Health Care

August 09, 2009
  • Politics

I find myself pretty fascinated by the state of health care in the United States. It has become (or it has been made) the issue of the moment, and rightfully so in my opinion. Our country is an outlier in terms of heath care in seemingly paradoxical ways. Compared to the rest of the world, we spend by far the most money on heath care but certainly don't have the healthiest people. We are the only industrialized country without a form of universal health care (I'm not saying that one would want this, but it certainly makes us odd compared to the rest of the world). Health care prices are going up at an alarming rate and are threatening to make our defect soar and strangle businesses throughout the country. What can we do about it? Should we do anything about it?

I found the following article fascinating. I just recommend reading it, but in case you're skeptical or lazy, I'll pull out my favorite quotes:

Article -Come on, the general surgeon finally said. We all know these arguments are bullshit. There is overutilization here, pure and simple. Doctors, he said, were racking up charges with extra tests, services, and procedures.__

The surgeon came to McAllen in the mid-nineties, and since then, he said, the way to practice medicine has changed completely. Before, it was about how to do a good job. Now it is about How much will you benefit?

- Most Americans would be delighted to have the quality of care found in places like Rochester, Minnesota, or Seattle, Washington, or Durham, North Carolinaall of which have world-class hospitals and costs that fall below the national average. If we brought the cost curve in the expensive places down to their level, Medicares problems (indeed, almost all the federal governments budget problems for the next fifty years) would be solved.

_ - I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country. A couple of years ago, I spent several days there as a visiting surgeon. Among the things that stand out from that visit was how much time the doctors spent with patients. There was no churnno shuttling patients in and out of rooms while the doctor bounces from one to the other. I accompanied a colleague while he saw patients. Most of the patients, like those in my clinic, required about twenty minutes. But one patient had colon cancer and a number of other complex issues, including heart disease. The physician spent an hour with her, sorting things out. He phoned a cardiologist with a question.__ _

Ill be there, the cardiologist said.

Fifteen minutes later, he was. They mulled over everything together. The cardiologist adjusted a medication, and said that no further testing was needed. He cleared the patient for surgery, and the operating room gave her a slot the next day.

The whole interaction was astonishing to me. Just having the cardiologist pop down to see the patient with the surgeon would be unimaginable at my hospital. The time required wouldnt pay. The time required just to organize the system wouldnt pay.

The core tenet of the Mayo Clinic is The needs of the patient come firstnot the convenience of the doctors, not their revenues. _ _

-I asked Cortese how the Mayo Clinic made this possible.

Its not easy, he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors goal in patient care couldnt be increasing their income. Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible. No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs.

- Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of cordination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the countrys best electrician on the job (he trained at Harvard, somebody tells you) isnt going to solve this problem. Nor will changing the person who writes him the check. - Activists and policymakers spend an inordinate amount of time arguing about whether the solution to high medical costs is to have government or private insurance companies write the checks. Heres how this whole debate goes. Advocates of a public option say government financing would save the most money by having leaner administrative costs and forcing doctors and hospitals to take lower payments than they get from private insurance. Opponents say doctors would skimp, quit, or game the system, and make us wait in line for our care; they maintain that private insurers are better at policing doctors. No, the skeptics say: all insurance companies do is reject applicants who need health care and stall on paying their bills. Then we have the economists who say that the people who should pay the doctors are the ones who use them. Have consumers pay with their own dollars, make sure that they have some skin in the game, and then theyll get the care they deserve. These arguments miss the main issue. When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes.

The debate over health care has quickly turned ugly and has become incredibly polarized. You are either a socialist who wants the government to be a single payer who covers all medical needs, or you're an anarcho-capitalist who wants to kill Medicaid and Medicare. I think Obama's biggest mistake is not shifting the tone and direction of the medical debate. As a president who still retains a high approval rating, he should be focusing discussion on how to eliminate waste, over consumption, and bad medical practice from the system. The money in the stimulus package to modernize medical records was a good start. But I think the key, as the article suggest, is to separate the care that a doctor gives from the money that he receives. Rather, it should not be the means on which a salary is determined, but rather the outcome as a whole. Doctors shouldn't receive money based on the tests that they do, but on the overall quality of care that they provide.

On top of this, we need to dramatically increase the time they are able to spend with individual patients and the extent to which they can consult with other doctors and treat as a group (after all, we all know that Dr. House would be nothing without his trusty team). This issue is linked to the issue of how doctors are paid. It's clearly more lucrative for a doctor to see 100 patients a day and spend 5 minutes with them than to see 20 patients and spend between 20 minutes and an hour, depending on the patient. Spending more time with patients will automatically turn the focus of medicine on prevention instead of reaction. Getting a PET scan isn't preventative, but talking to your doctor and having him explain in a detailed and customized way how to stay healthy is.

The point is, I think pretty much everybody whose at least partially sane can agree on most of these issues. And they are the key to heath care reform, and they aren't necessarily linked to either universal health care, eliminating completely the government's role in heath care, or anything in between. And this is the part of the debate that I'm not hearing. So, I propose that we all get together and go to a town hall meeting as an angry mob. And, instead of holding up signs that portray Obama as Hitler (which, by the way, makes so little sense it pains me physically), we hold up signs outlining the model of the Mayo Clinic and demanding that other hospitals and local clinics follow suit. I guess it's not quite as flashy, but it has the added benefit of actually being productive.