Thursday, December 31, 2009
Health Care Reform - From a Doctor's Perspective
Health Care Reform - From a Doctor's PerspectiveBy Phillip B Duncan, MD, FACC
I am a cardiologist practicing in the Richmond/Petersburg area. I established my cardiology practice in Richmond, VA in April 1984. My goal since the inception of my practice was to leverage technology with sound practice to produce the best outcomes for my diverse patient population.
As a minority physician and small business owner, I feel that I can offer some useful insights on the need for comprehensive healthcare reform.
Talking Points:
- Reimbursement Reform
- Healthcare Technology
- Administrative Efficiency
- Medical Liability/Tort Reform
- Medical Education Reform
- Patient Responsibility
It is a fact that we will see a change in the way healthcare is delivered in America. The current system is not economically viable, and it does not result in the outcomes that we hope for. The only question is whether we enact effective comprehensive reform proactively or wait until inaction or half measures result in a cataclysmic change in the healthcare we receive in this country.
The fact that our healthcare system is complex necessitates a comprehensive approach to reform. Tinkering with bits and pieces will inevitably lead to changes in other areas in expected and unexpected ways. Whether reform is enacted in one bill or several, anything less than a comprehensive coordinated approach is doomed to result in unacceptable setbacks in reaching our common goal of high quality affordable care for all Americans.
The hallmark of any reimbursement strategy should be leveraging healthcare dollars spent on facilities, providers, device companies, equipment companies, and Pharma, to receive high value care for all Americans. The dollars should be spent by those who spend them the most efficiently, whether that is government or the private sector.
As a provider I feel that fair compensation for time and effort spent on achieving the best outcomes is of utmost importance. Providers need to be compensated fairly for time spent directly and indirectly on behalf of achieving best outcomes for patients.
Reimbursement cannot be based purely on patient outcomes, since this is not based solely on the providers’ performance. Pure outcomes based reimbursement will put the most at risk populations at even higher risk as providers and facilities avoid providing care to avert poor outcomes.
The appropriate use of technology in healthcare goes far beyond the wider adoption of information technology. In our current environment there has been an unproductive conflict between providers and payors on the use of technology. On the one hand providers will sometimes revert to high tech tests to boost there bottom line, or in the practice of defensive medicine.
Payors response is to ratchet down reimbursement, or create artificial impediments to the use of high tech medicine even when it would clearly benefit the patient, and may ultimately reduce the overall cost of care.
In the area of information technology we are asking providers and facilities to make a large upfront investment, without any expectation of recovering that investment. We also have the problem of a disjointed information infrastructure, without adequate bandwidth to move information quickly and efficiently.
Resources spent on redundant and useless tasks only take away from those spent on the best outcomes for patients. The resources of time, personnel and money are best spent when they impact the well-being and safety of the patient.
Tactics that act as impediments to care (in the hopes that they will influence utilization, and therefore drive cost down) are blunt instruments that often only shift the expenditures to another area. Credentialing practices that require duplication of known data, serves no purpose at all. These are just a few examples of administrative inefficiency.
There are few areas of healthcare that evoke such passion. Physicians will say "if it were not for the fear of frivolous lawsuits, I would not order as many unnecessary tests and procedures". Patients will say "how can you possibly limit my compensation if a physician mismanages my care, resulting in bad outcomes". Lawyers will say " lawsuits are the last hope in protecting the public from bad doctors, and negligent facilities".
As in most highly contentious issues there are grains of truth in all these arguments.
As a physician I can say that the awards granted in lawsuits are not our biggest concern, it is the threat of being sued. While caps on damages help to hold down malpractice premiums in many States, they do nothing to change physicians behavior.
If pending suits were filtered through a board that would throw out suits with little merit, this would reduce the number of frivolous suits (those that occur when patients have less then optimal outcomes despite acceptable practice). Damage caps should be set based on the degree of negligence, the extent to which that negligence contributed to the poor outcome, and the severity of the outcome. This would limit the resources spent on unnecessary lawsuits, but insure that true negligence was dealt with appropriately.
True and effective malpractice reform is an important part of the formula that will allow us to work on changing physician, patient, and legal behavior in a fashion that will lower healthcare cost and improve outcomes.
America enjoys having a number of talented well trained physicians, with access to the world's best medical technology. Based on a number of factors the demand is outstripping the supply, and the technology is not uniformly available. This leads to de facto rationing and a situation where at risk populations suffer disproportionately from the burden of disease.
Many geographies and demographics go unserved or underserved. The public's expectation of medical care continues to rise. Medical education costs continue to rise. There is a growing shortage of those willing to train future medical professionals.
We must reform our methods of identifying those who should aspire for careers in healthcare. Our methods of paying for those who pursue those careers need to be reformed. Most importantly our training of those individuals has to adapt to the changing healthcare needs of a present and future America.
This is actually a misnomer. We are all potential patients, but our responsibility begins before we are labeled such. It is really personal responsibility. Every individual plays a role in their health outcomes. It includes lifestyle choices, compliance and personal involvement in our care.
It will be impossible to hold the healthcare system fully responsible for outcomes without controlling for level of personal responsibility. There are a number of ways to influence personal behavior (ex. tobacco tax, seatbelt laws), but at the end of the day personal choices will most significantly influence the health of the American people.
Summary:
The ideas presented are interrelated and interdependent. It is my hope that these ideas will constructively add to the voices that bring about effective and comprehensive healthcare for all Americans. I would appreciate the opportunity to discuss more specific ideas regarding the issues outlined above. I know that time is short. I am also well aware that we stand on the threshold of making tremendous strides to improve health and healthcare for all Americans.
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