Government Intervention in Health care is the Problem – not the Solution – as

Thriving Free Market Solutions Already Exist

A Doctor’s Diagnosis and Treatment Plan: An Upcoming Five Part Series

Charles J. Willey, M.D., General Internal Medicine

St. Louis and Festus, Missouri

Dr. Willey has been successfully practicing general internal medicine for 25 years, and lives with the American health care dilemma on a daily basis. He not only diagnoses and treats individual patients, but diagnoses and treats the health care system as well. He was the founding CEO of a thriving 70- physician medical group.  During his thirteen years as CEO, he directed implementation of their electronic records system in 1998 and invention of their own evidence-based, electronic prescription writer in 2001.  In 2003, he guided the group to form what is one of the most most efficient patient-centered and physician-friendly health plans in the country.

 

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Passage of the so-called health care “reform” bill would be an epic American tragedy.    It is tragic because it will make matters worse, epic because it may be irreversible.  That is why I call it Un-Reform.

 

Unlike the politicians and pundits who continue to offer ad hoc solutions to our country’s health care issues, I have the benefit of firsthand knowledge working every day in the U.S. health care system.  I am aware of what most Americans are not: that effective private sector solutions are already in the works to correct our current challenges. 

The Un-reform proposed by Congress and President Obama takes medical and financial decisions away from the patient/doctor unit, driving quality and service down, and costs up. It moves us to an impersonal and inefficient government-run bureaucracy, and away from what should be the two most critical decision makers on our health care:  the patients and their doctor. 

This Un-reform will counteract what is already taking place in the private sector, ground-shaking natural correction and innovation. Like the stock market, the health care industry has been repairing itself, and does not need massive government intervention to find solutions to existing health care problems of high costs, inconsistent quality, non-portability, the uninsured and the uninsurable (due to pre-existing conditions), among others.

These are just a few of the free market trends and developments you may already be seeing at your hospital and doctor’s office:

• *development of highly useful, efficient, and secure information technology to improve quality, and increase transparency of both quality and costs;  
• *movement away from impersonal mega-insurance and mega-institutional care towards more personal and localized organizations;  
• *integration of sound medical cost control and payment mechanisms with quality care management; 
• *a novel approach to risk pools which invites the uninsurable as well as the uninsured into the system by reducing costs;
• *reinvestment of health care savings into “Smart Benefit” or health savings plans for the patient, employers, and the systems. 

 As these and many more programs mature and become more commonplace, not only will they bend the cost curve to favor patients and all payers and eliminate systemic waste, but the medical care, service, innovation, and long term health outcomes will improve for all Americans, including those currently unable to access the system. All this can occur with very little governmental intervention.

Sadly, the “reforms” proposed, as recently as late Saturday night, will transform all of American healthcare directly into Medicaid, an already failing system which uses our tax dollars for bureaucracy and bailing out medical disasters, not quality patient care. It fails to cover the cost of services and burdens physicians with onerous paperwork and red tape; physicians would literally rather care for Medicaid patients for free than participate in the program. Even regular Medicare is now well on its way to becoming Medicaid; over the last eight years, primary care physician reimbursement has remained stagnant, and specialists’ have been cut 50 percent, the result of which is that the time and technology necessary for high quality and low cost care is unattainable. Indeed the time-honored profession of general internal medicine is nearly extinct.

In this information age, health care and medical financing can and must be managed together. Thus, the tragic dichotomy at the center of what is ailing American healthcare: should the patient/doctor unit make medical and financial decisions regarding health care, or should government make the medical and financial decisions regarding health care?

 Consider how my everyday experience illustrates this for the average patient: 

A worried 45-year-old male smoker, let’s call him Joe, presents with left-sided chest pain that fluctuates with his breathing, bending, and touching. In the Medicaid system, without a primary care physician, Joe will present to a hospital emergency department quite anonymously.  The emergency doctor’s top two priorities, saving life and preventing injury, are sadly followed by a third, law suit prevention.   Even though Joe’s pain has minor inflammatory chest features, he will be screened for: pulmonary embolus with D-Dimer, congestive heart failure with BNP or Pro-BNP, acute coronary syndrome with Troponin.  

