Which Side Are Docs On?

Politicians and physicians share a professional perspective that the painless optimal solution is often out of reach and that they'll have to settle for an imperfect answer than will impose some discomfort.

This quest for the least painful option defines the ongoing dance between doctors and the White House. The Obama administration basically argues that change is inevitable and the only question for physicians is whether they'll help drive or risk becoming road kill.

But doctors are harder to cow than insurance companies, who have no friends, or pharmaceutical firms, who are simultaneously loved for their product and hated for their pricing. Doctors have a lot of friends - the patients who rely on them. As Ceci Connolly points out in the Washington Post they outpoll even a popular president.

On the other hand, they do not speak with a single voice and are very aware that reforms may advantage some physicians - especially those providing primary care - at the expense of others like highly-paid surgeons. That gives doctors reason to try to get on the winning side rather than defending a status quo that seems increasingly untenable.

The quest for evidence-based medicine, embedded in already-enacted economic stimulus legislation, gives reformers a tool to recruit doctors. New research would define optimal care, which often is different - and less expensive - than what doctors are doing today. How to turn these findings into practice is a key question.

Doctors can reject it, attempt to stick to their old habits, resist efforts to impose it on them and rally their patients against rules imposed by faceless bean-counting bureaucrats. That worked when they successfully resisted and rejected managed care a decade ago.

Things have changed since then. The cost problem is seen as more acute. There's a growing realization that there's substantial overconsumption. And opposing protocols set by reputable scientists would be much tougher than pushing back on insurance companies that had meager public support.

Or physicians can get with the program, embrace such research and argue that it will allow them to provide the best possible care that has always been their goal.

The choice isn't easy for many physicians who still have years of practice ahead because they don't know how onerous the standards, which won't exist for at least a decade, will be.

Doctors are being asked to gamble about the future, something they often do in making treatment decisions. The Administration is betting that they'll ultimately conclude that joining the process and trying to influence it, both now and later, is the best of the imperfect options they face.

Right now, it looks like that's a pretty good bet.

Comments

[TheBurdicks]

Mr. Jaffe,
With all due respect for your efforts at having a positive effect, I must disagree with you. We are not going to get what we need.
We all know that we spend twice as much so that we can rank 37th in the world.
Why?
Our system, and everything on the table, is in some way related to insurance. Public or private, inclusive or exclusive, insurance (even single payer) is a non starter.
Insurance deals only in intervention in illness and injury. Illness and injury represent health system failures (low quality). And there is bias for more expensive interventions (expensive low quality) in any insurance bureaucracy, public or private.
As our auto manufacturers have so painfully realized, if you do not redesign your systems to reduce failures (improve quality), you cannot be competitive. This is fundamental quality control / quality improvement in any system.
The only way to reduce failures (improve quality) in health care is through Preventive Medicine. Insurance cannot accommodate Preventive Medicine, which is an inexpensive public health educational activity.
We must have universal national health care, focused on prevention, and free of any form of insurance. We must design the quality in before we ship the product.
If we fail, like the auto manufacturers we too will be bankrupt, awash in a sea of health care losses.
Or we can spend less than the rest and be numero uno again.

[Jim Jaffe - Huffpost Blogger]

Dear Dr. Burdick -- thank you for your thoughtful comments, which appear to support the theory that taking one's problems to a barber will probably result in a proposed solution that includes a haircut..

We apparently agree that the major problem here is that too much is being done without improving health. This overconsumption pattern has been documented repeatedly and appears to be growing worse, according to the presentations Peter Orszag did while at the CBO.

You say that insurance companies are responsible. They are an easy scapegoat. No one likes them and everyone loves their doctor. But this doesn't explain the pattern of practice issue. Medicare is an insurance plan, but spends twice as much per patient in Miami than Minneapolis without any resulting difference in health status. Similarly Hopkins spends a whole lot more responding to a given diagnosis than Mayo does, again without any impact on health status. Insurance is involved in all these examples.

