President Has Gone Over To The Dark Side

President Obama has succumbed. The lure of the Dark Side -- with its Blame Game -- was too powerful. Though he acknowledges that "our healthcare system is broken," he points the flying fickle finger of shame at people: this time the doctors.

Doctors as Villains
We have known for decades that over-, under- and mis-use of medical technology produces bad outcomes and wastes money. We have known for millennia that incentives affect human behavior, and providers are human.

Under fee-for-service, the more the doctor does, the more she/he gets paid. Some doctors do too much (over-use). Under capitation, the less the doctor does, the more she/he gets paid. Some doctors do too little (under-use). The system is inconsistent and contradictory.

None of this surprises me. What astonishes me is how the majority of doctors actually ignore what is in their personal financial best interest when deciding what is best for the patient.

As a pediatric cardiologist, I could order an echocardiogram on every single child I see with a heart murmur. The test carries no risk. I could rationalize the need. It would generate lots and lots of money. The problem is that word "generate:" it should really be replaced with "waste." While all those unnecessary echoes would be revenue to the hospital, they would be unneeded costs for the nation.

President Obama has fixated on this under- and over-use problem decrying it as a major cause of healthcare over-spending and by inference, blames the doctors.

Differences in Practice Patterns: Money and Quality
Representing the Administration on Charlie Rose (June 15, 2009), Peter Orszag of the Budget Office pointed the finger at the doctors saying that: a) different quantities of health care delivered in various parts of the country produced similar quality, and b) homogenizing these differences, i.e., curbing doctors' overuse, could save billions without impairing quality of outcomes. I am sure he means well, but he hasn't a clue.

The measures of quality used for comparison were all negatives: days in hospital; discharge diagnoses; complications; deaths; and hospital bills. Not one measure of outcomes-we-want, like restored function or longevity. "Quality" is not the absence of death.

Secondly, his offhand estimate that changing doctors' practice patterns could be a major factor in reducing national unsupportable healthcare spending is ludicrous. The amount saved by standardizing practice patterns is less than a drop in the bucket compared to: worthless (but costly) bureaucracy and regulations; perverse incentives; actions without evidence; and defensive medicine -- to name but four out of ten reasons for healthcare spending.

Finally, many (most? all?) doctors use "too much" or "too little" health care when the "right amount" is unknown: not unknown to them but unknown to everyone. A national database of medical processes and positive outcomes would show what works; what does not; and what it costs. Such a database does not exist. Why not?

How the Regs Prevent Learning "The Right Amount"
There are a host of regulations, HIPAA merely the latest and greatest, aimed at keeping medical information isolated and unshared. Examples have been given in previous blogposts. Efficient transfer and free exchange of medical information -- which could teach us those magical "right amounts" -- is trumped every time by what bureaucrats believe are vital security measures, more important than learning to do good for patients.

When the Administration talks about how medical records will improve efficiency and outcomes, they need to note that the major source of inefficiency and inability to share information is their own regulatory bureaucracy.

Prior Recipients of the Villainy Award
The doctors are merely another in a string of culprits identified as responsible for our health care mess. Prior villains include the hospitals; big pharma; and the ever-popular insurance companies. Interestingly, two who have never been singled out have been trial lawyers and the administrative bureaucracy itself.

Does Blaming Ever Solve Anything?
Blaming the doctors is wrong for three reasons. 1) As above, the assignment of blame is unfair. 2) Blaming per se always does one thing and always fails at a second. It invariably produces defensive behaviors and invariably fails-to-fix. 3) Even the President (rightly) said that the problem is a broken system. If he wants to make things better -- fix the problem, not the blame.

Fix what is broken: the system. Don't blame the parts.

Follow Deane Waldman on Twitter: www.twitter.com/dwaldman@thesys

Comments

[krocklin]

Hippocrates oath? What a joke.
I have been going to dermatologists for years. I learned from a friend of one of then he has a huge mansion and collects antique cars.
And yet then I was referred to another dermatologist. He had Hippocrates oath on the wall of the room he examined me in. He not only told me the other dermatologist's biopsies were false, he only charged me $82.
I had never paid less that $600 on up.
This man however was one in thousands of doctors.
Hippocrates oath is a joke.

[Derelict outlaw]

You demonstrate real courage IMO Dr. by risking not doing echos on all your kids or new murmurs. After working over seas for a few years I got completely out of the habit of doing defensive medicine dictated by the insurance companies and the protocols of fear generated by the CYO atmosphere in our litigious culture. Tort reform has to go hand in hand with health care reform, that's what's stalling the process IMO.

