A Model for Professional Action
Patients have a critical role to play in cutting costs in the health care system. Anxiety about outcomes or lack of trust in their providers or the system of care may lead patients into demanding postures that drive up the cost of their care without adding to the quality of outcomes. It also may give the physician an increased concern about being sued, which will lead to even more tests and procedures to defend against accusations that something was omitted from care. While there may be instances where the patient’s demand for a test or procedure leads to an improved outcome, that event is far outnumbered by a disastrous increase in costs and risks.
Take a patient in the office with a simple cold and cough. The lungs are clear, there is no fever and the patient is in no respiratory distress. When told that the condition is a cold, the patient questions the diagnosis. “I really can't afford to be sick right now. Can't you give me something to make this go away faster?” The patient wants an antibiotic and there is little reason for the doctor to say no, or is there? Though antibiotics don't help in the common cold, I have had patients leave my practice after I refused to prescribe an unnecessary antibiotic. Why fight it? This issue has become so important because of the development of dangerous resistant organisms that threaten everyone. It wasn't because of the cost of antibiotics, but the risk that drove doctors to get together to reduce abuse. What did they do?
Get Smart: Know When Antibiotics Work is a health education campaign of the National Center for Infectious Diseases of the Centers for Disease Control and Prevention. Over 200 health care professionals attended their last meeting in 2004 dedicated to promoting appropriate antibiotic use. The AMA, the American College of Physicians and the American Academy of Pediatrics are all part of the process. They had a variety of ideas presented at the conference aimed at decreasing inappropriate antibiotic use in people and animals. (The indiscriminate use of antibiotics in cattle and birds contributes to resistance of bacteria in humans. Recent experience with anti viral medications and the bird flu have demonstrated just how quickly resistance can develop. In 2005, the CDC declared that Amantadine and rimantadine, formerly effective treatments for Influenza A, were no longer effective in the majority of cases. They traced resistance directly back to the use of anti viral drugs by Asian chicken farmers trying to protect their birds from the “bird” flu.)
The CDC has provided physicians with guidelines for appropriate antibiotic use and a media campaign highlighting the dangers of inappropriate antibiotics has been directed to the public. I’ve seen newscasters on the evening news and morning TV shows giving the message. They’ve even developed a medical school curriculum about appropriate antibiotic use that is available to any school that wants to use it. It is an all out campaign.
Why is this so important? Inappropriate antibiotic use may contribute slightly to the overall cost of medical care, but not that much. Physicians and physician groups are intimately involved in the program because it has clinical relevance, addresses concerns about the quality of medical care and has been deemed to be important in the scientific media. Any cost savings here are purely coincidental, at best an example of how improving quality can reduce costs.
The campaign to reduce unnecessary antibiotic use, however, should be a model for a campaign to reduce any and all unnecessary expenses in the medical field. It is directly analogous to any future campaign to reduce health care expenses.
In either situation, physicians desperately need a reason to spend extra time and effort doing the right thing to achieve a common objective which is not solely determined by the need to treat the patient and which does not contribute to financial gain. Inappropriate antibiotic use has a small effect on each patient, but a large effect on the community as a whole. Excess spending on health care is the same. For each patient it may be a small expense. The aggregate is harmful to everyone and to society as a whole.
In order to succeed, organized medicine and all its various organizations had to make this focus on appropriate antibiotic use a legitimate area for discussion, research and practice. They had to make it clear to physicians and patients just why it was necessary to change behavior. They had to make it clear to the individual patients that they are not being denied their right to antibiotics, they are being given proper medical care according to the best scientific guidelines. They had to make the community aware that the failure to provide antibiotics to a patient with a suspected viral illness is not malpractice or breach of duty.
It will take just such an effort to change behavior concerning costs. As it stands today, physicians have no incentive to try to reduce costs. There is no institutional or organizational support for such efforts and some patients continue to expect and demand access to every treatment out there that might help. Failure to treat is a much more heinous crime than over treating, and a physician today is more likely to be sued for failure to diagnose and treat a real condition than for trying to diagnose or treat a condition that isn’t there.
This, then, is a call to action. There should be debates at scientific conventions about the value and ethics of considering cost as a factor in the care of patients. Payers should demand that these discussions take place among physicians. Government institutions such as the NIH should study the issue and convene expert panels to review the situation. The full power of organized medicine should develop a strategy to contain costs while providing quality medical care. This is the only strategy for medicine that will prevent a meltdown of the system and risky government decisions that may mean the end of the most creative and beneficial medical establishment on the planet. We need to get to work and we need to get to work now!
Wednesday, September 23, 2009
Tuesday, February 3, 2009
Health Care Solutions - Dear Mr. Obama
Dear Mr. Obama,
As a physician and a leader in the health care community, it has been bothering me that with all the talk of changing the health care system under your new administration, I have not formulated my own approach to the problem. I have not entered the debate in any coherent way, yet, I know that I have strong opinions. What are they?
I decided to try to write my ideas down to stimulate my own thinking a bit. Thanks for being the recipient of my thoughts. I’d appreciate your reaction.
To begin with, I believe that a government run single payer system would be a disaster. It would be cumbersome, would squelch innovation and demoralize patients and providers alike. We would all end up working for the government. Salaries would be controlled and incentives would be artificial and narrow. Worse, if the recent PQRI (physician's quality reporting incentive) program is any example, incentives will be poorly designed and frustrating.
If not a government single payer, what then? Like the AMA and ACP, I would put forth a series of principles for a good program:
First, availability and payment of health insurance should be separated from employment. Having a job should not be a prerequisite to having health insurance, period. Make the employers pay a tax, like the unemployment insurance tax that we already pay, but get individuals their own insurance. And coverage should be portable between and among states.
To make the process simpler, insurance buying groups should be available to everyone. Let Wal-Mart, Sears or General Motors offer to help you buy your health insurance. They can negotiate with insurers for a large group of people, get the best rates and insure proper administration and accountability.
Second, everyone should have coverage. By providing basic insurance to twenty-somethings who now slide by for free, we will lower the cost for everyone.
Third, there should be no preexisting condition exclusions or waiting periods. Everyone should be able to buy basic insurance regardless of age, illness or history.
Fourth, allow insurers to offer a basic policy that does not cover every possible disaster that might befall a person. Basic insurance for preventive care, doctor’s visits, tests and hospitalization without all the bells and whistles (often called ”mandates”) would make basic insurance much more affordable.
To offset the limitations of basic insurance policies, create a “safety net”; a reinsurance system run by the government, for those who exceed the benefits allowed and need more coverage. Make it needs-based and make it available to everyone.