You raise an interesting point in comparing the situation with the auto industry. A lot of problems were created when consumers became more sophisticated and used information available on price and quality to migrate away from American cars. American medicine has fought long, hard and largely successfully to keep such basic data from the public.

Preventive medicine sometimes works. But sick people will inevitably run up most of the bills . Until we find a more efficient way of treating them, we're not going to see a lot of progress.

[TheBurdicks]

We already know a more efficient way of treating the sick. It's called Evidence-Based Medicine. It's science. It's free. All doctors know about it (although many ignore it). It will help, but not help enough. We'll still spend too much. I don't think the problem is so much sick people, but rather overweight, poorly fed, underexercized, overstressed people, who inevitably will get sick. Preventive Medicine is the only way to address these issues, and it does work. Always.
Insurance doesn't address any of the critical issues, it just gets in the way of reforming our health care system, reform which will come mostly through Preventive Medicine, but certainly also through reforming medical practice and medical records, reducing administrative overhead, and getting competitive prices on pharmaceuticals.
Insurance has nothing to do with health care reform we can see working successfully in Grand Junction, CO, in the Scott and White system (where the President of the AMA, Jim Rophack, worked), in the VA health system, at Mayo, at Intermountain Health Care in Salt lake City, but certainly not in McAllen, TX.

[JuliaRain]

If this doesn't clear it up for Americans about which doctors are motivated by gre ed, I don't know what will

Ex-Hospital CEO Battles Reform Effort

http://www.washingtonpost.com/wp-dyn/content/article/2009/05/10/AR2009051002243.html?hpid=topnews

The Cost Conundrum
What a Texas town can teach us about health care

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

[TheBurdicks]

Julia,
You're right, most doctors are greedy, as are most insurance company executives, medical businessmen, politicians, patients, and, sadly, Americans. Maybe it's just a part of human nature, or maybe a failure in our individual and collective upbringing, or maybe a sign of the times. I wish I did, but I just don't know.
But the real problem, even in McAllen, TX (where I once worked in an ER for a bit), isn't the people. The people are rarely the problem. Statistics, in the study of Quality, prove that in any system, 95% of the problems, 95% of the failures, are problems and failures in the design of the system. You just can't get to Quality in any system, unless Quality by design is the starting point.
In health care, insurance is the mortal enemy of Quality. Insurance rewards health care system failures, paying doctors, businessmen, and businesses lots of money for each and every failure in the health care system, the bigger the failure, the better. Insurance fails to even acknowledge so much as a single health care success story. To do so would be anathema to the fundamental business of insurance, the rewarding of failure.
Dwight

[JuliaRain]

If this doesn't clear it up for Americans as to which doctors to trust, I don't know what will.

Ex-Hospital CEO Battles Reform Effort

http://www.washingtonpost.com/wp-dyn/content/article/2009/05/10/AR2009051002243.html?hpid=topnews

The Cost Conundrum
What a Texas town can teach us about health care

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

[droftim]

Listen to AMA President James Rohack in this program and I think you'll understand what side he is on. He couldn't speak two sentences without injecting a comment about the importance of insurance companies.

http://www.sciencefriday.com/program/archives/200906191

[oustfan]

I'm curious as to how this does affect the specialized surgeons. Can someone a "rich old white guy" still pay a million dollars to have a heart transplant done by a top surgeon? Or do all surgeons just operate on a first come, first served basis?

[Jim Jaffe - Huffpost Blogger]

I don't think any of the plans would preclude a top surgeon from charging anyone, irrespective of gender or race, a million dollars for an operation. But there could be rules like those for Medicare that require any physician who chooses to participate to treat all eligible patients for the set fee. Those who choose not to participate can operate on anyone not eligible and charge any price that's mutually agreed upon.

[TheBurdicks]

Oh, and I want someone to remind me to enter my posts in the correct sequence.

[Jim Jaffe - Huffpost Blogger]

thanks for all. as the Great Philosopher said, "you can't always get what you want." But in this case it appears the odds are good that we'll get what we need. That should be good enough.

[JuliaRain]

"That should be good enough."

