Progress

Kodak announces it will stop making Kodachrome, and I don't care. I'm down with digital. I mention this so as not to sound like a Luddite in the following paragraphs.

I don't know if we'll get health care reform or not; nor, if we do, whether it'll be in any way significant. Unlikely. Meanwhile, there are examples in surgery which illuminate one aspect of the problem of skyrocketing costs. Technology, in a word. Technology as selling point; technology as sexy; technology for its own sake. Unlike my digital camera, medical technology includes much about which it can be asked: "Huh?"

Previously I've expressed an opinion on "NOTES" surgery. More recently, I opined about robotics. I've also described the way I did gallbladder surgery through a single small incision, as an outpatient, with recovery times the same as laparoscopy, at significantly less cost. The latest hotness is single incision laparoscopy. The linked article describes a half-inch incision. Maybe. What they stick in is this baby, which, according to what I've read, requires a 3.5 cm incision, or about an inch and a half. In total, that's at least half again the total length of incisions made in standard laparoscopy, for removing the gallbladder, anyway. No less painful, one would assume; although the pain isn't that great, usually, in either case.

Now I must admit I've neither seen nor done it. As I've said about laparoscopy and robotics, it's fun to do, and I have no doubt this wrinkle is fun, too. So far the operative times are longer than "regular" laparoscopy, which equates to more expensive. In that article, the recovery is no different from standard stuff. Without knowing for certain, I'd say there are also issues with exposure and perspective, since the camera and tools are all coming in at the same angle. That, one might predict, adds up to higher risk. Time will tell.

The other day I read an article about a kid who had his spleen removed this way. Nice scar in the belly button. Humbly, the surgeon says it's not about fame, or being first. It's about preventing the trauma of a scar. The cynic in me says it's about referrals. But what do I know?

Here's my point, about which time might well prove me wrong. In my opinion, NOTES, robotics, and single-incision laparoscopy, so far, have one thing in common: dubious value compared to other options, more expense, and possibly more risk. For what? In the case of robotics, marketing. In the other two, marketing and cosmetics. These are examples, it seems to me, of therapies which, if effectiveness research becomes pervasive and meaningful, may well be taken off the list of covered procedures. And then what? Well, for one thing, the disconnect between reform and having it all will be illuminated. Maybe, rather than disallowed (which, realistically, is unlikely) the extra costs of these operations will need to be paid by the patient. Surgery which is purely cosmetic, after all, is never covered by any payers.

In any case, this is the sort of thing that doctors and patients alike will need to face if and when real cost control is effected. It won't be pretty, even if the data are there. Because when have data had anything to do with anything?

Fee For Service

Not too many years ago, as the many-layered onion that is physiciandom brought tears more and more constantly to my eyes, I said, "What the hell, I give up. If this is all just a way to break us down and put us on salary, bring it on. Just tell me how much I'll get, and I'll decide if I want to keep doing it."

Paperwork propagating like potatoes; rules compounding themselves like viruses; payments receding like ice-caps. There's no doubt it affected my enjoyment of my work, steadily plunging the pleasure, the honor, the gift, and the psychic rewards of being a surgeon deeper into the bulb of the allium, harder to find without crying. And yet such thoughts find little if any resonance with the public. Fee for service, it's said, is the root of the economic evils of our health care system. I don't entirely disagree: what we have now is the worst of all possibilities.

There are many ways in which health care doesn't follow other capitalistic models. Attempts at controlling costs have included, for instance, both restricting and increasing the number of doctors produced in medical schools. Neither worked. To date, disguised and dressed in many pretty outfits, the main tool for cutting costs has been reducing payments to physicians and to hospitals. At best, results are mixed: forced to work harder and harder to maintain income, many doctors (speaking) have burned out and quit in their prime. Turned into bean-counters, those that stay have adopted methods that frustrate patients: cramming more visits into an hour, charging for phone calls, etc... Ancillary charges are outrageous: a friend recently wrote me about a $3,500 CAT scan, a charge of $850 for a simple automated blood test. (Not that anyone but the uninsured actually pays them: in some sort of dance macabre, insurers reimburse ten or twenty percent of those fees and the rest is smoke.)

