"US health system reform--what's missing?" Humanity

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. 

See also:

HF update from ACC: Tackling readmission rates, galectin-3; chronic lung disease comorbidity

Your comments

	"US health system reform--what's missing?" Humanity
	# 1 of 7	March 26, 2012 10:09 (EDT)
	ABRAHAM KURIEN M.D.	After practising as an internist and cardiologist in India, United Kingdom and finally in the United States for 20 years, I left the practice of medicine at age 57 at the height of my abilities, because caring for the welfare of the sick and preventing illness, the essence of being a physician was no longer a systemic understanding about the provision of healthcare in the country. Medicine had become industrialized. While bureaucracy and laws are essential for the effective functioning of any system of social structure, these had become the core concern of government in providing health care. We had transformed the acts of caring into financial transactions and those who performed them into technicians who delivered instrumentation and drugs, consumer products, manufactured by corporations that designed and produced expensive gadgets for investigations and unaffordable drugs peddled by ever present sales representatives. We became repair engineers who outdid motor mechanics! The institutions where professional competence was enriched by compassion became factories where malfunctioning human machines were brought to be repaired and damaged parts replaced by metal prostheses. After discharge efficiency inspections of charts by those who did not care to take care of the sick, but wanted to earn their comfortable living by retrospective audits, became the methodology that replaced professional evaluation of the integrity and quality of the physicians who were given the privilege of being healers. Diagnosis related groupings and payments became the method of creating financial efficiency at the cost of inapprorpiate early discharges and one day surgeries which burdened patients.We assumed that death was always the result of the failure of medical care as a technological entity. These changes were an alien culture to me. I pleaded with Hilary Clinton to approach any attempt at creating a national Health Care system with the interests of the patient as its center. There I failed. I repeated my pleas to the Obama Adminsitrations. there also I have failed. We, physcians failed to act in 1992 and in 2009 in a concerted manner on behalf of our patients. That was because we did not recognize what was  in jeopardy and continues to be even now  - it is the humanity of the patient, the physician and indeed of our culture as a nation, as represented by our government, led by lawyers and bureaucrats.  it is the affordability of being taken care of. We could have foretold the disaster we face now, but we did not raise our voice as prophets. We only wanted to be professionals preoccupied with the present.   Abraham Kurien
	# 2 of 7	March 26, 2012 10:21 (EDT)
	solon	To eliminate hundeds of billions in medical costs, the bare essence: 1. Malpractice reform: Pass legislation to immunize physicians from malpractice for NOT ordering tests and procedures. 2. Medicaid: Pass legislation to make physicians charges for services for medicaid patients deductible.  Of course, both proposals  would require controls.
	# 3 of 7	March 26, 2012 09:57 (EDT)
	Cindi Moore	Once Again Melissa, Bravo!!
	# 4 of 7	March 30, 2012 07:48 (EDT)
	Christopher Lillis, MD	This is a wonderful message.  Humanity NEEDS to be part of the discussion, but politicians do not have our life experiences as practicing physicians.    Doctors can be organized, and can make policy differences.   I urge those interested to attend this conference:  https://ssl1.americanprogress.org/o/507/p/salsa/donation/common/public/?donate_page_KEY=7100   You will have the chance to interact with decision makers in policy.  Share your clinical experience.  Make a difference!
	# 5 of 7	April 1, 2012 08:34 (EDT)
	Melissa	Cindy, thanks so much for your accolade and your post!   Christopher, I checked the date for your symposium. I would absolutely love to be there, just as we all know:  Life gets in the way. Office gets in the way. Family issues with health are staunchly in the way. The daily grind of the office, patients needing to get in. Tests results need to be given. Testing needs to be supervised, and therein lies the rub.......and the naysayers are counting on it!!! If all of us had a week to converge on Washington D.C.,........say for instance a million cardiologist/internist/FP march!  It might get their attention. It would have to be planned during, ...for instance....a spring break or at least far in advance, widely advertised and with an agenda that could be attended by as many as possible...perhaps like the inngauration! , when families plan to be off together with their physician family members, in order not to disrupt offices so much it could work! Good luck Melissa
	# 6 of 7	April 13, 2012 05:42 (EDT)
	George Rodriguez-Paz	Dear Melissa: I always read your comments with a lot of hope that I know most of us physicians and especially cardiologists feel the same way and I must say that I agree with your views and comments in their entirety. However, I would like to add that if it is true that we as physicians have continued to accept in a passive fashion the detriments imposed in our profession by bureaucrats, businesses, and politicians , we as a profession have not been inspired by our professional socieities. Long time overdue there has been a need for a more drastic reaction to the failures of our healthcare system. This as any other revolution in world history requires charismatic personalities and leaders with vision and conviction. I used to be a member of the AMA, ACCP, ACP, and I have dropped all those memberships from the frustration I have felt to see that at the end the solutions proposed by all societies has been a mere compromise to satisfy interests shared by a few in our profession and the very same people who continue to jeopardize the autonomy of our intellect in the name of "improving healthcare and cut healthcare costs". Having said this, I want to be naive and believe that we still have in our hands the moral power to make a real change. I applaud your idea of an organized march in Washington D.C. of cardiologists around the nation and any other specialties that share our concerns demanding that our voice is heard, that without our voice , our direct input, any hope of a real change to improve what most of us still believe is the best healthcare in the world is not destroyed forever. It is imperative that the leaders of our professional societies act decisively and fearless to defend with our heart and soul the essence of our profession and to respect it. I thank you for how elegantly you translate in paper your thoughts and your concerns. keep it up!!! Sincerely. George Rodriguez-Paz
	# 7 of 7	April 16, 2012 08:35 (EDT)
	Eric	Go Melissa !  George is correct, I am always inspired by your thoughtful and elegant responses to current medical system failures; you have a sixth sense. If you organize a MARCH in DC for 2013, (not just another wonk-filled useless conference with the usual "experts"), but a REAL march on Washington, next Spring Break we will all be there.  Your inspiring messages resonate with many physicians in the trenches and you can help bring the humanity message to Washington with a few of your friends & followers from around the country. Just say the word and you may be surprised.  Godspeed Melissa!

You must be a member (with full membership) to post a comment.

Already a member?

Enter your login information below:

 Remember me on this computer

Forgot your username and/or password?

        Login        

Enjoy all the benefits of theheart.org

With full membership, you can check out our educational and editorial content, search the site, receive our newsletters, join discussions, download slides and much more.

Membership is free!

    Join now for full access