Health Care Anew

Health Care Reform Redux

This morning’s Boston Globe included an article by reporter Marcella Bombardieri summarizing the health care reform proposals of Democratic presidential candidates Clinton, Obama, and Edwards. Particular attention was given to the proposals of Senator Clinton, who headed up the failed and famous health care reform effort during the early years of her husband’s administration.

Predictably, the emphasis of all three proposals is the provision of coverage for the uninsured. The Clinton campaign organization estimated the cost of her proposal at $100 billion per year. Knowing how such things work, it is probably safe to assume that the real number would be more than double that.

Her organization proposes to finance her program with a combination of “savings from healthcare innovations such as electronic medical records and more preventive care and a rollback of President Bush’s tax cuts for the wealthy.” Actually, the effect of electronic medical records has up to now been to increase cost. Preventive care also increases cost because it causes people to live longer and run up more medical bills.

The new $100 billion (or, more likely, $200+ billion) would be a windfall for an already prosperous and overfinanced health care delivery system and would give it a major shove in the direction of the 20% of the national economy towards which it seems headed.

We would all like for everyone to have health insurance. But that is not the only issue involved here. The cost of health care is out of control and unless something is done about that, even the government won’t be able to afford to pay for health insurance.

The article quoted Robert D. Reischauer, president of the Urban Institute, as doubting that the proposals would be enacted because of the press of other issues like the Iraq war.

I, too, predict that they will go nowhere. My reason is that they would cause more problems than they would solve.

Another Step along the Way

For years we believed that doctors did the best they could, but sometimes things just didn’t work out. Doctors got paid for what they did and if things went wrong they also got paid for fixing them. Hospitals got paid, too.

In recent times, we have come to understand that medical mishaps don’t just happen. Most of them can be prevented by following recommended protocols.

That raises the question of why doctors and hospitals should be paid for treating patients for the consequences of preventable medical errors.

The emerging conclusion is that they shouldn’t. It started with refusing to pay for so-called “never events,” like amputating the wrong leg or repairing the wrong shoulder. Now serious consideration is being given to not paying for things like the treatment of hospital-acquired infections.

I predict that it will happen and the effect will be to give a big boost to a change in medical culture that is already under way.

At present, if hospital trustees are told by their executives that the incidence of hospital-acquired infections in their hospital is too high, they are likely to respond with concerned tongue clucking and the opinion that perhaps someone should look into it. The executives are expected to do what they can, so long as they don’t interfere with medical practice.

But if those same executives report that the hospital is losing income because of such infections, the trustees are much more likely to rise into action. Infections are medical business that trustees are apt to stay out of. But money is their province and if there is a money problem they are much more likely to expect their executives to fix it.

Of course, fixing the problem will require “interfering” in medical practice. But since the purpose is ostensibly financial and not clinical, the efforts of the executives are much more likely to be accepted.

Effective reform of health care requires dealing with the delivery system as a whole, not just its non-clinical part. Anything that facilitates that, like not paying for medical errors, will move reform another step along the way.

An Almost Breakthrough

Have you heard of MinuteClinic?

MinuteClinic is a company that is creating and operating clinics staffed by nurse practitioners. According to its web page, it is now operating in 21 states with, I would judge, about an average of a dozen clinics in each state. Their standard operating hours are 8 a.m. to 8 p.m. Monday through Friday with 30 minutes off for lunch at 2:00 p.m., and 10:00 a.m. to 4:00 p.m. on weekends.

According to an Op-Ed piece by Michael Howe, CEO of MinuteClinic (The Boston Globe, September 10), the average charge for a visit is about $60, compared with six times that much in a hospital emergency room.

The medical profession seems to be going more or less bonkers over this, despite complaints all over the country about a shortage of primary care physicians. They raise questions about quality, but Howe’s piece said that for patients presenting with sore throats, MinuteClinic follows best practices 99 percent of the time, compared with 55 percent for the medical community nationwide.

I have suspected for some time that we really don’t need physicians to provide primary care any more. MinuteClinic seems to be based on that same opinion. If it is correct, that has important implications for the redesign of the health care system. The nursing profession does not share the medical profession’s sense of independence and as a rule is much more amenable to standardization and discipline. If primary care becomes recognized as a nursing function, progress in implementing evidence-based standard practice will become much easier.

But there is a problem with MinuteClinic. Its clinics seem all to be located in CVS pharmacies. The suspicion that they will be pressured to generate business for CVS is inevitable and can only reflect adversely on their credibility.

But their emergence is a breakthrough. Almost.

The Free Choice of Physician Siren

One of the most formidable barriers to health care reform is our dedication to the right of free choice of physician.

Our culture is known for its strong beliefs in individual freedom and human rights. It strikes us as elementary that individual patients should have an unrestricted right to choose the physicians who will provide their care.

Under free choice, my insurance company can hope that my physician utilizes medical resources prudently, the hospital can hope that my physician is disciplined and cooperative, and I can hope to be provided with good care.

But none those things will be assured. For one thing, the obligation of my insurance company to pay whatever physician I choose limits its ability to encourage physicians to utilize supporting services responsibly. For another, the hospital can only get my business through the physician I select and will therefore be more interested in gaining that physician’s favor than in controlling the cost of care and overseeing the quality of medical practice. As for me, my choice is as likely to be influenced by bedside manner or the recommendation of a neighbor as by an informed judgment about the physician’s competence.

In a reformed health care system, physicians would be part of and accountable to an institution such as a hospital or large group practice, which would be responsible for being sure that its physicians practiced in a disciplined, responsible and clinically competent way. As a patient, I would first choose my insurance company based on considerations of cost and the quality of care provided by the health care institutions that it offered. I would then choose my physician from within the institution’s staff.

That sort of system would promote discipline and fix accountability for cost and quality. But it would not include free choice of physician as we know it.

My dictionary reports that in classical mythology, a siren was a sea nymph who lured sailors to their destruction by their seductive singing. Comparing that to being lured into a health care crisis by the idea of free choice of physician is a little bit of a stretch, but it makes the point.