The number and type of policies should be limited to prevent confusion and buyer paralysis. Patients need simple choices with simple differences to make the program work. We can’t have a thousand different types of policies. Limit the number of policies but open the market for administration of those policies.
Fifth, the government should invest in and promote evidence based research and only provide robust coverage for treatments shown to be beneficial and cost effective. Physicians should participate in this effort and support it.
Physicians should get together to encourage cost effective use of existing and emerging technology. While entrepreneurship is an American value to be encouraged, government and insurance should not be forced to pay for innovations that have not yet been proven. (The lawyers need to be reigned in! Forcing them to sue the government will discourage them a bit.) It may slow innovation down, but it will allow more people to keep basic care affordable. Those basic insurance policies won’t include high risk or high cost or experimental treatments. Coverage will have to come from the safety net programs, and they will be monitored and carefully reviewed.
Physicians should adopt cost effectiveness as a standard of practice. Our attitudes towards reducing medical costs should be similar to our attitude towards avoiding the unnecessary use of antibiotics. A program similar to “Get Smart: Know When Antibiotics Work,” a health education campaign of the National Center for Infectious Diseases of the Centers for Disease Control and Prevention should be initiated for medical costs. Everyone should know that unnecessary testing and treatments do have negative consequences both for the individual being tested and treated and for society as a whole. Only physicians can have the power to change the conversation. We need to do it for the good of our patients and the good of the country.
Sixth, a “blame free” injury compensation system, combined with a transparent program to investigate allegations of physician incompetence and malfeasance should be instituted. There is no reason why physicians should have to pay for the bad outcomes that often accompany even good quality care.
When a patient sustains an injury in the medical system, whether through accident, incompetence, neglect or anything short of malicious harm, there should be a system of compensation, like the Workers Compensation system, available to them.
The investigation of physician incompetence should include a national registry, open hearings and due process. To protect physicians from malicious accusations, the names of accusers should be available to defendants. An impartial and professional panel should review claims before accusations are made public.
Seventh, electronic systems of care need to be developed and promoted and made affordable to physicians and all providers of care. While we could allow a thousand flowers to bloom, it would be better if a few well known and hardy programs could be promoted, at cost, to physicians everywhere and supported (tech support will be easier if there are fewer programs). (As a Mac user, I regret that the Mac might lose under such a system. It is a price I am prepared to pay.)
We need more information about quality of care by individual providers and institutions. Quality reporting would be enhanced and promoted by the interconnection of electronic systems (i.e. RHIOs). Data about quality processes and outcomes could be collected by provider, group or at any level in the system and made available to buyers and users of our services. It is time for us to stop hiding what we do and to start being accountable and public. (patient data, of course, needs to be protected.)
I think that’s it:
1. Health insurance should be separated from employment.
a. coverage should be portable between and among states.
b. insurance buying groups should be available to everyone
2. Everyone should have coverage.
3. Eliminate preexisting condition exclusions.
4. Allow insurers to offer a basic policy.
a. create a “safety net”
5. Government should invest in and promote evidence based research
a. Physicians should adopt cost effectiveness as a standard of practice.
6. Create a “blame free” injury compensation system.
7. Promote electronic systems of care.
a. we need more information about quality of care
Jef Sneider, MD
Syracuse, NY
As a physician and a leader in the health care community, it has been bothering me that with all the talk of changing the health care system under your new administration, I have not formulated my own approach to the problem. I have not entered the debate in any coherent way, yet, I know that I have strong opinions. What are they?
I decided to try to write my ideas down to stimulate my own thinking a bit. Thanks for being the recipient of my thoughts. I’d appreciate your reaction.
To begin with, I believe that a government run single payer system would be a disaster. It would be cumbersome, would squelch innovation and demoralize patients and providers alike. We would all end up working for the government. Salaries would be controlled and incentives would be artificial and narrow. Worse, if the recent PQRI (physician's quality reporting incentive) program is any example, incentives will be poorly designed and frustrating.
If not a government single payer, what then? Like the AMA and ACP, I would put forth a series of principles for a good program:
First, availability and payment of health insurance should be separated from employment. Having a job should not be a prerequisite to having health insurance, period. Make the employers pay a tax, like the unemployment insurance tax that we already pay, but get individuals their own insurance. And coverage should be portable between and among states.
To make the process simpler, insurance buying groups should be available to everyone. Let Wal-Mart, Sears or General Motors offer to help you buy your health insurance. They can negotiate with insurers for a large group of people, get the best rates and insure proper administration and accountability.
Second, everyone should have coverage. By providing basic insurance to twenty-somethings who now slide by for free, we will lower the cost for everyone.
Third, there should be no preexisting condition exclusions or waiting periods. Everyone should be able to buy basic insurance regardless of age, illness or history.
Fourth, allow insurers to offer a basic policy that does not cover every possible disaster that might befall a person. Basic insurance for preventive care, doctor’s visits, tests and hospitalization without all the bells and whistles (often called ”mandates”) would make basic insurance much more affordable.
To offset the limitations of basic insurance policies, create a “safety net”; a reinsurance system run by the government, for those who exceed the benefits allowed and need more coverage. Make it needs-based and make it available to everyone.
The number and type of policies should be limited to prevent confusion and buyer paralysis. Patients need simple choices with simple differences to make the program work. We can’t have a thousand different types of policies. Limit the number of policies but open the market for administration of those policies.
Fifth, the government should invest in and promote evidence based research and only provide robust coverage for treatments shown to be beneficial and cost effective. Physicians should participate in this effort and support it.
Physicians should get together to encourage cost effective use of existing and emerging technology. While entrepreneurship is an American value to be encouraged, government and insurance should not be forced to pay for innovations that have not yet been proven. (The lawyers need to be reigned in! Forcing them to sue the government will discourage them a bit.) It may slow innovation down, but it will allow more people to keep basic care affordable. Those basic insurance policies won’t include high risk or high cost or experimental treatments. Coverage will have to come from the safety net programs, and they will be monitored and carefully reviewed.
Physicians should adopt cost effectiveness as a standard of practice. Our attitudes towards reducing medical costs should be similar to our attitude towards avoiding the unnecessary use of antibiotics. A program similar to “Get Smart: Know When Antibiotics Work,” a health education campaign of the National Center for Infectious Diseases of the Centers for Disease Control and Prevention should be initiated for medical costs. Everyone should know that unnecessary testing and treatments do have negative consequences both for the individual being tested and treated and for society as a whole. Only physicians can have the power to change the conversation. We need to do it for the good of our patients and the good of the country.
Sixth, a “blame free” injury compensation system, combined with a transparent program to investigate allegations of physician incompetence and malfeasance should be instituted. There is no reason why physicians should have to pay for the bad outcomes that often accompany even good quality care.
