $17billion could pay for ALL uninsured children in America!