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
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