When a patient sustains an injury in the medical system, whether through accident, incompetence, neglect or anything short of malicious harm, there should be a system of compensation, like the Workers Compensation system, available to them.
The investigation of physician incompetence should include a national registry, open hearings and due process. To protect physicians from malicious accusations, the names of accusers should be available to defendants. An impartial and professional panel should review claims before accusations are made public.
Seventh, electronic systems of care need to be developed and promoted and made affordable to physicians and all providers of care. While we could allow a thousand flowers to bloom, it would be better if a few well known and hardy programs could be promoted, at cost, to physicians everywhere and supported (tech support will be easier if there are fewer programs). (As a Mac user, I regret that the Mac might lose under such a system. It is a price I am prepared to pay.)
We need more information about quality of care by individual providers and institutions. Quality reporting would be enhanced and promoted by the interconnection of electronic systems (i.e. RHIOs). Data about quality processes and outcomes could be collected by provider, group or at any level in the system and made available to buyers and users of our services. It is time for us to stop hiding what we do and to start being accountable and public. (patient data, of course, needs to be protected.)
I think that’s it:
1. Health insurance should be separated from employment.
a. coverage should be portable between and among states.
b. insurance buying groups should be available to everyone
2. Everyone should have coverage.
3. Eliminate preexisting condition exclusions.
4. Allow insurers to offer a basic policy.
a. create a “safety net”
5. Government should invest in and promote evidence based research
a. Physicians should adopt cost effectiveness as a standard of practice.
6. Create a “blame free” injury compensation system.
7. Promote electronic systems of care.
a. we need more information about quality of care
Jef Sneider, MD
Syracuse, NY
Saturday, February 2, 2008
Why Managed Care Doesn't Work
It is 2 a.m. and you are frantically searching for the number to call your doctor. Your child is ill, with a fever and a rash, and you have been up for hours. The answering machine at you doctor’s office indicates that the number may be used during the hours of 9 to 5 Monday through Friday, and that in case of emergency, you should call another number. You jot it down, and can hear the telephone switches as the call is relayed to yet another number. A pleasant voice comes on the line to tell you that all the operators are busy, but that they will get to your call in the order that it was taken, please don’t hang up. You hang on, impatient with the nice voice on hold telling you how to tell whether you need a flu shot, when an operator answers. She wants to know your name, phone number, your insurance plan and contract. Before you can tell her that your child is sick, she informs you that your contract is being managed by an organization called NCU (Night Call Unlimited) and that you must call an 800 number. You call, of course, and another voice asks you to touchtone the numbers corresponding to your contract number, then wait for the next available operator. As you wait, your child falls asleep, and you decide to hang up quietly, go back to bed and hope for the best.
This scenario may sound like a nightmare, but from a managed care company’s perspective it may be the best outcome of a system designed to lower the cost of health care. After all, your child seemed to improve, using a method known as the “waiting list cure”, and almost no health care resources were utilized.
This scenario exemplifies the type of managed care that has given HMOs a bad name, undermined the success of HMOs and forced employers to look for a new savior to provide high quality health care insurance to their employees at a controlled cost. Too many employees complained about the shortcomings of managed care; they complained about restricted panels, restricted referrals to specialists, drug formularies, and most damaging, about the managers who seemed more concerned with saving money than taking care of their health problems.
If we are to understand the need for a totally new approach to controlling health care costs, we should probably understand some of these more important solutions to the problem that have been tried previously. Managed Care was a promising new approach to improving quality and care in the health care system in the 1970s. Let’s analyze how it works, and the reasons that HMOs will not be the answer to the problem of cost and quality control.
When I started to work in managed care in the late 1970s, it was HMOs that held the promise of high quality care at reduced costs. The expansion of HMOs was made possible by federal funding and legislation that, among other things, protected health plans organized as HMOs from lawsuits based on outcomes of administrative decisions. Thus funded and protected and offering more for your money, HMOs flourished and spread in many markets around the country.
There were several models of organization that allowed HMOs to operate under US and state laws. These included staff model HMOs like Group Health Cooperative of Puget Sound, group model HMOs like Kaiser Permanente and Independent Practice Associations (IPAs) and network Models like most of the plans that still exist today in most markets around the country.
In order to control quality and cost, HMOs limited their panels of physicians to doctors who would sign contracts, accept limited fees, and abide by the rules of the HMO. In the case of staff model HMOs, the doctors were employed by the HMO and naturally developed loyalty to the plan, created and followed the rules and complied with guidelines, or left. A group practice HMO would act in the same manner if HMO members made up a significant majority of the group’s patients. In an IPA, where the number of HMO members tended to be a small percentage of the doctor’s patients, there was little loyalty or compliance with HMO rules. Often, HMO attempts to use financial incentives to encourage physician compliance with organizational rules and guidelines was either too small to create sufficient incentive or too negative to allow physician buy in. Group and staff model HMOs had a definite advantage in physician cooperation, but they could only grow slowly by adding physician (or NP/PA) staff and “bricks and mortar” to house them. Non HMO physicians complained about not for profit health plans and groups that were supported by government grants and protected by regulations, but HMOs did grow and look successful for a while in the 1980s and early 90s.
A report by the Rand Institute answered a very important question in the 1980s: Do HMOs work? That is, can health care delivered by HMOs be delivered at a reduced cost, per person? The answer: yes, HMOs work. HMOs can reduce the cost of health care for their enrollees. Rand compared patients similar in age and sex and health care statistics who were in HMOs to a similar group in “traditional” care systems. The HMO patients, matched in this way, got their medical care for less. Point made.
The next question to answer was: did the HMO patients get their lower cost care by reducing quality? Quality has always been hard to measure in health care, and this question was more difficult to answer. Still, the answer came soon, and the answer from RAND and others was that patients covered by HMO insurance had health care outcomes of similar quality to those in the traditional system. Some groups of patients fared better, some fared worse. The more highly educated patients generally got better care, and those with less education and money, less sophistication, if you will, often received less care and had worse outcomes1 . Overall, quality was similar and costs were lower. It was proved. So, if HMOs can reduce health care costs without reducing quality for the majority of patients why aren’t HMOs the answer? What were some of the problems that have lead to the demise of the HMO?
