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18th June 2009

health care reform meta

posted in On doctoring |

Chris moves to Boston at the end of this month (I’m hoping for one more quick visit, but he’s booked solid with going away parties and moving companies). On July 1st, he’ll be working with my hero, who distills the health care reform arguments and gets down to the heart of the problem, and does so beautifully. Dr. Gawande’s latest article in the New Yorker is a must read. I’m sending a copy to my representatives, because nobody, nobody is addressing the real issues that affect medicine. I strongly disagree with Pres. Obama’s ideas of health care reform (and I’ve agreed or at least grudgingly understood why with all of his decisions so far–but I knew back in November that while I was supporting his election, it wasn’t on the platform of health care reform), but I loath every other politician’s idea as well. They aren’t in health care. They see health care from a business model, and the focus is on “saving money,” while insisting on continuing to provide care exactly how it is now.

“…We are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.

“There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.

“Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of cordination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got 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? Getting the countrys best electrician on the job (he trained at Harvard, somebody tells you) isnt going to solve this problem. Nor will changing the person who writes him the check.

“This last point is vital. 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. Heres 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 theyll 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. 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.”

From The Cost Conundrum, The New Yorker, June 1, 2009.

A few short months after I started residency, the neurology department switched from paying their physicians a salary that was based on experience and tenure to a “relative value unit” compensation system, meaning that patient visits or procedures were reimbursed based on a calculated fee. A basic office visit would be 2 RVU, doing injections for headaches would make it worth 10 or performing an EMG would give you 30. You had to make a certain number of RVUs in order to get a base salary, anything else you do is “gravy”. Things changed overnight. Attendings who used to lecture at noon time suddenly were squeezing in more clinic patients or doing another procedure. My program director is the only one who lectures any more. When on service (meaning they’re in charge of the patients who are admitted to the service and over the residents), attendings leave for a few hours to see clinic patients, cutting into the time that they spent teaching. My neurology clinic was a disaster. Instead of learning how to diagnose and treat migraines, seizures, Parkinson’s, etc, I had lectures on how to document my notes, so that they would generate the most income.

Contrast that to the internal medicine side, who pay their physicians a set salary. The attendings work their two weeks on service every three to six months. They staff the residents clinics and I never hear anything about how I need to see more patients or finish my notes in X amount of time so they can get all of the billing. The focus is instead on my learning: making sure that i understand thoroughly what the cholesterol panel on my diabetic should be for heart attack and stroke prevention. I just learned that that the internal medicine doctors will be getting a 15-30% pay cut next year because of the economy (and some piss poor economic decisions by higher management–but that’s a rant for another day). So far, I haven’t seen it affect the care that they are providing their patients or the education that they are providing me – a vastly different and much more preferable. I understand that unfortunately in this capitalistic* society, medicine is a business as much as anything and that I will have to face monetary decisions once I graduate, but I strongly disagree that it should be influencing my medical education or the care I provide my patients, to this degree.

Also check out his other article Getting There From Here that has a fascinating history lesson in how health care coverage and insurance evolved over the past century, as well as an examination of why idealism should not prevail in our quest for a better medical system. It’s a beauty as well.

Now if we could only get good tort reform as well…

*I support capitalism, but I don’t support endless greed (such as CEOs of private insurance companies or hospitals making billions of dollars a year), which is what our current system seems to be based on. We seem to be learning lessons very slowly.

(Sorry if I lost your comments. I was transferring all of my entries to my other blog, which for some reason copied everything 3 times, and then I clicked delete on the wrong entry. Argh)

This entry was posted on Thursday, June 18th, 2009 at 8:50 pm and is filed under On doctoring. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.


  • I really dislike the current health care reform plan too. We need something, but I don’t think that’s it.

    Revenue value units is pretty scary to contemplate. At the same time, we don’t want to end up with communistic medicine where being a doctor pays less than working in a nail salon (like the kind of stories I’ve seen out of Cuba).

    It’s also difficult to balance the two equally ridiculous stereotypes that turn up in the debate — the medicaid patient going to the ER for the sniffles because it’s free vs. the hardworking poor who lost their insurance and now never go to the doctor even for things that any rational person would. Yes, some people go to the ER too much, and people who don’t have insurance end up with large bills.

    People complain about the UK and NHS but their system sounds like it basically works. That’s the model I would prefer, unless there’s a better one I haven’t heard about.

    I’m all for capitalism, but what dismays me is what’s happening these days, the sort of hypercapitalism that destroys any other ideals or rationality. I work for a Fortune 500 company that is turning a healthy profit but the only insurance they offer is essentially catastrophic major medical. It’s better than nothing, but just barely, and the reason behind it is basically corporate greed.

    wow, you so didn’t need me to write a novel here, did you?

  • Wow; enlightening. When will these people learn that if you structure a rewards system one way, that’s how people will gear themselves to it.

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