(In a related note, I read that President Obama's doctor isn't happy with Obama's health reform proposals. In the article the good doctor says neurosurgeons get $20,000 for "cutting into the neck" of his patients. Now, I have no idea what goes on in Chicago, but I'd propose that, if twenty grand is an actual fee, like the $3,500 CAT scan, the reimbursement is a small fraction. In this post I don't want to get, yet again, into the frictions between surgeons and real doctors; but such a claim suggests a certain amount of hyperbole in the discussion. On the other hand, he implies he's for a single-payer plan; on that, we agree!)

Pay for doing stuff is the wrong incentive, so we are told. It leads to over-ordering of tests, over-doing of procedures. Can't entirely disagree. Read Atul Gawande in The New Yorker, or Buckeye Surgeon in Buckeye Surgeon. But if it's a problem, what is the solution? Salaries, says Atul. Better docs, says Buck. And me. With the right incentives.

I've said before -- to hoots and snark -- that I don't think many physicians are in it primarily for the money. But I do believe that, as in most other professional pursuits, people willing to work hard and who produce superior results have an expectation of some sort of recognition. Which includes income. And that's precisely why I said above that what we have now is the worst of all possibilities; fee for service with no incentives for quality, no differentiation among bad, mediocre, and excellent providers. For doing a colon resection in half the operative time (saving thousands in OR costs), sending a happy patient home two or three days (or more) sooner than average (saving thousands in hospital costs), with a lower rate of complications, I got exactly the same reimbursement -- from Medicare, from any insurance company -- as the surgeon who did none of those things. If, to a payor, a colon resection is a widget, the only criterion for payment for which is agreement to accept the latest slice in compensation, why bother to do those things? (Getting patients home quickly requires, among other things, making rounds two or three times a day, which most docs no longer do -- but which I always did. Faster operative times result from many things, among which are attention to detail, making sure in advance that what you need is in the room, keeping the team informed of what's coming next. Even helping move the patient and clean the room. Not seen frequently. Since I retired.)

A high percentage of doctors are human beings. That means they often respond like other people. Incentives and disincentives have an effect on behavior. Which is among the reasons "effectiveness research," or whatever the proper name for the effort (the blocking of which is desired by several legislators on the rive droit) to identify best treatments, makes nothing but sense.

I suppose it gets tiresome to read such treati. The bottom line is I think a system works best when there are incentives -- positive and negative -- to do the right thing. Some will, no matter what. (Of those, some have hung it up...) Salaries (at least those with no opportunity for adjustment based on performance) encourage laziness; capitation encourages the withholding of care. Fee for service which makes no allowance for differences in quality encourages abuse. And burnout.

Based on the snippets coming from the halls of Congress, I'm pretty well convinced that whatever so-called reform we get will fail substantively to address the real problems in our system: insurers, excessive or inappropriate "care," reasonable reimbursement across all fields of medicine, costs. And, for the life of me, I can't understand why.

Well, of course, I can.

One More Time

When I was "interviewed" for a website recently, one of the questions was if another blogger and I had stopped feuding. Not that I know of, was what I said. I'm not sure if there's been a feud, for one thing. For another, I feel teensy bad that many moons ago I did make some (possibly inappropriately) snide comments about his chosen field. The reason I bring it up now is that there've been a lot of articles lately that suggest that lots of people have no idea what it really means to be a doctor. Crazy stuff, some of it.