First, the consumer had a basic problem. Satisfaction with the system just wasn’t sufficient. Satisfaction is one measure of quality in any consumer driven system. Patient satisfaction with care covered by HMO insurance fell short of non-HMO care too often. When physicians participated in HMOs, their decisions were second guessed by demanding patients who questioned the physician’s motivation for advocating low cost conservative treatments or failing to advocate for more advanced treatments. When administrators became involved in making decisions to deny care, people became outraged! These patients wanted every opportunity to access every possible type of care without extra cost. They felt entitled to it, no matter what their HMO contract stated. (One local HMO cynically advertised against another HMO by having actor/HMO executives laughing around a table about how “patients don’t read their contracts!” Therefore the HMO could put any restriction into the contract allowed by law and get away with it.)
Entitled patients were supported by eager lawyers who saw the large financial reserves of the HMOs as low hanging fruit ready to be harvested. Who could deny a new treatment to a woman dying of breast cancer? What jury would support the greedy HMO executive against the poor ill woman? The answer? None. Women were given access to high dose chemotherapy with bone marrow transplantation as a treatment for breast cancer after lawyers successfully convinced judges and juries that HMO executives were making arbitrary decisions about care just to save money! (As if that was a greater sin than making the decision for any other reason.) When it turned out that bone marrow transplantation didn’t prolong life for breast cancer patients, the problem all but disappeared, the patients died anyway and the lawyers kept their money, but the damage had been done. As we’ll see, restricting access to expensive and questionable care is one of the key elements in the function of an HMO. Once the lawyers had HMO executives on the run, there was no place to hide. Courts had upheld the paranoia of patients afraid that decisions were being made to save money, not to give quality care, and the HMOs were all painted by that broad brush stroke of condemnation.
This was the beginning of the end of the HMO industry as a thriving and growing industry capable of saving the American health care system. Further nails were hammered into the coffin by malpractice lawyers and, ironically, employers and the quality movement.
This scenario may sound like a nightmare, but from a managed care company’s perspective it may be the best outcome of a system designed to lower the cost of health care. After all, your child seemed to improve, using a method known as the “waiting list cure”, and almost no health care resources were utilized.
This scenario exemplifies the type of managed care that has given HMOs a bad name, undermined the success of HMOs and forced employers to look for a new savior to provide high quality health care insurance to their employees at a controlled cost. Too many employees complained about the shortcomings of managed care; they complained about restricted panels, restricted referrals to specialists, drug formularies, and most damaging, about the managers who seemed more concerned with saving money than taking care of their health problems.
If we are to understand the need for a totally new approach to controlling health care costs, we should probably understand some of these more important solutions to the problem that have been tried previously. Managed Care was a promising new approach to improving quality and care in the health care system in the 1970s. Let’s analyze how it works, and the reasons that HMOs will not be the answer to the problem of cost and quality control.
When I started to work in managed care in the late 1970s, it was HMOs that held the promise of high quality care at reduced costs. The expansion of HMOs was made possible by federal funding and legislation that, among other things, protected health plans organized as HMOs from lawsuits based on outcomes of administrative decisions. Thus funded and protected and offering more for your money, HMOs flourished and spread in many markets around the country.
There were several models of organization that allowed HMOs to operate under US and state laws. These included staff model HMOs like Group Health Cooperative of Puget Sound, group model HMOs like Kaiser Permanente and Independent Practice Associations (IPAs) and network Models like most of the plans that still exist today in most markets around the country.
In order to control quality and cost, HMOs limited their panels of physicians to doctors who would sign contracts, accept limited fees, and abide by the rules of the HMO. In the case of staff model HMOs, the doctors were employed by the HMO and naturally developed loyalty to the plan, created and followed the rules and complied with guidelines, or left. A group practice HMO would act in the same manner if HMO members made up a significant majority of the group’s patients. In an IPA, where the number of HMO members tended to be a small percentage of the doctor’s patients, there was little loyalty or compliance with HMO rules. Often, HMO attempts to use financial incentives to encourage physician compliance with organizational rules and guidelines was either too small to create sufficient incentive or too negative to allow physician buy in. Group and staff model HMOs had a definite advantage in physician cooperation, but they could only grow slowly by adding physician (or NP/PA) staff and “bricks and mortar” to house them. Non HMO physicians complained about not for profit health plans and groups that were supported by government grants and protected by regulations, but HMOs did grow and look successful for a while in the 1980s and early 90s.
A report by the Rand Institute answered a very important question in the 1980s: Do HMOs work? That is, can health care delivered by HMOs be delivered at a reduced cost, per person? The answer: yes, HMOs work. HMOs can reduce the cost of health care for their enrollees. Rand compared patients similar in age and sex and health care statistics who were in HMOs to a similar group in “traditional” care systems. The HMO patients, matched in this way, got their medical care for less. Point made.
The next question to answer was: did the HMO patients get their lower cost care by reducing quality? Quality has always been hard to measure in health care, and this question was more difficult to answer. Still, the answer came soon, and the answer from RAND and others was that patients covered by HMO insurance had health care outcomes of similar quality to those in the traditional system. Some groups of patients fared better, some fared worse. The more highly educated patients generally got better care, and those with less education and money, less sophistication, if you will, often received less care and had worse outcomes1 . Overall, quality was similar and costs were lower. It was proved. So, if HMOs can reduce health care costs without reducing quality for the majority of patients why aren’t HMOs the answer? What were some of the problems that have lead to the demise of the HMO?
First, the consumer had a basic problem. Satisfaction with the system just wasn’t sufficient. Satisfaction is one measure of quality in any consumer driven system. Patient satisfaction with care covered by HMO insurance fell short of non-HMO care too often. When physicians participated in HMOs, their decisions were second guessed by demanding patients who questioned the physician’s motivation for advocating low cost conservative treatments or failing to advocate for more advanced treatments. When administrators became involved in making decisions to deny care, people became outraged! These patients wanted every opportunity to access every possible type of care without extra cost. They felt entitled to it, no matter what their HMO contract stated. (One local HMO cynically advertised against another HMO by having actor/HMO executives laughing around a table about how “patients don’t read their contracts!” Therefore the HMO could put any restriction into the contract allowed by law and get away with it.)
Entitled patients were supported by eager lawyers who saw the large financial reserves of the HMOs as low hanging fruit ready to be harvested. Who could deny a new treatment to a woman dying of breast cancer? What jury would support the greedy HMO executive against the poor ill woman? The answer? None. Women were given access to high dose chemotherapy with bone marrow transplantation as a treatment for breast cancer after lawyers successfully convinced judges and juries that HMO executives were making arbitrary decisions about care just to save money! (As if that was a greater sin than making the decision for any other reason.) When it turned out that bone marrow transplantation didn’t prolong life for breast cancer patients, the problem all but disappeared, the patients died anyway and the lawyers kept their money, but the damage had been done. As we’ll see, restricting access to expensive and questionable care is one of the key elements in the function of an HMO. Once the lawyers had HMO executives on the run, there was no place to hide. Courts had upheld the paranoia of patients afraid that decisions were being made to save money, not to give quality care, and the HMOs were all painted by that broad brush stroke of condemnation.
