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Tuesday, October 12, 2010

What now? What must we Champions of Medicine do, other than not spend $5000 to attend Newt Gingrich's party?

Quite a number of perfectly adequate and hard working doctors have been invited to go to Washington to dine with Newt Gingrich. Most of us have decided not to go, though the tenderloin did sound tempting. But now that we aren't going, and health care reform is most likely a done deal, what is left for us to do? We are the Champions of Medicine, so are we just supposed to throw our capes over our shoulders and ride off on our white horses? "My job here is done..." I will say, as the music starts and the credits begin to roll.

Despite our hard work over the last harrowing year, there are still some problems with the American Health Care System, as it is sometimes called. It is too expensive, costs are rising and people are suffering because they can't get the care they need.

What have we gotten with the Affordable Care Act? We have funding for various projects aimed at making medicine more cost efficient and we have payment methods, public and private, that will make it possible for more people to get medical care at a cost they can afford to pay.

This is a major step in the right direction, but there are some major missing pieces. Mr. Gingrich would like to scrap it and start over, but then he clearly hasn't read it since he thinks we now have socialized medicine. Much of what wants to be improved in medicine can't be legislated, so I would like to keep what we now have and see what else needs to be done.

Costs are still rising and this is, at least at this point, threatening to stifle economic growth at a time when our country is struggling to be competitive in a world market where medical care is not a major part of the cost of doing business. This needs to be turned around quickly.

Despite new regulations requiring insurance companies to make policies cover basic medical needs at a cost that people can tolerate, insurance products are even now getting more expensive and less generous. Our continued reliance on insurance to pay the bills not only limits any incentives for costs of medical care to go down, but makes the insurance companies powerful enough that they will certainly have a significant influence on policy which will lessen the effectiveness of the regulations.

Doctors don't understand the new laws and are fearful and suspicious. This is causing doctors who have been in practice to consider narrowing the scope of their practices so they are less vulnerable to public insurance changes, and in many cases to consider retiring. The widespread experience of being sued for malpractice already shortens the careers of many physicians, and the lack of any serious attempt of the recent bill to solve this problem has disillusioned many of us.

So what must we do?

First costs need to go down.  In looking at everyday medical practice as it goes on in my community it is clear that much of the excess money spent in medical care is due to the whims of care providers, inadequately informed by science and without knowledge of the costs involved. Almost nobody knows what most of the tests or medications we prescribe cost. Merely being made aware of costs, coupled with more widespread education on appropriate use of medications and testing would make a huge and nearly instant impact on medical costs. This can happen, but could be facilitated by our national organizations. If they are unable or unwilling to mandate transparency of costs and provide leadership on appropriate care, we can do this at a local level through working with our hospitals, clinics and pharmacies to share information.

Costs could also be impacted by changing the way physicians are paid. If we were not only aware of costs but were paid to care for a group of patients rather than by the individual encounter, there would be strong incentives to keep patients as healthy as possible so that they didn't require doctor visits or hospital care. This would line our incentives up with what patients really want: for us to keep them healthy and care for them effectively when they are sick.

One way of providing health care of this type would be through community health care systems on a cooperative model. Communities of people already spend huge amounts of money on health care, and if they pooled those resources and that money did not need to move through an insurance company in order to pay for necessary care, it would buy a great deal more health care. The health care bill supports creation of structures like this, but does not in itself make them happen. That is up to us, in our communities.

I'm not sure it is possible to reassure doctors that all will be well as health care reform goes into action, but if our own national organizations, such as the American College of Physicians and the AMA, show leadership in making our own positive changes we will all feel more in control of the process. 

Suing for malpractice continues to be the dysfunctional approach often taken when a patient has a bad medical outcome or a mistake is made, especially if care was very expensive. We can, even now, tackle this in our communities by making ourselves aware of bad outcomes and medical mistakes and offering compensation as well as honestly evaluating what went wrong. This process can be done by hospitals and clinics, and has been shown to reduce costs overall.  Suing for malpractice destroys lives of both injured patients and physicians, as they spend years in rancorous argument, and the medical community then loses the opportunity to learn from mistakes.  Any federal law reforming medical malpractice is certainly years away, since the tort system has traditionally been a way to protect those who are vulnerable, and it is hard to make the case that medical injury should be handled differently from other sorts of injury.

I'm thinking that perhaps there is still quite a bit of work for all of us Champions of Medicine to do. I think I'll save my  5 grand and travel expenses and hotel fees and just hang out here at home and work on this stuff.

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