In the formative days of this blog, I wrote once about shortcomings I saw in family practice docs coming right out of training. (I find many of my older posts embarrassingly bad, so I'm not even going to look for and quote myself.) What I hope I said was along these lines: worse than a doctor who doesn't know stuff is a doctor who doesn't know s/he doesn't know stuff. Compared to specialty training -- in which it seems half the time is spent reminding (putting it nicely) trainees how little they know -- it was my impression that (at least at one time) the opposite seemed true of family practice. I probably didn't acknowledge that it's nearly an impossible task: teaching people a smattering of everything -- enough to know both what they're doing and to recognize when they don't. Still, the FPs I worked with who were freshly minted knew much less than they thought they did about the topics with which we dealt in common: breast lumps, breast cancer. Gallbladder problems, hernias, hemorrhoids. Colon things. Various stuff. (I put on some seminars, which helped.) And yet they happily (because, I assume, they weren't taught any differently) took on issues with no sense of discomfort or of a need for input. It may be intangible: but a doctor simply MUST know his/her limits. The shorter the training, the less intense (maybe, even, the kinder and gentler), the more poorly is that goal met. Now, in all specialties, that appears to be exactly where we're headed.

I think I also said -- and if I didn't, I should have -- that the FPs I knew who'd been around awhile were excellent docs. It just seemed to take a while to assimilate the sense of limits (not to mention to broaden the limits outward); and I think that's not as true of most specialty-trained docs. Acknowledging once more that many doctors share much in common with human beings, it's true that within any subset there are exceptions to the left, and to the right.

So why am I picking this scab again? Because of my recent post in response to an article in the NYT decrying doctors' incomes, and the comments thereon, as well as several related posts and comments in the recent medical blogosphere. Still more: I got an email from an excellent young medblogger asking my opinion about a post by some sort of health/fitness blogger in which he claimed that it should take way less time to train doctors; that you ought to be able to learn surgery in a couple of years. Procedures, he said, are often taught nowadays by reps from instrument companies, so how hard can it be?

Related is the concept bandied about by commenters here and elsewhere that all our health care money problems will be solved simply by cutting what doctors are paid and by cranking out way more docs. Perhaps the best of all was the prediction that any gaps in physician availability would be happily made up by women who want to be part-time docs and moms.

Still another connected issue is the on-going discussion among other bloggers regarding the 80-hour work week, and how us old farts who trained in the days of much longer hours simply haven't a clue about how clueless we are. These generally include tirades at how particularly egregious is surgical training and the arrogance of those within -- more the teachers than the teachees. But them, too.

And finally, my blog and those of others are rife with comments by people who've been treated egregiously by doctors. Truly. Egregiously. I'm embarrassed just to read some of the stuff; particularly as it reveals complete lack of communication skills, compassion, and empathy on the part of those doctors.

OK. I probably have neither the will nor the skill to do justice to bringing together all of these themes. Except to say this: there seems to be a very schizophrenic attitude about physicians. People want more knowledgeable doctors, ones that will listen better and explain more clearly. Docs that will fully enumerate and carefully explain all the issues and choices for any situation; who will be sensitive to their individual needs, who will both guide them but let them make all their own decisions. And, of course, doctors with comprehensively flawless knowledge and impeccably perfect skills. People criticize doctors -- surgeons especially -- for having a god-complex, but they want god-like perfection. To achieve it, they suggest flooding the market with doctors and spending less time training them. And, of course, after people flock to become these perfect doctors, to pay them less and less for their efforts. Highly qualified, well-motivated folks with altruism aplenty will fight their way to the front of the line.

Especially moms.

Talked to the tooth fairy lately?

Times Two

Sunday's New York Times had a couple of features of medical/surgical interest. The first was a very long article on the variations in cancer treatments at various centers in the US, focusing on a young woman with colon cancer. She was diagnosed at Stage IV, meaning it had spread to her liver; in her case, very extensively. It was evidently only by her own perseverance that she finally ended up with intense chemotherapy and radical liver surgery which, statistically speaking, has a low probability of long-term benefit but which, for now, has left her overtly disease-free. Orac posted extensively on the subject, making anything I'd say mostly overage. But it is a very significant issue, even if the article -- as one would expect regarding a very complex topic -- has certain shortcomings. That there are variations in approaches to many illnesses -- in this case cancer -- and in the skills and philosophies of the doctors rendering the care is a problem for which there will never be a perfect solution. But it speaks for the creation of (and agreement upon!) well thought-out protocols covering a wide range of possible expressions of the disease, and is an argument in favor of something about which I have mixed feelings. Namely, "centers-of-excellence." Suffice it, for now, to say that I agree that for certain complex problems a team approach is ideal, and finding ways in which to evaluate the outcomes of such teams is laudable; but what I've seen of it leaves a certain amount to be desired. For example, I know of a place designated a center of excellence not far from where I am, in a field with which I have professional familiarity, that seems anything but. If the idea is a good one, the execution is what it's all about. Nor did the article address the even more difficult question of cost-benefit. Tough stuff, all of it.


