Health Care Reform: It’s Not Just About What Happens in Congress

Posted on June 22, 2009

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Two insightful articles on the topic of health care reform appeared over the weekend. Both are worth a read.

The Myth of Prevention,” by physician and novelist Abraham Verghese, was in the Wall Street Journal. The article discusses a number of issues: the idea of preventive medicine, the effect that Medicare’s reimbursement scheme has had on the practice of medicine, and several other topics. Discussing Medicare, Verghese writes:

A skewed reimbursement scheme set up by Medicare, a system that pays generously when you do something to a patient, but is stingy when you do something for a patient, is largely to blame. Cut, poke, sew, burn, insert, inject, dilate, stent, remove and you get very well paid; if you learn how to do this efficiently, maybe set up your own outpatient center so you can do it to more people in a shorter time (which is what happened when this payment system was put in place in 1989) and you are paid even more. If, however, you are a primary care physician, and if, just like the young doctor who saw my parents yesterday, you spend time getting to know your patients, and are willing to play quarterback when your patient enters the hospital, so that you can herd the consultants and guide the family through a bewildering experience that gets surreal if you are in the intensive care unit, then you may have great personal satisfaction but you will make five to tenfold less than your colleagues in the doing-to disciplines.

On the topic of prevention he writes:

Prevention of a disease, we all assume, should save us money, right? An ounce of prevention . . . ? Alas, If only such aphorisms were true we’d hand out apples each day and our problems would be over.

It is true that if the prevention strategies we are talking about are behavioral things—eat better, lose weight, exercise more, smoke less, wear a seat belt—then they cost very little and they do save money by keeping people healthy.

But if your preventive strategy is medical, if it involves us, if it consists of screening, finding medical conditions early, shaking the bushes for high cholesterols, or abnormal EKGs, markers for prostate cancer such as PSA, then more often than not you don’t save anything and you might generate more medical costs. Prevention is a good thing to do, but why equate it with saving money when it won’t? Think about this: discovering high cholesterol in a person who is feeling well, is really just discovering a risk factor and not a disease; it predicts that you have a greater chance of having a heart attack than someone with a normal cholesterol. Now you can reduce the probability of a heart attack by swallowing a statin, and it will make good sense for you personally, especially if you have other risk factors (male sex, smoking etc).. But if you are treating a population, keep in mind that you may have to treat several hundred people to prevent one heart attack. Using a statin costs about $150,000 for every year of life it saves in men, and even more in women (since their heart-attack risk is lower)—I don’t see the savings there.

The second article, published in the Washington Post, is “Primary-Care Doctor Shortage May Undermine Reform Efforts” by Ashley Halsey III. Halsey looks at the current (and growing) shortage of primary-care and family physicians. The increasing scarcity of primary-care doctors is one potential roadblock to real health care reform.

Convincing medical students to make a career of family medicine is a challenge. According to the article, the average annual income for family physicians is $173,000. This compares to an average of $335,000 for oncologists, $391,000 for radiologists and $419,000 for cardiologists. Further complicating matters are attitudes toward primary-care medicine among aspiring doctors:

“There’s definitely a huge bias against family medicine and primary care,” said Winston Liaw, who is serving his residency at Fairfax Family Practice.

Djinge Lindsay said most of her classmates at George Washington University’s medical school went into specialties for the “money and prestige.”

“The attitude is that primary care is a fallback if you’re not smart enough or good enough,” said Lindsay, now a resident in primary care at Georgetown University Hospital.

By 2000, 14 percent of U.S. medical school graduates were entering family medicine. Five years later, the figure was 8 percent, and a recent survey of students interested in internal medicine showed that 98 percent wanted to become specialists.

The career path of these doctors has also been shaped by a desire for greater control of their lifestyle.

“It’s an important job to them, but it’s not their whole life,” said Terence J. McCormally, a Fairfax family doctor who graduated from medical school in 1978. “The class of 1978 was all into delayed gratification: ‘We’ll work long hours, and we’ll stay at the hospital to all hours.’ Medical students now aren’t willing to delay gratification.”

Many want jobs that do not carry as much responsibility for on-call or weekend work. Far more doctors, women in particular, prefer jobs that require fewer than 40 hours a week.

One important theme these two articles have in common is the perspective that real health care reform is going to require changes that go beyond whatever legislation eventually comes into being. Patients’ expectations, as well as the way in which physicians practice their art and the expectations that they bring to the table, will also play major roles in determining what health care in the U.S. looks like in the future.