Obama’s Un-reform of Healthcare will mean Medicaid for All

Government in Healthcare is the Problem – not the Solution – as

Thriving Free Market Solutions Already Exist

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

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

St. Louis and Festus, Missouri

Part I:  Quality, Service and Efficiency Innovation

Innovation is a hallmark of American healthcare, and to date, of no other country on the planet.  Technology has the potential to transform health care delivery and population health to previously unimaginable levels of quality and efficiency, at a lower cost…

…if it is permitted to breathe, and if planned Un-reform does not suck the life from it.

Regularly, from the vantage of my Internal Medicine practice, I see new competing innovations in information, treatment, patient-consumer choice, and overall efficiency.  These innovations are driven by the desire to improve the patient-doctor relationship and liberate care providers from the ever-increasing shackles of government rules and regulations. Innovations are bending the health care cost curve by increasing service and quality — the only true way to save money in health care.

1. Innovative treatment breakthroughs save lives, prevent disability, and relieve suffering for every segment of the population. These include surgical technologies such as the minimally invasive aortic valve replacement (2 vs. 5 day hospital stay) and the robot- assisted radical prostate removal (1 vs. 5 day hospital stay), discovery of metabolic basis of disease as in atherosclerosis and diabetes, and life-changing pharmaceutical interventions, as in diseases such as depression, schizophrenia, and rheumatoid arthritis. Consider coronary artery stenting, which now drastically decreases the need for open chest coronary artery bypass surgery (CABG); remarkably, ground-breaking medications for blood pressure, diabetes, and cholesterol, combined with proper diet, exercise and smoking cessation will soon diminish need for stenting. Astonishing advances in the science of human genetics are launching targeted treatments precisely at a patient’s diseased organ system, as with Metastatic Malignant Melanoma, until recently a fatal disease. Physicians now can genetically modify the patient’s own white blood cells to attack and kill the cancer cells to achieve sustained remission.  An even greater impact on population health and costs will come with improvements in genetic screening which will more precisely identify those patients susceptible to common, disabling, expensive, highly preventable chronic illness, such as coronary heart disease and diabetes.
2. Information technology is profoundly improving patient access, service, and quality of health care, and naturally generating competition through transparency into the complex system. Physicians regularly access the latest treatment and pharmaceutical innovations through online databases, bypassing wasteful and ineffective care options. We all can effortlessly scrutinize the costs, quality, and opportunities of our health care system visiting  comprehensive websites, such as www.dhss.mo.gov/HA (Missouri hospital infection rates), www.hospitalcompare.hhs.gov (Medicare’s site assessing hospitals), www.healthgrades.com (private sector health care quality reporting), and www.leapfroggroup.org/cp (business association health care quality reporting.Look at the devastating and preventable chest wound infection after coronary bypass; for up to twelve weeks, the hospitalized patient waits for their rib cage — split wide open – to slowly heal and close on its own. Many do not survive it, at a cost of hundreds of thousands of dollars.  Yet since the Missouri reporting, all four of the hospitals I attend have strengthened their infection control; hand sanitizers now appear outside every patient room, substantially reducing infection rates. Both physicians and patients are able to monitor these websites to avoid high risk and costly outcomes. They are directly responsible for improving health care quality and service, and reducing costs.Likewise, in my practice I find my patients solving problems, answering questions, and requiring fewer office visits as a result of reliable consumer-directed health knowledge websites such as <health.nih.gov>.This allows physicians more time with the very sick patient, who is more informed and thus prepared to participate in diagnosis and care.  Many have mastered home blood pressure monitoring which, when reported to the medical team on-line, will decrease the visit time and increase feedback for better blood pressure control.  Far fewer see me for heart burn, learning online about dietary changes and over-the-counter medications, which were formerly prescription. Allergies are often now self-managed with online information and OTC medications.
3. Clinicians and other providers are aligning into groups to pioneer patient-centered, cost-cutting innovations to improve service and quality, and advance cost competition.  They are offering services like on-line scheduling, medication refill ordering, clinician communication, and pre-visit education.  Secure online medical histories can eliminate the need for some visits, enable selected on-line visits, and make necessary visits more productive and effective. Common chronic diseases such as diabetes and congestive heart failure are moving towards team-based care using qualified nurse practitioners led by a primary care internist or family practitioner.  The team can follow these chronically ill patients critical health data online, using home monitoring systems within a secure WEB data portal. Patients post their daily diabetes, blood pressure, and cholesterol data, and the system alerts the team instantly of a missing post or abnormal results.Electronic medical record and data warehouses enable care for the needs of entire populations of patients, instead of just the patients we see in the office. In this model of care, the old school internist or family physician delegates to and mentors the outpatient care team of PhD-caliber nurse practitioners and is their “Go To” diagnostician for difficult cases.  This physician then has more time to direct hospitalized patients, preserving continuity of care in this critical time of need. Disease-specific specialists and their clinicians may lead in the treatment of less common or more severe and more technical, chronic diseases.  These innovations shift the focus of care to where it is precisely needed.  By empowering self care, employing clinicians who may be better suited to manage common chronic disease, using online monitoring for early intervention as well as to motivate lifestyle changes, these innovative models of care will save money by improving service and quality of care.
4. Surgery is evolving towards innovative specialty centers, where procedures such as joint replacements would occur in a center of excellence with orthopedic-specific expertise, equipment, and processes.  Certain cases would be denied, to preserve the infection- free environment, and standard staphylococcus screenings of patients and clinicians would be enforced.  Heart surgery is well suited for similar specialization. The result will be innovative, infection-free facilities, higher quality, higher volume, less expensive per case … a more patient-centered model of care. The traditional hospital operating room would handle the less common, more complicated and emergency cases, possibly reserving rooms as the infected case specialty rooms.  With higher complexity, higher risk, and teams on call 24-7, these cases would command pay at a higher level for each case.  But the costs of most other cases would substantially reduce, while quality and service are increased.