The other commentary decried the fee-for-service model of physician reimbursement, in the context of running up costs because doctors get paid to do things. In part, the article, by Alex Berenson, says:

"Americans generally do not seem to mind the fact that doctors are well paid. In public opinion surveys, doctors usually rank as the most trusted professionals. Congress has repeatedly blocked Medicare’s efforts to reduce the amount it pays for each procedure doctors perform, even though overall Medicare payments to doctors are soaring and the cuts are legally required to keep the program’s budget balanced. [Ahem. Sorry to interrupt, Alex: whereas it's true that in the past couple of years, some fees have been allowed to rise a couple of percentage points (hardly "soar"), that's only after having cut reimbursement by around two-thirds, steadily, over several previous years.] The way that doctors are paid may be an even more significant factor driving up costs and may lead to unnecessary care, said Dr. Peter B. Bach, a pulmonary physician at Memorial Sloan-Kettering Cancer Center and a former senior adviser to Medicare and Medicaid. In the United States, nearly all doctors are paid piecemeal, for each test or procedure they perform, rather than a flat salary. As a result, physicians have financial incentives to perform procedures that further drive up overall health care spending. Doctors are paid little for routine examinations and very little for “cognitive services,” such as researching different treatment options or offering advice to help patients get better without treatment. “I don’t have a view on whether doctors take home too much money or not enough money,” Dr. Bach said. “The problem is the way they earn their money. They have to do stuff. They have to do procedures.”

Primary care doctors and pediatricians, who rarely perform complex procedures, make less than specialists. They are attracting a declining percentage of medical students, and some states are facing a shortage of primary care doctors. Doctors are also paid whether the procedures they perform go well or badly, Dr. Bach said, and whether they are crucial to a patient’s health or not... “Almost all expenditures pass through the pen of a doctor,” he said. So a doctor may decide to perform a test that costs a total of $4,000 in order to make $800 for himself — when a cheaper test might work equally well. “This is a highly inefficient way to pay doctors,” Dr. Bach said....

....Private insurers like H.M.O.’s are more aggressive than Medicare in second-guessing physicians’ clinical decisions, and they will refuse to pay for imaging scans or other expensive new procedures. Now Medicare and private insurers are moving cautiously to change the current system. Recently, they have proposed pay-for-performance measures that would give doctors small bonuses if their care meets the standards set by national medical organizations such as the American Heart Association. But all those measures are a minor fix, said Dr. Alan Garber, a practicing internist and the director of the Center for Health Policy at Stanford University. Instead, he argues, the United States should move toward paying doctors fixed salaries, plus bonuses based on the health of the patients they care for..."

I get it. It's easy to think -- and it's not entirely false -- that some doctors make treatment decisions based in part on how much money they'll make. (Being as honest with myself as I can, I don't believe I ever did. I know I rejected operating on lots of folks who were all teed up for it by their referring docs. But if someone pulled all the data out my brain -- what's left of it -- and ran some sort of algorithm or other, maybe it could show some cases...) And it's probably true that if doctors were all on salary, overall health costs would go down. But the questions are 1) why, and 2) what would it look like?

I've mentioned before, and I should reiterate here: many doctors -- including, amazingly enough, some surgeons -- are (or sometimes act like) human beings. Incentives and rewards are as likely to be important to them as to actual people. Working hard for its own sake, striving for excellence without any tangible recognition will be seen in some -- but hardly most-- doctors if they go on a salary. Because, unsurprisingly (or maybe surprisingly, to pundits) that's not how it works in real life. I've been in the military, and I've worked at VA hospitals. Try getting a case on after three p.m. Try getting a lab test or Xray thenabouts. Work another patient into a crowded schedule? Stay through lunch, after hours, come in early? Sorry. That's what ERs are for. If Alex is ok with it, so am I. Sleep, I've discovered, can be a pleasant thing.