This was the beginning of the end of the HMO industry as a thriving and growing industry capable of saving the American health care system. Further nails were hammered into the coffin by malpractice lawyers and, ironically, employers and the quality movement.
Thursday, January 24, 2008
The Physician and Cost
Don’t you just long for the good old days, the days when providers were called doctors, and their clients were patients; the days when Human Resources was still called Personnel and the days when a company could offer Blue Cross and Blue Shield and employees would be happy to have insurance and no one would ever think about the quality or cost of the health care they were getting? Were things really so bad then? The employees got their coverage when they were sick, and the management went down to the Greenbriar Clinic every year for their Executive Physicals, including barium enemas and Cardiac stress tests, and everyone was happy. Mothers stayed in the hospital three days after the baby was delivered, the doctor decided which shots to give the kids and when, the employer expected you to be out of work for six weeks after the baby was born, and the father would be expected to keep working. If you had cancer they would tell your family but not you about it while you were dying so as not to worry you. Tonsils were all out, and a week long stay in the hospital for high blood pressure or to diagnose an ulcer was routine. Most doctors were actually paid by their patients, and the patients had to contend with insurance reimbursement. Those were the good old days!
The great thing about the good old days is that we seemed to have had unlimited resources, and the bad thing was that the nice picture leaves out lots of people. For those with jobs and insurance or money, things were fine, and even for those without insurance, it seems that the doctor would accept a chicken in return for a house call, and free care was often provided.
Increasing technological advances during and after WWII contributed to the huge success of medicine as a force combatting many of the historical ills of individuals and society. In very rapid succession infectious diseases were “conquered “ one after another, surgery advanced, and amazing pharmaceuticals made life more bearable than ever. Medicine as an industry has been on an amazing and rapid growth curve for both cost and quality for the last 60 years and we haven’t looked back.
It was probably the increasing universal availability of coverage through insurance (1920s), and the creation of Medicare and Medicaid (1960s) that contributed most to the growth in doctors’ incomes and the growth in the cost and availability of new procedures. The cost went up without control because no one seemed to care what anything cost if it was for our health.
By many accounts, American medicine is the greatest medical establishment in the world. American medicine has been innovative and successful in developing the methods and tools to fight disease. Diseases have been conquered and life span expanded for millions. Our doctors have won Nobel prizes for advances in every field, and our scientific institutions lead the world in medical research in many fields.
Others would not agree with that analysis, or would temper it with a bit of reality: they might claim that the practice of medicine in America has failed the American people in many ways. It has failed to bring the promise of good health and longer life to millions of Americans. The poor and the uninsured lack access to the system that provides benefits to so many others. By many measures of quality, the United States is not the healthiest country on Earth. Our children die too often and too young, our life expectancy lags behind other developed countries, and we fail to immunize all of our children against preventable diseases.
Behind these arguments is an economic reality, accepted by everyone. The United States spends, by far, the most money per capita on health care for its citizens of any developed country. If we spend so much, one would expect us to have the best outcomes in the world, but we don’t. Therefore, the critics claim, the system has failed; it is inefficient and wasteful. They call for an overhaul of the system to reduce cost and improve quality. A “single payer” system is often suggested, such as that which exists in many countries, most notably, neighboring Canada, and so the argument goes on.
Today each individual patient wants the best care available regardless of costs (as long as they don’t have to pay) and physicians want to do everything possible (as long as they get paid) and our collective governments and employers (who pay the bills) want those things, too, but they also want to see some sort of responsible control over the costs of the system. Neither patients nor physicians are directly accountable for the cost of care - they don’t pay the bills. There is a disconnect between those who pay for the service and those who receive it which sets up a system without feedback that stimulates a continuing upward spiral of costs. The American medical system has made great accomplishments and holds the promise of even greater achievements in the future, but the incredible costs of care will eventually force government intervention which will threaten everything in it which doctors and patients hold dear.
To avert this catastrophe, for that is what it would be for everyone who is a part of the private health care system and our patients, physicians must find a way to factor cost control into everyday activities. After what looked like a good start in the 1980’s. HMOs failed to deliver on the promise to deliver quality health care at a lower cost. In the 1990s, the Clinton’s were thwarted by the insurance industry, and others, from introducing market forces into the system. A more managed care environment since then has given us hassled physicians, high malpractice premiums and double digit inflation in the cost of medical insurance.
In 2006, General Motors announced that it would be laying off 30,000 workers, primarily because of the burden of their health care and pension costs. Ford was doing the same. While market forces and management decisions may have contributed to their recent setbacks, there is no doubt that the cost of health care for employees and retirees is a major and ever increasing source of expense for Americas largest corporations. In addition, in state after state, budgets strain under the load of Medicaid costs that are out of control. My own property taxes have been going up regularly, and 50% of my county budget is devoted to paying the costs of a Medicaid program that can’t even pay a physician the cost of providing care to a patient. (Our local Blue Cross Blue Shield plan had to close medical clinics that it managed because it couldn’t afford to deliver care with the reimbursements that it was getting, even from itself). It is a crime that a billion dollar company like our local BC/BS couldn’t spend a few thousand dollars per year to keep a needed clinic open. Obviously it is better business to sell health insurance than to deliver health care. Even the federal budget, with its trillions of dollars, cannot continue to support a war on terror, respond to unexpected natural disasters and still assure medical care to every American.
Physicians have contributed significantly to this situation. While physicians services accounts for only a small proportion of the total cost of care, the decisions made by physicians affect almost every cost in the system for every patient. As long as physicians ignore the cost of care, and patients expect someone else to pay for it, costs of the system will be destined to spiral upward.
Physicians have been single-mindedly focused upon giving the best possible care to each patient, without regard to cost. This is not necessarily a bad thing, however, it has come to be considered almost unethical to even consider the cost of care in medical decision making. ‘Rationing’ is a dirty word in medical and political discourse, as is ‘cost control’. Medical Societies and the AMA have rushed to form committees and organizations dedicated to improving the quality of health care by every measure imaginable, yet there is no credible medical organization dedicated to cost control. Quality gurus tell us that improving quality will reduce cost, or at least make us more efficient, yet there has been limited success in demonstrating this outcome.
As doctors, the argument goes, we can’t advocate for cost control because it contradicts our oath. It is a part of our ethical duty to provide care according to the patient’s need and without regard to the patient’s ability to pay. That concept gets taken to an extreme when even the county, the state or the country we live in can’t afford the care that we provide!
