Health Care Anew

Our romantic selves continue to cling to the medical ideal of the friendly GP in solo private practice in an office above the drug store.  The strength of that myth is what is keeping us from openly recognizing that the prototype health care provider of the future will be the local hospital that employs its medical staff.

But occasionally, reality creeps through.  Page 4A of the November 9 issue of the Omaha World Herald included a locally written article on changes in medical care as discussed in a recent forum at the University of Nebraska Medical Center.  The following paragraph appeared in the middle of the article: 

“Reimbursement by the government and insurers slowly is moving away from paying doctors for doing procedures and toward a system in which doctors are salaried hospital employees and are rewarded for keeping groups of patients healthy.” 

Referring to doctors as salaried hospital employees in a newspaper article is something few would have dared to do not so long ago.   Maybe, at long last, that is changing.

 

 

As I think I have mentioned before, I came to realize early in my career that everything I did to improve efficiency in the hospital cost more money. Managers and doctors would justify things they wanted to do on the grounds that they would reduce cost, but when it came time to implement them, they seemed always to require a budget increase somewhere without an offsetting decrease somewhere else. 

Apparently, things haven’t changed all that much.  According to an article in the November 12 issue of the Omaha World Herald, (copied from the Raleigh, NC News and Observer), “….the federal government is offering as much as $22.5 billion in incentives for adopting computerized patient records – up to $63,750 per doctor.”   

All of this, of course, is an attempt to make the provision of health care more efficient by spending more money. 

After a few such experiences, I concluded that we in health care were going about it in the wrong way.  We were trying to improve things without disturbing the underlying culture and basic structure of the health care establishment and there doesn’t seem to be any way of doing that.  There are investments that make it possible to reduce cost, but they all involve changes that affect somebody adversely. 

It’s a truth we still haven’t accepted in health care and so we continue to think we can reduce cost by spending money.

 

 

I read somewhere the other day that part of the 700-odd billion reduction in Medicare expense used to finance the Accountable Care Act (a.k.a. Obamacare) was attributed to a projected reduction in waste, fraud and abuse. 

It has occurred to me that perhaps waste, fraud and abuse is something for which we should be grateful.  It seems that whenever you want to expand an existing social program and don’t have quite enough income to cover it, you can count on a projected reduction in waste, fraud and abuse.  And then the next time you want to expand it and are looking around for money, there is waste, fraud and abuse reduction again waiting to be tapped.  One wonders how many social benefits we would be lacking if it were not for the availability of waste, fraud and abuse reduction. 

So all together now, let’s hear it for waste, fraud and abuse.

 

 

The idea that free choice of health care provider is some kind of inalienable right, regardless of who pays the bills, looms as one of the most important barriers to getting the cost of health care under control. 

Although the system of delivering health care has changed a great deal in recent times, medical practice remains at the center of it.  Thus, changing the way medicine is practiced has to be an essential element of any realistic attempt to restrain or reduce the cost of health care.  Physicians are not likely to do that on their own.  They practice the way they do because, all things considered, it is the way they believe works best for them and their patients. 

But they would look at it differently if practicing the way they do came to have adverse economic consequences for them,.  If insurance companies were able to refuse to pay physicians they determine to be wasteful, incompetent, or both, such physicians would have a powerful incentive to improve.

But the principle of free choice prevents that from happening.  So long as insurance companies have to pay whatever doctor the beneficiary chooses, a powerful tool for change will be foregone. 

Actually, free choice is not as important as it is made out to be.  When doctors die, retire or move away, their patients have to find new ones.  People move from one town to another and have to change physicians.  When patients go to the emergency room, they are cared for by whichever physician happens to be on duty at the time.  If they get admitted to the hospital as medical patients, they may well be treated by a hospitalist physician they do not select.  There are few complaints about any of these things. 

But if their insurance company asks them to change doctors it is considered a violation of a right that politicians of every stripe promise to protect. 

It’s another example of how cost control in health care requires culture change.