In "my solution (here and here)" I suggested the opposite of salary: in fact, I argued that paying every doctor the same for a given item of work was counter-productive; that finding ways to incentivize and reward higher quality would lead to lower costs and better results. The NYT article suggests salary plus "bonuses based on the health" of their patients. Can you say "can o' worms?" Might some doctor-humans prune their practices of difficult patients? Could those willing to take on the very sick be penalized? And, to tie the two Times articles together, in a a world of salaried physicians, my crystal ball says the lady in the first piece would have an even harder time getting the care she got.

Breaking ranks with the majority of my peers, I've said a single-payor system makes sense to me. But salary doesn't. It will indeed lower costs, because people simply won't bust their asses any more. I did significantly more than twice the average number of operations per year than the typical general surgeon (and because I was in a large (enormous) clinic with very high overhead for specialists, I made less than the average surgeon in the country, by a depressing amount); I did it because people needed the care. But I'm pretty damn sure I'd have cut my hours back to what everyone else was putting in if I'd been on a salary. If we go there, wait times will go way up. There'll be waiting lists. In training, at the VA, there were people waiting for every sort of operation: as Chief Resident I could have simply made up schedules based on what I wanted to do, maybe never getting around to some. And let's be real: as I've also said before, if you take away reward for hard work and excellent product, you'll find a very different sort of person -- on average -- choosing to become physicians. If that's not seen as a problem, so be it.

To use the Rumsfeldian/Socratic method here: Is the system broken? Yes. Does it need major overhaul? Sure as hell. Is the solution to put doctors on salary? NFW. Not unless we are, as a nation, willing to accept longer waits for more mediocre care. That old human thing, once again.

More Solutions, Long Post

Free health care isn't free. The money has to come from somewhere; the question is how to get it into a bucket, and then how most effectively to get it back out, to where it's needed. People frame it in all sorts of ways, depending on their political persuasions. Andrew Sullivan says that in arguing for government to pay, liberals would have us all be permanent supplicants. Brilliant. And it fits nicely onto a bumper sticker. But it's fatuous. If the ultimate virtue is the taking of money out of one's own pocket and paying directly for one's health premiums, then probably less than 10% of Americans are virtuous. (No comment.) Premiums are paid by employers, by governments, but by only a few individuals themselves (I'm among them.) We're already supplicants. (Well, not me.) If there were universal coverage, taxes would go up somewhere, but premium expenses would go down. The money that goes into the bucket, in other words, would be mostly a wash. Left hand or right hand, it comes and goes. My argument is, in part, that by eliminating the countless insurers and their enormous overhead (their profits, their executive pay and shareholder dividends -- not to mention countless redundant clerical no-sayers) you could fill the bucket to the same level and have lots left over. That would be good, by whatever method the money is taken from us, and by whichever agency it's given back in the form of health care. Package it with a name that makes you happy. Money comes from us one way or another, gets centralized somewhere, and returned in the form of plaster and penicillin. In what way does having insurers in the middle help that happen?

The always-thoughtful Eric worries: "The problem I have with single-payer systems is that I fear a serious erosion in innovation - what compels a single-payer to add coverage for a new-but-expensive lifesaving modality? If your choices are "take what you're given" or "pack sand and pay for it yourself", new technology won't be deployed to save people's lives nearly as quickly." He makes an important point, but, like my concern about monolithic control of reimbursement, it can be addressed (so says me, the non-politician, non-economist, non-systems-wonk) by having at the top panels of consumers and providers making reality-based (remember that bygone concept?) decisions. If such a structure were in place, given that we're now talking about a single entity instead of hundreds, it would be possible for providers and consumers actually to have control. This makes a strong argument for single-payor, as opposed to our current situation, wherein we're divided and conquered. How should such panels be constituted, by whom, with what feedback loop attached to the citizenry? I'm thinking, I'm thinking! But I'm guessing people much smarter than I could figure it out.