Doctors are just plain afraid to talk about ways to reduce the cost of care. It is as though even talking about it will threaten the quality of patient care and the professionalism of medical practice. Yet every other industry thrives on discussions of cost.
Would the automobile industry be producing cars that give such incredible value without concerns about cost? Every engineer working on every aspect of every car has to think about the cost of every feature. The result is a product that has the best features at the best price. Competition between producers guarantees that everyone benefits by giving the most market share to the company that provides the best combination of cost and quality.
Would computers be twice as powerful and twice as fast every year at half the cost if no one cared about costs? My desktop computer today, an Apple G5, has lightning speed, enormous storage capacity, a crystal clear screen and great functionality for less than the cost of my first Apple computer in 1986.
Buyers care deeply about the price of their cars and their computers. For those with money, a particular purchase may be a sign of affluence. For the vast majority, a car is one of the two most expensive items they will ever buy, and they shop carefully. Price is important, and so are features. Fit and finish, customer satisfaction and performance are important. People who otherwise don’t deal with technology in other parts of their lives learn to talk about fuel efficiency and horsepower, acceleration and torque. Safety information is analyzed and published frequently. Can anyone imagine a health care system in which patients shopped with equal enthusiasm?
Health quality improvement experts have talked for years about making quality information available to the consumer. The trend has just started with the availability of information about big items like heart surgery survival and mortality statistics in some markets. New York is a leader in this trend and my local hospital benefits because of its excellent record.
Yet, medicine has NO discussion of cost. Patients don’t care about costs if insurance is paying the bill. Doctors don’t care about cost because insurance is paying the bill. Insurers have traditionally just passed along the cost of care to employers and the government. Even employers until very recently saw health insurance as a payment in lieu of salary, and unions negotiated it that way, so even employers didn’t care about costs until very recently.
The result is an inefficient system that is costly to begin with and growing out of control. Implementing what should have been an obvious and logical concern about the cost of health care now becomes a radical revolution which is threatening to everyone, especially patients who fear limits on the availability of care and physicians who fear that quality will suffer and their incomes will fall.
The failure to care about costs has infiltrated every aspect of health care - even the cost of equipment. Replacing the EKG machine that I bought to start my practice 14 years ago will cost me more than it did in 1993. It won’t have any more features than before, and it’s just a computer and a printer combined. Why is it so expensive? Electronic medical records systems are prohibitively costly, and in spite of all the money in the system, no one seems to be able to pay for it. The perception that there is a surplus of money in the system and the lack of accountability for costs - we’ll just pass them through to the payers - has taken the pressure off manufacturers of medical equipment. They charge more just because they can!
I am dedicated to the premise that it is possible for cost control to be a part of our health care system without adversely affecting quality of care, and that physicians can and must take an active role for it to succeed.
There are those who will immediately criticize this effort. I alluded to them earlier. Physicians who feel that any discussion of cost is out of bounds, unethical, fraught with danger or just plain bad for every one. Without even reading what I have written, they will call me communist or traitor or idiot or just plain “bad doctor”. I understand their concern.
However, I have been practicing medicine for almost 30 years. I spent 14 years working in and managing an HMO, trying to provide the best care to a group of enrolled patients while making money for a corporation that provided their insurance. Our physicians did a good job, but the inherent conflict of cost control and quality, and the need to keep the best doctors while being economical in salaries and service ultimately caught up with us. I left before the demise of the company to start my own private practice, to see if the principles of management and medical care delivery that I had learned would be useful in the context of a private practice. My business plan made the following promise to my patients:
Medical care is expensive. I will work with patients and payors to insure that they get the very best value for money spent on care which is provided or arranged by me or my staff.
For 14 years I have tried to live up to that promise and still give patients the best quality care that I could. For my practice, I defined quality very simply:
Everyone deserves quality medical care, but what is quality? Quality in this practice means that I give personal service to each individual and family with the same care and attention that I would give to a member of my own family.
Reviews of my practice by insurers and outside review organizations regularly show that medication costs are low, my patients experience fewer emergency room visits for chronic disease, and the overall cost of care is below average. United Health Care recently awarded my practice two stars for quality and efficiency. I have never been cited for giving poor quality care, and I have not been sued for malpractice since the first time in 1979, just a year after I started practice, while working in an HMO group practice. I have maintained my license with the state of New York and have achieved fellowship in the American College of Physicians. I could go on, but my credentials are available for anyone to review any time. (my web page is www.drsneider.yourmd.com)
My personal practice has shown that good quality medical care can be combined with a concern for cost without adversely affecting patient care.
A testimonial such as mine is not any real evidence, but there are other examples of cost management and quality medicine out there. The Group Health Cooperative of Puget Sound and Kaiser Permanente continue to be successful models for excellent quality care at a manageable cost, but they are struggling to succeed inside a system that fights them every step of the way. Some will immediately point to complaints about care from these organizations or financial problems they may be having. We must remember that these organizations exist in a society that has different standards. They are pounded daily by patient expectations and community standards that don’t include cost in the equation. Their very existence and continued success is a testimony to the commitment and innovation of their staff and leadership.
Even if California and northwest Washington State are able to sustain profitable HMOs like Kaiser and Group Health, the rest of the country is not. The inherent conflict between the physicians oath to help each individual patient and the economic imperative to control costs makes patients and employers uneasy. Demands for less restrictive policies and broader panels of physicians have made managed care plans or HMOs start to look like old fashioned indemnity plans - which no one can afford any longer. The adoption of some classic HMO management techniques by traditional insurers has further blurred the line between HMO and indemnity insurance. HMOs are trying to attract patients by offering the flexibility of an indemnity plan, and indemnity plans are trying to compete financially by adopting HMO management techniques. Both sides are failing to control the cost of health care as premiums go up by double digits every year in many communities.
How can physicians contribute to the control of health care costs, avoid a conflict of interest and still deliver quality care? There is a way out of this dilemma, and it involves a reordering of priorities to include cost control in all equations of care. Managing the cost of care should not be the primary goal for physicians, but it should be on the list of physician responsibilities. This is a change that is necessary. We must move discussions about cost from the list of taboos onto the list of considerations in every case.
This is a critical undertaking. We want to continue to advance the scientific basis of medical care and make it available to everyone, and in order to do this we must control the cost. But cost control cannot be the primary goal. Just as I believe that physicians must not participate in assisted suicide, because saving lives, not ending them is our goal, physicians should not be primarily engaged in cost savings activities that ultimately deny needed care to individuals.