The government’s role in this burgeoning innovation has thankfully been minuscule so far and should remain so.  Innovation requires new ideas and risk-taking. It requires specific working knowledge of the health care system and its current weaknesses.  Innovation of this scale requires private capital, and lots of it. As a high demand emerging industry, healthcare innovation will attract that capital if left relatively unfettered by ever-changing government regulation.  Private sector innovation happens quickly.  None of these are the public sector’s strengths.

Nothing will snuff out effective change faster than the overreaching, unqualified, and slow hand of government. Specifically, Congress chronically underfunds primary care and now with the House proposed “Doc Fix” that locks in 10 years of no increase on top of the previous 8 years of essentially no increase it is literally to the point of extinction, even while innovations in primary care are the foundation of  models to improve population health and save healthcare costs.  Congress actually placed a moratorium on specialty hospitals. Senate Un-reform proposes to tax medical devices and innovations. Lagging behind private insurance, Congress does not permitted Medicare to pay for patient web access, online monitoring, or electronic visits, likening itself to Frank Lloyd Wright’s “floo-floo bird,” which always flies backward, never looking ahead to see where it can go.

My message to government is this: Let the market experts decide which innovative risks are promising and which are not. Remove tax disincentives for investment in promising innovations which increase treatment options, improve patient care, trim costs, and facilitate information dissemination.

Instead, become the most reliable, accessible, and unbiased source of evidence-based information for physicians and our patients. Detail treatment efficacies, costs and recent research for diagnosis, treatment and chronic management of all diseases and conditions. Develop reporting standards and risk adjustment measures with performance targets.  Continue the great work at the NIH.

But leave the innovation – which is saving money, time, and lives – to the experts in their fields.  They live the health care system every day.  Let them imagine, invent, and create, free from the restraints of heavy regulation and taxation. The results will lower costs of health care, reduce premiums, invite the uninsured into the system, foster cost-saving efficiencies, and return responsibility for the costs of care to the patient and doctor.   New government bureaucracies will do exactly the opposite.

_________________________________________________________________________________________

This is the first in a five part series authored by Dr. Charles Willey to promote free market solutions for health care – Medical Financial Reform. Over the coming weeks, look for future articles discussing topics outlined in the introductory article :

• 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 for the medical/financial health of the population with the population itself, not with the legal system or a bureaucracy.