Why not aspire beyond that? Good enough for who?

[TheBurdicks]

Oh, and,
Competetive bidding for health system purchases of pharmaceuticals, supplies, and equipment.
I want pharmaceutical research shifted to the University campus.
I want an end to advertising of pharmaceuticals to either physicians or consumers.
I want lobbyists barred from the health care arena.
And I'm getting a little impatient with the foot dragging of Democrats, Republicans, and President Obama. I want them onboard or on an airplane and headed home.
The time for Change is right now. Tomorrow may be to late.

[JuliaRain]

Dr. Burdicks, very grateful for your posts. Thank you.

[CentristScientist]

Pharmaceutical research can not be done on University campuses. If you have ever worked in research at universities, it would be pretty apparent to you that they do not possess the organization and technology for massive high-throughput undertakings like those used in drug development. Sure, universities provide invaluable research information, but not that kind.

[pros54]

Which university institution are you referencing?

[ShamusDaedal]

I agree totally, doctor!

I’m a retired anesthesiologist. The “free market” concept with “comparison shopping” just doesn’t work in Emergency rooms!! Gunshot victims don’t have the time for that.

But the purchases of drugs, supplies, services of “administrators” and more are quite amenable to “shopping”!

Is a hospital administrator really worth more than three or five times the value of a specialist who trained nearly a decade after medical school? How silly, but that’s what the system lets them get.

Are drug prices that can reach a 1000 % markup over cost not obscene?

Should scissors that can be had at a notions counter for 18 dollars really be worth the 165 bucks if found in a Hospital Supply catalog?

I saw these things first hand as a “hospital based” physician while the admitting doctors who sent in their patients missed it. I was there all the time and saw it clearly.

Remember, all those dollars come from PATIENTS. The “Medical Industrial Complex” is a huge efficient vacuum sucking the life out of the sick and infirm.

Other countries just do not permit it!! Only SINGLE PAYER fixes the problem.

[classicalgeek]

They're not $18 if you use a 40% off coupon.

[Jim Jaffe - Huffpost Blogger]

well, it is clear that we're not going to get single payer anytime soon, tho it is possible that what's done now could lead us in that direction. these things tend to evolve over time, as medicare has. the important thing now is not to let the quest for the perfect -- which some see as single payer -- undermine less comprehensive progress.

[TheBurdicks]

I'm with most Huffington Post commentors, most of my friends, and most of the regular people out there.
I want Single Payer Health Care, with insurance companies sidelined to offer their nonsense to anyone foolish enough to pay.
I want a practice environment with mandated Evidence Based Medicine, with algorithms embedded in Electronic Medical Records, based on the VistA open source platform. Google these.
I want a shift in emphasis from expensive interventions for rich old white men, toward Preventive Medicine for young people, with mandated health education in the media, school, home, workplace, and medical facility.
I want restrictive taxation of tobacco, alcohol, fast food, and other proven health hazards.
I want decriminalization of drugs with a shift to education and rehabilitation.
I want health care for everyone.
I want to be rated #1 in the world for health quality, while spending less than other developed countries.
All possible. Yes We Can.
Dwight Burdick, MD

[JuliaRain]

Bravo!!! I think America can too!

[DannyDanson]

That's what I'm talking about we can do all this but we have to demand it, and point out who is against this and why withou the fearmongering.

I hear a lot of talk on the right about the need for "tort reform" as a means of cutting cost, and one of the reason for not moving towards a single payer system.

I was wondering, and I'm not a Doctor or even close to one, if there may be an way to use "comparative effectiveness research data" and a Doctor's voluntary agreement to consider these findings as a hedge agains't potential lawsuits made against doctors and hospitals, maybe some gov't body comprised of medical professional could put these standards together and monitor and support providers (Who have voluntarily agreed to participate in the program) and in return since the decision made by that doctor considered the scientifically accepted research the governing body would lend some degree of insurance or legal protection agaisnt law suites, this would incentivize participation, and save the industry from substantial loses.

Just an idea.