In trying to understand this problem and propose some solutions, I hope to examine how medicine works as a business, the factors that contribute to the increase in medical costs, and the conflict between cost and quality that physicians face every day. Then we can try to understand HMO management techniques - just how do they attempt to control costs and do they even care about quality? Once we understand the driving forces behind the cost of care, physician’s conflict and the HMO/managed care approach, let’s look at specific examples cost and quality control in practice. We can review various models of health care delivery systems and their success at providing quality care and controlling cost. I want to look at specific problems that face us as we age or become ill, specifically intensive care, experimental programs and end of life care. How do Americans look at the value of life and longevity, the promise of medicine and the realities of end of life care? Finally, is there a model that can help us achieve high quality health care at a controlled cost? What would it look like, and is there any evidence of success; is there any hope for doctors or patients? We’ll see.
The great thing about the good old days is that we seemed to have had unlimited resources, and the bad thing was that the nice picture leaves out lots of people. For those with jobs and insurance or money, things were fine, and even for those without insurance, it seems that the doctor would accept a chicken in return for a house call, and free care was often provided.
Increasing technological advances during and after WWII contributed to the huge success of medicine as a force combatting many of the historical ills of individuals and society. In very rapid succession infectious diseases were “conquered “ one after another, surgery advanced, and amazing pharmaceuticals made life more bearable than ever. Medicine as an industry has been on an amazing and rapid growth curve for both cost and quality for the last 60 years and we haven’t looked back.
It was probably the increasing universal availability of coverage through insurance (1920s), and the creation of Medicare and Medicaid (1960s) that contributed most to the growth in doctors’ incomes and the growth in the cost and availability of new procedures. The cost went up without control because no one seemed to care what anything cost if it was for our health.
By many accounts, American medicine is the greatest medical establishment in the world. American medicine has been innovative and successful in developing the methods and tools to fight disease. Diseases have been conquered and life span expanded for millions. Our doctors have won Nobel prizes for advances in every field, and our scientific institutions lead the world in medical research in many fields.
Others would not agree with that analysis, or would temper it with a bit of reality: they might claim that the practice of medicine in America has failed the American people in many ways. It has failed to bring the promise of good health and longer life to millions of Americans. The poor and the uninsured lack access to the system that provides benefits to so many others. By many measures of quality, the United States is not the healthiest country on Earth. Our children die too often and too young, our life expectancy lags behind other developed countries, and we fail to immunize all of our children against preventable diseases.
Behind these arguments is an economic reality, accepted by everyone. The United States spends, by far, the most money per capita on health care for its citizens of any developed country. If we spend so much, one would expect us to have the best outcomes in the world, but we don’t. Therefore, the critics claim, the system has failed; it is inefficient and wasteful. They call for an overhaul of the system to reduce cost and improve quality. A “single payer” system is often suggested, such as that which exists in many countries, most notably, neighboring Canada, and so the argument goes on.
Today each individual patient wants the best care available regardless of costs (as long as they don’t have to pay) and physicians want to do everything possible (as long as they get paid) and our collective governments and employers (who pay the bills) want those things, too, but they also want to see some sort of responsible control over the costs of the system. Neither patients nor physicians are directly accountable for the cost of care - they don’t pay the bills. There is a disconnect between those who pay for the service and those who receive it which sets up a system without feedback that stimulates a continuing upward spiral of costs. The American medical system has made great accomplishments and holds the promise of even greater achievements in the future, but the incredible costs of care will eventually force government intervention which will threaten everything in it which doctors and patients hold dear.
To avert this catastrophe, for that is what it would be for everyone who is a part of the private health care system and our patients, physicians must find a way to factor cost control into everyday activities. After what looked like a good start in the 1980’s. HMOs failed to deliver on the promise to deliver quality health care at a lower cost. In the 1990s, the Clinton’s were thwarted by the insurance industry, and others, from introducing market forces into the system. A more managed care environment since then has given us hassled physicians, high malpractice premiums and double digit inflation in the cost of medical insurance.
In 2006, General Motors announced that it would be laying off 30,000 workers, primarily because of the burden of their health care and pension costs. Ford was doing the same. While market forces and management decisions may have contributed to their recent setbacks, there is no doubt that the cost of health care for employees and retirees is a major and ever increasing source of expense for Americas largest corporations. In addition, in state after state, budgets strain under the load of Medicaid costs that are out of control. My own property taxes have been going up regularly, and 50% of my county budget is devoted to paying the costs of a Medicaid program that can’t even pay a physician the cost of providing care to a patient. (Our local Blue Cross Blue Shield plan had to close medical clinics that it managed because it couldn’t afford to deliver care with the reimbursements that it was getting, even from itself). It is a crime that a billion dollar company like our local BC/BS couldn’t spend a few thousand dollars per year to keep a needed clinic open. Obviously it is better business to sell health insurance than to deliver health care. Even the federal budget, with its trillions of dollars, cannot continue to support a war on terror, respond to unexpected natural disasters and still assure medical care to every American.
Physicians have contributed significantly to this situation. While physicians services accounts for only a small proportion of the total cost of care, the decisions made by physicians affect almost every cost in the system for every patient. As long as physicians ignore the cost of care, and patients expect someone else to pay for it, costs of the system will be destined to spiral upward.
Physicians have been single-mindedly focused upon giving the best possible care to each patient, without regard to cost. This is not necessarily a bad thing, however, it has come to be considered almost unethical to even consider the cost of care in medical decision making. ‘Rationing’ is a dirty word in medical and political discourse, as is ‘cost control’. Medical Societies and the AMA have rushed to form committees and organizations dedicated to improving the quality of health care by every measure imaginable, yet there is no credible medical organization dedicated to cost control. Quality gurus tell us that improving quality will reduce cost, or at least make us more efficient, yet there has been limited success in demonstrating this outcome.
As doctors, the argument goes, we can’t advocate for cost control because it contradicts our oath. It is a part of our ethical duty to provide care according to the patient’s need and without regard to the patient’s ability to pay. That concept gets taken to an extreme when even the county, the state or the country we live in can’t afford the care that we provide!
Doctors are just plain afraid to talk about ways to reduce the cost of care. It is as though even talking about it will threaten the quality of patient care and the professionalism of medical practice. Yet every other industry thrives on discussions of cost.
Would the automobile industry be producing cars that give such incredible value without concerns about cost? Every engineer working on every aspect of every car has to think about the cost of every feature. The result is a product that has the best features at the best price. Competition between producers guarantees that everyone benefits by giving the most market share to the company that provides the best combination of cost and quality.
Would computers be twice as powerful and twice as fast every year at half the cost if no one cared about costs? My desktop computer today, an Apple G5, has lightning speed, enormous storage capacity, a crystal clear screen and great functionality for less than the cost of my first Apple computer in 1986.
