Health Care Reform, the issue that is consuming and dividing our country is primarily health insurance expansion, and only tangentially addresses the fundamental dysfunctions in the American Health Care system. Without going deeper into the culture of health care, the extremes of profit contrasted with efficacy, any reform will cause entrenchment of a non viable, wasteful and unhealthy existing system.
The most effective presentation of this disjuncture was written by Dr. Atul Gawande in the current New Yorker Magazine, The Cost Conundrum
Dr. Gawande, with credentials including being himself a physician, a Rhodes scholar and having been deeply involved in all aspects of public health, also has the rare skill of writing clear compelling prose.
Being the scientist that he is, he looks at two entities, each with the same task, the Mayo Clinic and the McAllen (Texas) Medical Center. Both have highly trained professionals with access to the same advanced devices, techniques and resources.
The core tenet of the Mayo Clinic is "The needs of the patient come first"—not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. I asked Cortese how the Mayo Clinic made this possible.
"It’s not easy," he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focused first on what was best for patients, and then on how to make this financially possible.
We are beginning to see something that is not dictated by any law, but by a culture, a shared sense of what it means to be a doctor, nurse or hospital attendant. Now lets look at McAllen Medical Center, and their culture and think about which one of the two centers reflects the emerging norm or our national for-profit medical establishment.
Then there are the physicians (talking about McAllen) who see their practice primarily as a revenue stream. They instruct their secretary to have patients who call with follow-up questions schedule an appointment, because insurers don’t pay for phone calls, only office visits.
They consider providing Botox injections for cash. They take a Doppler ultrasound course, buy a machine, and start doing their patients’ scans themselves, so that the insurance payments go to them rather than to the hospital. They figure out ways to increase their high-margin work and decrease their low-margin work. This is a business, after all.
In every community, you’ll find a mixture of these views among physicians, but one or another tends to predominate. McAllen seems simply to be the community at one extreme.
Do we really think we can write laws that will eliminate the gaming of the system, turn those who feel that ever increasing personal income is the their first priority rather than the care of the sick?
Activists and policymakers spend an inordinate amount of time arguing about whether the solution to high medical costs is to have government or private insurance companies write the checks.
Here’s how this whole debate goes. Advocates of a public option say government financing would save the most money by having leaner administrative costs and forcing doctors and hospitals to take lower payments than they get from private insurance.
Opponents say doctors would skimp, quit, or game the system, and make us wait in line for our care; they maintain that private insurers are better at policing doctors. No, the skeptics say: all insurance companies do is reject applicants who need health care and stall on paying their bills. Then we have the economists who say that the people who should pay the doctors are the ones who use them. Have consumers pay with their own dollars, make sure that they have some "skin in the game," and then they’ll get the care they deserve.
These arguments miss the main issue. When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. (from his extended metaphor of our present system which is like building a house without a prime contractor or supervising architect, a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later)
The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes. You get McAllen.
The New Yorker Article is a must read for those who want to understand the defects of our current medical system. While Dr. Gawande speaks of the efficiency of the Mayo Clinic model, there are times when they must refuse the demands of their clients for treatment that they know is not appropriate.
Such demands have become deeply entrenched not only in America's culture, but that of the world, as I wrote about in this essay, Health Care in the World of Tomorrow.
President Obama has said that nothing will come between the patient and his/her doctor under his plan. I guess that means the McAllen doctors too. I hope the government does come between such doctors and their patients, whom they view as primarily a vehicle for fleecing the existing system.
When reduced to a partisan issue, perhaps winning means getting a Health Care Reform bill passed this year. The question for citizens, which we are all first and foremost, is whether this will spark the kind of cultural change described in the New Yorker article, one that could actually increase the health of all of us; or whether a bill manipulated by existing interests will perversely reinforce the pathologies of Health Care as a Business.