I haven't seen "Sicko" yet, but I've seen M. Moore's other movies, so I'm guessing that at its center, he has the problem right, and that in examples and solutions he's overplayed his hand with anecdotes and shot himself in the foot with hyperbole. Speaking of which, in a review of the film James Christopher of the London Times says, "What he hasn’t done is lie in a corridor all night at the Royal Free watching his severed toe disintegrate in a plastic cup of melted ice. I have." Interesting: in my opinion, universal health care has no business covering the re-implantation of toes. Fingers, yes (depending on which ones). Toes, unh-uh. If surgeons use big toes to replace thumbs, -- and they do, they do -- that they are otherwise dispensible, foot-wise, is spoken to. A thing to which it is spoken.

And that gets us to the nitty-gritty. The bucket isn't bottomless. We can decide how much it holds, but at some point we also have to decide for what kinds of care the contents will be doled out; unless we want to make it bottomless, which we could in theory, but won't and can't in fact. Keep the costs down, we all say, except (you know what's coming) when the care in question is for us or our loved ones. "Spend a little as possible on them, and as much as needed on me" is a plan, all right, but is hardly a workable one. (Less so in the minds of one political party than the other). But let me be clear (since I've given myself the soapbox): I'm OK with tiers in the system. Not tiers of joy, to be sure. But this is America; plus I've said in my previous post that I think payments to providers ought to reflect quality of work: if I'm asking for rewards for the quality of my work, I can't begrudge it elsewhere. It's not without moral unclarity (if health care is a right, it doesn't automatically follow that people should be barred from obtaining different levels thereof), but the idea that there might be a difference between basic coverage given to all, and that available to those willing and able to spend more is one I can accept. It's just the way it is: a system that is the same for everyone with no avenue for opting up won't fly, pragmatically, at this point in the US; but one that provided everything for everyone under all circumstances will bankrupt us, absolutely, eventually. Heck, we're heading there (bankruptcy) already, on more than one track.

It's either/or. Either we decide as a nation that we're happy spending whatever it takes on health care, or we address the issue of rationing (ok, let's call it "prioritizing.") Some countries do it openly: in England, on "the National" it was true at least at one time that, for example, a person of a certain age with a certain percentage of body burn got supportive care only: pain medication, comfort. Some do it de-facto and maybe even cynically: in Canada you have to wait a long time for certain procedures, which means some don't get them, even though it's not specifically proscribed. A few years back a British orthopedic surgeon responded to outcry over long waits for hip replacement by saying that the line wasn't as long as it looked, since some people die while waiting for the operation. Probably the hardest thing any health care worker does is deciding when further care is inappropriate. It goes on all the time; it's just not formalized. Somehow, sometime, on paper and in public, it needs to be. A comatose hundred-year-old in kidney failure doesn't get dialyzed. A ninety-five year old? Not him, either. Sixty? Sixty-five? OK, eighty-five? And if the idea is repulsive -- which it is -- and if it simply can't be addressed (certainly Congress never will), then let's just agree that the best we'll ever do is nibble at the edges. Which, to date, has pretty much meant nothing more than continually lowering reimbursement to doctors and hospitals. Turnip. Blood.

Outraged comments on posts such as this notwithstanding, people willing to work extremely hard under lots of stress to provide an excellent product have a natural inclination to expect some sort of commensurate reward. Certainly no doctor expects to get as much as a mid-level executive for Healthcom, or as much as a second-string second baseman. But something that reflects work and which doesn't continually drop would be nice. The price for the current approach has been, and will continue to be, burnout of the best, and the looking elsewhere than medicine by the sorts of people you'd like to see choosing it as a profession. The problem with us goddamn doctors is that we're also human beings. Tell me what you think a colon resection is worth, then stop lowering the amount every year. And if you won't let me charge more on my own because I do a better job (every other professional does), then show me a way you'll try to figure out if I'm better and slip me a little something. If not, don't expect everyone to keep striving. It doesn't work that way anywhere else; increasingly, it's not working that way in medicine, either. Which makes the next paragraph, probably, wishful thinking.