 These very sensitive screening tests declare many false positives; without fail, at least one will be mildly positive, causing hospital admission, a CT Angiography, a nuclear stress test, and if not perfectly negative, a coronary angiography. More tests follow when these tests are not 100% negative (which they rarely are).  Fearing that this minor technicality will open the door to a baseless lawsuit, the ER doctor continues to uses all the technology at his disposal to appear more thorough to the legal system. Joe pays little to nothing, so never questions the decisions made. Without a primary care physician advocate, he doesn’t see the inherent health risk in the unnecessary testing and hospitalization, and no one assumes responsibility for his after-encounter care.  Without an advocate, up to $12,000 is spent on his behalf. 

All for a case of chest wall pain, treatable over the phone with ibuprofen. 

Now consider the outcome if Joe  were a member of an innovative integrated medical/financial plan, which  incentivizes healthy patient behavior, and pays physicians for long term patient health instead of underpaying them for each procedure and treatment, whether necessary or not.  (Note that this is the opposite of what is proposed in Un-reform plans, which rely on cutting payments and not on innovation.)

Instead, the patient would have an existing relationship with his primary care physician who would pursue an initial history and physical exam, and an evaluation for heart attack risks (and if high risk, would include a stress echocardiogram).  The physician has pushed him to quit smoking, and screened his baseline lab data, including LDL cholesterol, glucose, and renal function. When Joe calls his primary care physician with chest pain that fluctuates with breathing, bending and touching, the physician quickly reviews the patient’s records electronically, from anywhere, advises him to take ibuprofen, and visit him within 24 hours, with appropriate cautions.  The costs of two visits, blood work and echocardiogram and phone calls:  about $1,000 (not including the $1200 Joe saves per year by quitting cigarettes, which pays a significant portion of his annual health insurance premium.  Or, if Joe puts it in a health savings account annually at 2%, is $51,472 by the time he is age 75).

The end result is a healthier patient, a stronger physician-patient relationship advocating wellness, and evidence-proven effective care, balanced with cost containment. Doctors do less crisis management, spend more time with patients, and invest in technologies to achieve even greater efficiency. 

There are many solutions already in play around the country and more in development. We need to foster these market-based innovations, and not abruptly and drastically change the rules in an omnibus Un-reform bill.  We should allow time for market-based innovations to mature while modifying certain anti-competitive government regulations with surgical precision.

I will demonstrate in Parts I through V of this upcoming series that we do not need the health care Un-reform, too often just cumbersome interference, currently debated in Congress; instead, we need to foster Medical Financial Innovation among providers, patients, and payers within the industry. 

The foundational principles of Medical Financial Innovation should be:

• *centering and trusting decisions with the patient/doctor unit,
• *pairing medical decision making with financial decision making,
• *injecting long term incentives for wellness, cost containment, and efficiency into the system, and
• *increasing the responsibility of the patient/doctor decision unit for not only individual health, but population health as well.

 

Through these principles, innovations will solve current and future health care concerns. We already have more than enough money in American healthcare. It is ludicrous to contend that health care costs too much, and then propose to spend an additional 1.5 trillion to Un-reform it.  

The issue is not how much we are paying.  It is how, and for what, we are paying. 

The series will roll out in five parts, each built on these foundational principles.  They are:

            I. Quality, Service and Efficiency Innovation

            II. Lawsuit Abuse Innovation

            III. Reimbursement Innovation

            IV. Insurance Risk Pool Innovation

            V.  Benefit Design Innovation

 I look forward to hearing of your experiences with models of medical/ finance innovation, and to a lively dialogue on this important topic.

This entry was posted on Monday, November 9th, 2009 at 10:21 am and is filed under Blog, Latest News. 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.