Results tagged “health care reform”
The unfortunate politicians who have braved town hall meetings in recent days to talk about health reform seem to have been taken by surprise by the vitriol and volume of the push back. Yes, I know the audiences were marshaled and recruited to shout down the speakers but still the passion on display was genuine and not in the least surprising to me. What the President and our politicians should have known is that our personal health is the one arena of our lives (the other being our love lives) where reason and logic get thrown out of the window. Talk about our health and suddenly our education and civility vanish and we are a mob waiting to be ignited. The incredible thing is you can just as easily incite us to march for reform as you can against reform. All that matters is what button you push. Read More
It used to be you could look into the crystal ball and paint a picture for them of what their life would look like when they were done: it used to be that if they chose primary care, they would probably over a lifetime make perhaps 3 to 5 million dollars less than a colleague in a procedural specialty, be harassed with a lot more forms, longer hours, and unless they retreated to a concierge practice where they set a high dollar bar for admission to their practice, they would be very busy.
On the other hand, if they picked dermatology (and I love dermatology, and find it an intriguing discipline), they could count on a good lifestyle (very few dermatological emergencies), they would do lots of procedures, and make a healthy living. The same was true for ophthalmology, radiology--all very competitive disciplines for students to enter.
But what if:
- You get paid only for managing disease, for caring for a stable of patients--in other words, what if there is no fee for service? (By the way, Massachusetts is bravely going this route.) Doing more procedures then will cost you money, not mint money. Suddenly, many procedure based specialties don't look so hot.
- What if Medicare or insurers stopped paying for MRIs, CAT scans and PET scans on an individual basis, but rather only reimbursed for disease management ? The owners of such facilities (who in many cases are doctors) have counted on business continuing as usual and may fold like Chrysler dealerships. Radiology as a career choice might be less attractive.
- What if the physician who cared for the patient, who had formed a steady relationship with the patient over the years, who knew the family, and who was the one who admitted them to the hospital (and then acted as quarterback and kept a close eye on the consultants called in and ensured communication)--what if that individual got paid top dollar? Yes, what if primary care became the plum? Look at who President Obama picked to be Surgeon General: a primary care physician par excellence. There is a message there.
- the House releases its health care bill
- Center for Medicare and Medical Services (CMS) releases a revised physician pay schedule
- The FDA is about to finally get to rule over tobacco companies
07/07/09 9:02 AM
Medical Tests: "Does it work?" matters less than "Does it pay?"
When President Obama speaks about funding health reform, he keeps emphasizing that the money needed to achieve his goals of covering the uninsured, is already in the system:
"Two thirds of the cost would be covered by re-allocating dollars that are already in the health care system, taxpayers are already paying for it, but it's not going to stuff that's making you healthier." (From his appearance on ABC's Prescription for America).
I recently came across a great resource (thanks A.J.!), the California Technology Assessment Forum whose goal is to assess new and emerging technology. It is edifying to look at the list of tests it has assessed, pages of them, and to see how few meet its criteria for a test that improves health outcomes and is safe and effective. And yet the tests are being done and we are collectively paying for them.
Hats off to the President for taking on health care reform, because if you read the CTAF's list of tests that are ineffective, you are also looking at a list of device manufacturers and others who are doing very well on these procedures and tests--every one of them is going to battle him tooth and nail, primarily through their lobbyists in Congress. I sense the President is doing the right thing by taking the message to the public, to us, counting on our sense of outrage to say it is enough.
One of my former students, a brilliant physician who has gone into a rural practice where he does it all--delivers babies, takes care of children, adults, performs procedures--wrote the following to me (tongue in cheek) and I have his permission to use it:
"I justify ordering expensive and unnecessary tests in the following way: It is clear that the current health system is unsustainable. The sooner it collapses, the sooner we can start over again, hopefully with something better. I intend to do my part to bring the system to its knees as soon as possible. (That's only funny because I'm not that way.)"
It's only funny because he truly isn't that way.
I had the pleasure of being in the East Wing of the White House on Wednesday, one of about 160 people in the audience as President Obama appeared on national television, fielding questions about health care.
It was my first look at the President at close quarters. I came away with the impression that the President was possibly the most knowledgeable person in the room when it came to the current health care crisis. That's no small thing given the people who were there. We have had Presidents whose understanding of issues seemed confined to the precise talking points prepared by aides in briefings. This President knew his material well and was improvising as smartly as a jazz pianist, in response to questions.
The other thing I sensed was the President's tremendous passion for this cause. If there is something more important on his agenda, I don't know what it is. What also came across is that compared to everyone else who was there (physicians like me, the CEO of Aetna, the head of the AMA), the President was probably the only one whose interests in the health care debate were not self serving. His sole motivation seems to be to head off disaster, which seems inevitable if reform does not take place.