There's one thing to do before playing the rationing card. Doctors, as a group, have a hard time with it; but it's coming, and it needs to arrive. To the extent that it has arroven (yes, I know), so far it's pathetic. I refer to finding out what works, why some doctors get better results than others, why some can get the same results as others at half the cost. Determining, in other words, "best practices." Finding that out and putting in place methods to encourage the good and eliminate the bad. Care, that is. What we have so far, referred to by the much unloved acronym "P4P" -- which stands for "pay for performance" -- is, at best, silly; and at worst, counterproductive, because it's so stupid. An example of bureaucracy at its worst, the list of parameters seems to have been generated by a committee with little input from actual practitioners. Big surprise. I know medical quality is hard to quantify, to solidify into a checklist. But for surgeons, for example, the archetype is getting pre-op antibiotics into the patient no longer than an hour before surgery. Funny. In training, we were told to get it infused at least an hour ahead of time, so tissue levels could rise and equilibrate. Yeah, you can measure it and write it down. But what goes on much before that -- in terms of selecting and planning an operation -- and after that -- in terms of carrying it out and in providing post op care -- has volcanically more impact that the ticks of the antibiotic clock. Everyone knows that. Getting a handle on it is where the action is; but if it's possible at all, it'll take a hell of a lot of work. Thousands of records will need to be reviewed, outcomes compared, methods dissected. Necessarily, judgment will be called into question, egos will be threatened. Worse, errors in data collection and analysis will be made; conclusions may be wrong sometimes, or tainted. The various specialty societies and colleges will need to be at the helm, and it'll take time and will generate lots of heat (with good planning, maybe enough to reduce oil imports), but in my opinion it has to be done. All doctors and nurses know it: there are good ones, and better ones. And some bad ones. Crazy maybe, but I think most docs -- given the right incentives and handled in constructive ways -- will respond to information that allows them to do a better job, even if it means admitting that they may not have been in the past. Scream, yell, get pissed off, feel insulted. Then lie awake at night and think it over, look yourself in the mirror when you get up. And make some changes. Been there. Done that.

To the extent that people running for president are addressing health care at all, keeping the money-changers between consumers and providers seems to be a given, which strikes me as feckless and crazy. Why should a national health-plan include a layer which provides no care, is clearly dispensable, and which serves to suck huge amounts of money out of the system? It's like paying someone to put the key in your car before you start it.

So my thoughts distill to three things, needed in this order: a single-payor system that includes real and actual control at the top by providers and consumers; a no-holds-barred effort to find and encourage (enforce) best practices, which recognizes and rewards excellence; and, when all the money that's possible to save has been saved, the toughest of them all: prioritizing care; deciding which expenses make sense, and which don't -- rationing. (Alternative to number three: stop complaining about costs of health care.)

(I suppose it's not trivial that if the insurers were really to go away, there'd be lots of decent people without jobs. But that's hardly a reason to keep a useless system going. Maybe some of those displaced would be willing to do those jobs that, you know, Americans don't want to do. That way we could solve immigration, too.)

My Solution

Fourth of July. Birth of a nation. Childbirth. Health care. Seems a good day to step into the breech. As it were. Is our health care system salvageable? Does it have a pulse?



Several years ago, the clinic at which I worked signed an exclusive contract with a fairly large HMO; shock waved around the medical community, who felt we were trying to take over the town. A few years later, we threatened to fire the HMO, and that shock waved around the nation.

We'd come to the point at which the latest cut in reimbursement, announced via the usual one-way communique, was simply too much. Receiving the backside rather than the ear of the HMO, we sent letters to all our patients who were members (around twelve thousand, at the time) announcing the plan, along with toll-free numbers through which we'd help set them up in other plans. The HMO caved. It was, I'm told, written up in several health/finance magazines and hit the Wall Street Journal, as I recall. High fives.

For a while. Of course, it ended up only a holding action. We were able, on some occasions, to negotiate less onerous cuts; it's not as if we turned the tide. There is, however, a lesson. Our ability to get insurers to listen turned on two things: we were excellent, and we were big. Patients wanted to see us; lots of them. In that, I think, are some of the seeds of solution for the US health care crisis.