[oftenon]

HMOs interpret Hippocrates' oath with the same regard pigs have for opera.

HMOs are parasites. Institutionalized tumors. Tragic failures. Lobbying locusts. You strain for the gnat and swallow the camel, doctor. Get the diagnosis right and you'll understand why the patient lashes out.

[S1m0n]

I'm not convinced. If the structure of the present medical system has no influence over the medical decisions American doctors make, then nothing explains the clear differences between the frequency and kind of tests ordered by doctors in the United States vs Canada. Bluntly, the American system conducts FAR more such tests than the Canadian system does, to no discernable medical effect. Outcomes are the same.

[Emerald1943]

I agree with others that a single pay health care program would definitely be the best, but let's fact the facts, folks. Big insurance and big pharma are not going to let that happen. They have bought and paid for our lawmakers in spades! Millions upon millions spent to defeat any bill that would help the American consumer!!

I have said this before...and I will say it again.....

I wish I had a senator or two to do nice things for ME, but unfortunately, I cannot afford to BUY ONE!!! What a shame!

A couple of things need to happen before we see any significant change in our health care system...campaign finance reform, and tort reform. If we don't, we can expect big insurance corporations and greedy lawyers to continue to rake in the bucks!

[jhamm1]

IF that's the dark side, than Obama had previously gravitated to the "pitch black side" by placing the entirety of the blame for the status of our educational system on the teachers.

[jmpurser]

That's one of the problems with taking single payer off the table. Now there are NO SHORT TERM SAVINGS to be had from health care reform so we have to immediately start looking for SOMETHING to cut because if we really cover those 50 million people out there with no coverage things are going to get real expensive real fast.

Meanwhile Single Payer, you know, the proven method to fix our health care crisis we're not even going to talk about, would save $350 Billion a year UP FRONT to pay for covering the 50 million.

When you can't make the tough calls things go down hill fast. Someone in the presidents "team of rivals" needs to speak up for common sense.

[WorkingClass]

It didn't take long to take single payer off the table and out of the room. Once that was done meaningful reform was rendered impossible. People get angry watching their loved ones die. The fight isn't over yet.

[huh234]

a much appreciated persepctive - good show.

[Swards]

Agreed - the system currently pays only when your sick. There is really little incentive to lower costs to make more money. A national system would have more reason to provide preventative care, and keep you healthy. The system as it is, is broken.

[GreatNews27]

If we don't know who causes the waste and who profits from it(the people to 'blame' for the problem), however will we fix it? The 'system' is made up of people and procedures. People design the procedures. If we cannot afix blame, we cannot find the cause and we cannot cure the disease. Besides, look who opposed health care reform, those are the people we should blame. Are any doctors(besides the entire AMA), that oppose a public plan or single payer. I suspect there are.

[huh234]

I oppose star management reform - should I be blamed for solar flares?

Just because people have an interest in something not being broken worse doesn't mean they are part of the problem.

[RightsGuy]

THE LATEST FIGURES:

The Total Package: Health plan CEO compensation for 2008
May 14, 2009

Despite the trials and tribulations of the past year, the health insurance executives are still raking in MILLIONS of dollars at the end of the day. This is a look at some of the top total compensation packages from 2008 based on information gathered from the U.S. Security and Exchange Commission.

1. Ron Williams, Aetna - $24.3 million

2. H. Edward Hanway, CIGNA - $12.2 million

3. Angela Braly, WellPoint - $9.8 million

4. Dale Wolf, Coventry Health Care - $9 million

5. Michael Neidorff, Centene - $8.8 million

6. James Carlson, AMERIGROUP - $5.3 million

7. Michael McCallister, Humana - $4.8 million

8. Jay Gellert, Health Net - $4.4 million

9. Richard Barasch, Universal American - $3.5 million

10. Stephen Hemsley, UnitedHealth Group - $3.2 million

– adapted from a Special Report by Dan Bowman
http://www.fiercehealthcare.com/special-reports/total-package-health-plan-ceo-compensations-2008

Only a single-payer approach to healthcare reform will END THE INHUMANITY OF OUR FAILED HEALTHCARE INSURANCE SYSTEM, WHERE PROFITS ARE MORE IMPORTANT THAN PATIENTS’ HEALTH, and where people die because of it.

We need to get the insurance companies OUT of healthcare. Our fight for equal access to healthcare for all is about democracy, human rights, civil rights, and basic human decency.