An important moment for me personally came when a young woman asked the President the very question that I had been prepared to ask. She wanted to know why we could not emulate the example of other advanced democracies that manage to cover all their citizens for about half what it seems to cost us. The President's answer was revealing; he pointed out that most of those countries had a one-payer system whereas we in America, "...have an employer based system that has grown up over decades. For us to completely change our system, root and branch, would be hugely disruptive and I think would end up resulting in people having to completely change their doctors, their health care providers in a way that I'm not prepared to go. This is one-sixth of our economy. I think that we can build on what works, fix what's broken, and still have some substantial money."
The obstacles in the President's way are considerable: 1) people and businesses who are profiting hugely from the status quo; 2) a general fear of government interference; 3) fear in Congress about the amount of money to be spent on health care reform and finally, 4) the fact that legislators who have to make change happen often serve the interests of the people who gave them the most campaign money--pharma, insurers, organized medicine. These contributions are what taint our political process--call it first world corruption.
I got back to my hotel room at 10pm, just as the session (which had been recorded "live to tape") was finally being aired. I was surprised to see that one commercial shown during the health care debate was on behalf of "Patients United Now"--a group I know little about. The ad was sowing seeds of fear by having a Canadian patient talk about the difficulties of that system. They couldn't wait to hear what the President had to say it seems.
Oh yes, and the other thing on television competing on the other channels was the news of Governor Sanford's whereabouts. As to that . . . less is more.
Our costly health care system is unsustainable for doctors like Michael Kahn in New Hampshire, who, as he puts it, spends 20 percent of each day supervising a staff explaining insurance problems to patients, completing authorization forms, and writing appeal letters; a routine that he calls disruptive and distracting, giving him less time to do what he became a doctor to do and actually care for his patients.
The President's speech even quoted Newt Gingrich:
As Newt Gingrich has rightly pointed out, we do a better job tracking a FedEx package in this country than we do tracking a patient's health records.
The speech reminded me of a conversation a few days ago with a close friend who said casually, "Face it, Abraham, medicine is corrupt." I paused. I sputtered. I was about to say something. But I shut up. I shut up because (as the President explains) whether I like it or not, I am a beneficiary of a system of :
. . incentives where the more tests and services are provided, the more money we pay. And a lot of people in this room know what I'm talking about. It is a model that rewards the quantity of care rather than the quality of care; that pushes you, the doctor, to see more and more patients even if you can't spend much time with each; and gives you every incentive to order that extra MRI or EKG, even if it's not truly necessary. It is a model that has taken the pursuit of medicine from a profession - a calling - to a business.
We can quibble on the ways the President proposes to fund the changes he proposes, but I don't think we can quibble on the moral imperative to change the way we do business. As the President says,
"You entered this profession to be healers - and that's what our health care system should let you be."
(For another take on the speech from a thoughtful physician who also happens to be in New Hampshire, see KevinMD.com)
05/14/09 9:22 AM
If "Evidence Based Medicine" is like "Sex Based Intercourse" then "Comparative Effectiveness Medicine" is like . . .?
President Obama is in a bit of a bind, lets face it with his laudable goal to have health coverage for all uninsured Americans. The health care math is simple: we already spend a ton on health care and his goal will require spending more. His options are to generate new revenue, or the other option (the needed option, I would say) is to cut costs. But you saw what happened to Hilary years ago when she tried that. To quote from a great series of articles in the Annals of Internal Medicine, "A dollar spent on medical care is a dollar of income for someone." Cutting costs means cutting income for lots of different players and they won't be happy, and yet there seems to be no other way.
But President Obama thinks he can raise money largely through three methods that no one has proven can save money:
1) Investing in Information Technology: I don't see how that saves money but it does ensure that America's doctors will get better tans on their faces from long exposure to screen glow; the iPatient in the computer will get great care while the patient in the bed will wonder where the doctors are.
2) Preventive medicine: Studies actually suggest this usually costs more money, despite all the theories of how it should save money
3) And finally the President wants to invest in "Comparative Effectiveness" research so that we only pay for what works.
What helped create our present mess is a payment system that rewards procedures and expensive diagnostic testing, but does not reward primary care; it has necessarily resulted in a profusion of people and places who do things that are well reimbursed and a dearth of physicians doing primary care. We don't need comparative effectiveness research as much as we need a retooling of the payment system and some caps on spending. Let's pay for what works right now, and stop paying for what's not needed.
I worry that "Comparative Effectiveness" or "CE" is going to be the next medical buzz word, just like "Evidence Based Medicine" or "EBM" has been the buzz word for a decade. "Evidence Based Medicine" is a term which makes about as much sense as "Sex-based intercourse"--Were we practicing based on zodiac signs before EBM came along? (By the way, I borrowed "sex based intercourse" after hearing a prominent chair of medicine say it--I don't know if he coined it, but I thought it was brilliant). Soon we'll have a generation of physicians who are CE experts to bump out the EBM experts.
Lets take away the incentives to do to patient and instead create incentives to do for patients, to be with patients. We don't need to do comparative effectiveness trials to see if that works; we can just ask patients.
Abraham Verghese