Let me say it up front: I favor some form of a single-payer system.* It's my view that the many problems with such a system can be overcome: it's not single payer per se, as I see it, to which people seem to object. It's some of the accouterments. Before getting to that, I'll state what I think is the obvious: having countless health insurance companies -- many of them for-profit -- sucks gazillions of dollars out of the health care realm, in form of profits to shareholders, salaries of executives, and tens of thousands of workers in cubicles. Both in the bowels of the insurers' buildings, and in hospitals and clinics and medical offices around the country, people input data, make calls, argue for and against payments, follow differing contractual rules within and between companies; in short, money that could be spent on care of the sick is diverted into pockets of those who provide no actual service to those in need of it. They are money handlers, nothing more. Medicare, for all its faults, has by far the lowest overhead of any payer in the country. By real far. The only way to get the most money going to actual health care is to be rid of the multiple middle men. And women. There are many other needs, as well. But to me, that's where it starts.

The biggest problems with Medicare are that it treats providers like shit, has stupid rules, and responds little, if at all, to input from those who know what's going on. It not only doesn't recognize, but actually deincentivizes excellence. No small things; but there's no reason a single payer has to be that way. What I'm saying, basically, is this: let's have a single payer, and let's make it smart and responsive. I think it's not categorically impossible. Faint hope, I realize. But if we take it out of the hands of politicians (after they approve it), eliminating the kind of politics-based governmental incompetence with which we've been regaled of late, there's at least a theoretical possibility of finding a workable approach.

Which brings us back to the preamble of this post: when the HMO relented, it was because we were big, and excellent. I'm aware it's also because they had competition, and that a monolith has none. But there's a point: when providers are able to have a say in the process, the system works. Better, anyway. The most destructive aspect of Medicare, from the point of view of a hard-working physician who has the ethic of excellence above all, there's nothing more demoralizing than being told, year after year, that that hard work doesn't matter; that there's another cut in reimbursement on the way. That the excellence of one is regarded no differently, in terms of payment, from the mediocrity of another. So: it's surpassingly important that this imaginary system has reimbursement guidelines that result from input from the people that do the work. Is there any other professional group about which it can be said that over the past twenty years the trend of reimbursement for service is steadily downward? It's really and truly perverse, and the effect is obvious.

I can hear the keyboards tapping away in fury: you doctors are a bunch of egomaniacal, money-grubbing assholes. Well, sure. Nor do I claim to know what's a fair level of pay for a doctor, compared to other occupations. But I do know that a system which generally lowers that level, and which disallows the ability to set or bargain for one's own pay, and which pays the same for a given widget whether the widget from one maker is a better product than that from another -- that system is headed for self-destruction. And it's already selecting against the sort of people we'd like to see join up.

The solution to the US health care problem, then, begins with this: a single payer system which is responsive to those who provide the care, both in terms of setting fees, and in recognizing those who do excellent work. Competition is a good thing. So is doing a good job. Let's build it in. Impossible? Maybe. Will it be imperfect? Of course. There's a need to recognize the special situation of training institutions. And there's always the doctors who (some with justification, and some not) claim their complications are higher because they get the toughest cases. Being excellent attracts challenges. But there are ways to deal with that. Make it like figure skating: toss out the high and the low scores. Borrow from the gassy world of anesthesia and the splashy world of diving: set up degrees of difficulty.

I'm no economist, so I can't say how much money will be saved by eliminating the profit-taking and the inefficiencies of the myriad insurers. But it's significant.

As hard as it would be to make it work, it's the easy part. Really to get a handle on health care cost requires a hard look at best practices, along with the staring right in the face of prioritizing care. I'll talk about it, like unto spitting into the wind, next...


* Need a definition, here. "Single-payer," to me, means something akin to Medicare, as opposed to the Canadian or British system of government-run hospitals and salaried physicians. I still believe in fee for service, because when you have doctors employed by governments on uncompetitive salaries, you have, as we see in England, to import them. And they become terrorists.