Buyers care deeply about the price of their cars and their computers. For those with money, a particular purchase may be a sign of affluence. For the vast majority, a car is one of the two most expensive items they will ever buy, and they shop carefully. Price is important, and so are features. Fit and finish, customer satisfaction and performance are important. People who otherwise don’t deal with technology in other parts of their lives learn to talk about fuel efficiency and horsepower, acceleration and torque. Safety information is analyzed and published frequently. Can anyone imagine a health care system in which patients shopped with equal enthusiasm?
Health quality improvement experts have talked for years about making quality information available to the consumer. The trend has just started with the availability of information about big items like heart surgery survival and mortality statistics in some markets. New York is a leader in this trend and my local hospital benefits because of its excellent record.
Yet, medicine has NO discussion of cost. Patients don’t care about costs if insurance is paying the bill. Doctors don’t care about cost because insurance is paying the bill. Insurers have traditionally just passed along the cost of care to employers and the government. Even employers until very recently saw health insurance as a payment in lieu of salary, and unions negotiated it that way, so even employers didn’t care about costs until very recently.
The result is an inefficient system that is costly to begin with and growing out of control. Implementing what should have been an obvious and logical concern about the cost of health care now becomes a radical revolution which is threatening to everyone, especially patients who fear limits on the availability of care and physicians who fear that quality will suffer and their incomes will fall.
The failure to care about costs has infiltrated every aspect of health care - even the cost of equipment. Replacing the EKG machine that I bought to start my practice 14 years ago will cost me more than it did in 1993. It won’t have any more features than before, and it’s just a computer and a printer combined. Why is it so expensive? Electronic medical records systems are prohibitively costly, and in spite of all the money in the system, no one seems to be able to pay for it. The perception that there is a surplus of money in the system and the lack of accountability for costs - we’ll just pass them through to the payers - has taken the pressure off manufacturers of medical equipment. They charge more just because they can!
I am dedicated to the premise that it is possible for cost control to be a part of our health care system without adversely affecting quality of care, and that physicians can and must take an active role for it to succeed.
There are those who will immediately criticize this effort. I alluded to them earlier. Physicians who feel that any discussion of cost is out of bounds, unethical, fraught with danger or just plain bad for every one. Without even reading what I have written, they will call me communist or traitor or idiot or just plain “bad doctor”. I understand their concern.
However, I have been practicing medicine for almost 30 years. I spent 14 years working in and managing an HMO, trying to provide the best care to a group of enrolled patients while making money for a corporation that provided their insurance. Our physicians did a good job, but the inherent conflict of cost control and quality, and the need to keep the best doctors while being economical in salaries and service ultimately caught up with us. I left before the demise of the company to start my own private practice, to see if the principles of management and medical care delivery that I had learned would be useful in the context of a private practice. My business plan made the following promise to my patients:
Medical care is expensive. I will work with patients and payors to insure that they get the very best value for money spent on care which is provided or arranged by me or my staff.
For 14 years I have tried to live up to that promise and still give patients the best quality care that I could. For my practice, I defined quality very simply:
Everyone deserves quality medical care, but what is quality? Quality in this practice means that I give personal service to each individual and family with the same care and attention that I would give to a member of my own family.
Reviews of my practice by insurers and outside review organizations regularly show that medication costs are low, my patients experience fewer emergency room visits for chronic disease, and the overall cost of care is below average. United Health Care recently awarded my practice two stars for quality and efficiency. I have never been cited for giving poor quality care, and I have not been sued for malpractice since the first time in 1979, just a year after I started practice, while working in an HMO group practice. I have maintained my license with the state of New York and have achieved fellowship in the American College of Physicians. I could go on, but my credentials are available for anyone to review any time. (my web page is www.drsneider.yourmd.com)
My personal practice has shown that good quality medical care can be combined with a concern for cost without adversely affecting patient care.
A testimonial such as mine is not any real evidence, but there are other examples of cost management and quality medicine out there. The Group Health Cooperative of Puget Sound and Kaiser Permanente continue to be successful models for excellent quality care at a manageable cost, but they are struggling to succeed inside a system that fights them every step of the way. Some will immediately point to complaints about care from these organizations or financial problems they may be having. We must remember that these organizations exist in a society that has different standards. They are pounded daily by patient expectations and community standards that don’t include cost in the equation. Their very existence and continued success is a testimony to the commitment and innovation of their staff and leadership.
Even if California and northwest Washington State are able to sustain profitable HMOs like Kaiser and Group Health, the rest of the country is not. The inherent conflict between the physicians oath to help each individual patient and the economic imperative to control costs makes patients and employers uneasy. Demands for less restrictive policies and broader panels of physicians have made managed care plans or HMOs start to look like old fashioned indemnity plans - which no one can afford any longer. The adoption of some classic HMO management techniques by traditional insurers has further blurred the line between HMO and indemnity insurance. HMOs are trying to attract patients by offering the flexibility of an indemnity plan, and indemnity plans are trying to compete financially by adopting HMO management techniques. Both sides are failing to control the cost of health care as premiums go up by double digits every year in many communities.
How can physicians contribute to the control of health care costs, avoid a conflict of interest and still deliver quality care? There is a way out of this dilemma, and it involves a reordering of priorities to include cost control in all equations of care. Managing the cost of care should not be the primary goal for physicians, but it should be on the list of physician responsibilities. This is a change that is necessary. We must move discussions about cost from the list of taboos onto the list of considerations in every case.
This is a critical undertaking. We want to continue to advance the scientific basis of medical care and make it available to everyone, and in order to do this we must control the cost. But cost control cannot be the primary goal. Just as I believe that physicians must not participate in assisted suicide, because saving lives, not ending them is our goal, physicians should not be primarily engaged in cost savings activities that ultimately deny needed care to individuals.
In trying to understand this problem and propose some solutions, I hope to examine how medicine works as a business, the factors that contribute to the increase in medical costs, and the conflict between cost and quality that physicians face every day. Then we can try to understand HMO management techniques - just how do they attempt to control costs and do they even care about quality? Once we understand the driving forces behind the cost of care, physician’s conflict and the HMO/managed care approach, let’s look at specific examples cost and quality control in practice. We can review various models of health care delivery systems and their success at providing quality care and controlling cost. I want to look at specific problems that face us as we age or become ill, specifically intensive care, experimental programs and end of life care. How do Americans look at the value of life and longevity, the promise of medicine and the realities of end of life care? Finally, is there a model that can help us achieve high quality health care at a controlled cost? What would it look like, and is there any evidence of success; is there any hope for doctors or patients? We’ll see.
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