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"US health system reform--what's missing?" HumanityMar 25, 2012 17:44 EDT
I don't know the identity of the physician that stood at the microphone at the end of this presentation, but he hit the nail on the head. "Healthcare is a basic human right," he said; which raises the question, "If the right to healthcare is so basic, why is it so problematic?" When there's trouble in any country, it most usually has to do with the age-old struggle to balance the supply of cash with the demand for services, but that is a woefully inadequate summation. Like any complicated and dying patient whose symptom complex is driven by not just one, but two or even three different disease processes, so are the maladies of healthcare reform in our country. Following suit like a successfully metastatic cancer, those who seek to destroy the good things about our system are attacking simultaneously, at every vulnerable site, repeatedly and efficiently. Make no mistake, as a group of individuals, we as healthcare providers are vulnerable.
I read every page of the healthcare reform bill and posted on that issue a few years ago. I lamented that the word "cardiologist," the gatekeeper of the our country's most expensive DRGs, congestive heart failure the most damning, was never mentioned one single time in the entire diatribe. Congestive heart failure was never mentioned as an entity, period. Although trauma networks were addressed, PCI networking, a smoke-free America, and effective strategies for heart-failure prevention and readmissions were never mentioned. Behind what door were we all sleeping? Or more precisely, who was holding the door shut?
Dr Kavita Patel, an internist currently at the Brookings Institution, a nonprofit public-policy organization based in Washington, DC, said, "I'm pretty pissed about how I worked in the White House and at how bad a job we did in talking about healthcare reform. I'm trying to understand how we took something so amazing and frittered away an opportunity. I find myself constantly being amazed how little anyone understands where the faults lie and why we did not do a good enough job in reaching out to leaders like Jack [Lewin]. We did not reach out enough to talk about leadership. How can we communicate more effectively?" She then added, "Nothing is happening. We won't know what will happen until closer to November. There is uncertainty about the role of physicians." She then said, "My impassioned plea is that we must translate policy into sense. There is a dysfunction," and then pointed out that "in DC, we go after the vulnerable and the impression is that since they don't know what they want. . . . Let's go after them and impose policy. There is certainty, however. There will be payment reform. The deficit will not go away. The demographics of our country are changing, but as long as we keep Medicare age at 65, we are going to see a dramatic change in how we are going to think about it."
Then it was Dr Richard Anderson's turn, the owner of the Doctor's Company, "the nation's largest insurer of physician and surgeon medical liability," who asked rhetorically, "What is and what isn't in the bill? The standards of care, bending the cost curve, and defensive medicine," he answered. "It is impossible to mend the cost curve if we don't amend defensive medicine." Then he asked, "What's missing? Everything! In this 2500-page bill, there are only one or two mentions of professional-liability reform. Section 10608 extends federal malpractice protections to nonmedical personnel at free clinics. That's nice," he said, "but the real question is, 'Why aren't we all protected by the Tort Claims Act?' He then affirmed that "100% of medical care in America is defensive. The standards of care are standards passed down from the courts; 91% believe malpractice concerns result in defensive medicine, 93% report engaging in various forms of defensive medicine. Greater than 90% of med students and residents see defensive medicine as necessary. The cost?" he asked: "150–$200 billion per annum in defensive medicine alone." He then added, "Physicians are never going to escape accountability, but more decisions will lead to accountability without authority."
Dr Anderson then went on to address the "best practices that aren't." He said that "guidelines are often wrong" and pointed to a study of patients with CHF that showed that quality measures prescribed by federal government had no effect on outcomes. He then pointed to the recommended practice of instituting antibiotics for pneumonia implemented within four hours, which actually worsened outcomes. "The mammogram controversy," he said, "shows we cannot agree on the guidelines and the costs are enormous. $70 of the cost of each screening mammogram goes toward litigation."
Then there is the current electronic medical records (EMR) debacle. Dr Anderson believes "EMR is a holy grail." He thinks, "It's a once-in-a-lifetime $40 billion–plus opportunity, but it's working out incredibly poorly. The payment system, if used effectively, has a potential return of 15 to 1, but may be a net negative unless fully integrated." He then said, "Billing verification trumps clinical utility. The tower of Babel can be a moral hazard, newly minted, and if put into physician offices can be a flytrap for more litigation. Irrelevant information for documentation is added for reimbursement purposes. A lot of it is now 100% 'unreadable.' We have a long way to go before we harvest any of the value of what should be a major step forward."
There were some pieces of advice among those who delivered on a fantastic gripe session. "We need to put the poisonous politics aside, and we need to get to a better place in healthcare delivery" said Dr Anderson. "Here is an optimistic alternative view: Better coordinated care, the practice of evidence-based medicine, improved medical records, and a reduced need to sue for costs of care." Yep, I thought, and there is about as much chance of that happening as my winning the Lotto tonight, but I am resigned that we must try.
A female heart-failure physician from the audience put another salient point forward by adding, "No one hears us when we say patients must be held accountable. Just last week, on our heart-failure ward, a young woman was eating Kentucky Fried Chicken and French fries." I even lamented in the question-and-answer session that the ACC needed to drive harder on issues of mapping America for a timely PCI, smoke-free agendas, and uniformity in heart-failure management strategies. "We are on every single smoke-free legislation," said Dr Lewin. Dr Jerry Kennett added, "That is all a part of our Million Hearts campaign." Well, it might be, but it's not trickling down to our population, I thought. Nor is it rising up to the level of the White House.
The message was clear today that physicians are failing as a group because we aren't organized. We can't even decide if we want to be called "a group" of doctors or "individual groups" with our own special agendas. Abe Lincoln said it best, "A house divided cannot stand," but today I bet he would add something like, "A door cannot open with someone's foot barring the way" or "A door latch will not open by itself." We need to remove the feet, the hands, the lies, and the hidden agendas that prevent us from standing together as healthcare providers. President Obama needs to plan a weeks- long summit with the leaders of our country's largest healthcare organizations. He needs to make a few phone calls to the physicians on the forefronts of the fight against our most expensive diseases as well. He needs to hear how Dr Harlan Krumholz's group of physicians reduced 30- day heart-failure admits. He needs to hear how Dr Aversano's C-PORT trial proved we can promote safe and timely PCIs throughout our nation, and he needs to understand how a successful smoke-free America campaign can stop many of the drivers of our most expensive DRGs like cancer, stroke, heart disease, and COPD. He needs to examine the 17 most expensive medical diagnoses and summon physicians who work in those trenches to his side immediately for an urgent, long overdue and intense discussion. Finally, our president needs to remove his "lawyer's mantle" and understand that tort reform is a lifesaving chemotherapy for one of the most malignant cancers that's actually not just threatening but killing our healthcare system.
Dr Jack Lewin said it best; "There is a deafening silence in DC as to what we think." Well, I don't mind telling them what I think. We need a president that is "tripartisan," uniting both Democrats and Republicans on the side of humanity, because putting the humanity back in healthcare is the only thing that will ever work. Otherwise, any amount of effort never will.