In Defense of Real Health Care Reform

After a nearly 7 months absence, 2 new twin girls, born March 6th, and more sleep deprivation than I have ever thought it possible to survive, I return at long last to reveal to those who wish to listen the callings of my homeopathically inspired muse.

The fever of health care reform has infected the nation, and like so many others, I too am gripped by the controversy that surrounds this topic. While virtually no one views the mishmash of legislation currently being being debated in congress as the be all and end all of health care reform, we all love to argue about what would be better than what has been proposed. There are those who wish for nationalized health care and those who consider that to be anathema and wish to promote greater competitive forces in the medical marketplace, eschewing any kind of increase in government involvement. While most arguments seem to be recognizably couched in a particular political viewpoint, only a few seem to comprehend the realities of the systemic problems that drive up health care costs. I can not resist tossing my hat into the ring too at this heated moment: what kind of a blogger would I be otherwise?

I humbly submit that real reform of the health care reform can occur only by addressing the causes of the problem, not by addressing the symptoms alone. And so, inspired by Michael Pollen's In Defense of Food, I am here to defend real reform, as opposed to the ersatz
band-aid type that politicians are haggling over in the hallowed chambers of the legislature.

Any real reform must address the following problems:

1. There is little or no accountability among doctors or patients for their medical care. Choices are made without regard for cost, and sometimes without regard for effectiveness. Reforms must make doctors accountable for the amount of health care costs they generate, and patients responsible for the amount of health care costs they utilize. Otherwise we will continue to have the race to the bottom that taking no responsibility necessarily creates, and which characterizes our present system.

2. The excessive costs of medical education must be reduced. Doctors must be compelled to enter medical school with the understanding that in exchange for tuition and expense free education, they must commit 4 years of their post-residency lives to working in an underserved area, or with the uninsured or poor. The former prerequisite avoids the financially catastrophic costs of training that drive doctors to try to make more money than they need to live on, because of the high levels of debt they graduate medical school with. It also helps to solve the problem of treating those who lack access to service, which depending on how you tally it, amounts to at least 16% of the population (if you include only the truly uninsured) but may be at least double that if you consider the underinsured. For these four years of service doctors would be rewarded fairly, higher than they were paid as residents, but considerably less than the generally prevalent rates for doctors in the immediate post-residency years. This would save dollars, and help to pay the costs of educating our physicians.

3. Medical schools need to be mandated to graduate more primary care doctors as a percentage of their classes. This may be through direct law or by making taxpayer supported funding contingent on a school graduating a class with a minimum predetermined per cent in primary care residencies, and perhaps certain other undersubscribed specialties. This would hold down costs and help to make available the type of medical care our society needs most. In addition, primary care needs to be more equitably reimbursed compared to specialized care.

4. Malpractice needs to be reformed. Rather than cash awards, suspensions from practice or non-monetary reparations would be preferable. The costs of rewards for pain and suffering simply can't be born. Having doctors exempted from lawsuits during the time of public service would also help, although other forms of oversight of the quality of care would need to be substituted during that service period.

Another way of reducing malpractice costs would be to have doctors identified to the public as "high, medium, or low" intervention doctors, based on the amount of medical costs they generated in their practices. Doctors who generated the highest costs would also have the highest vulnerability to law suits and those who generated the lowest costs would have the lowest vulnerability to law suits. In other words, you can sue less if you choose a doctor who practices more conservatively. Your reward for choosing such a low intervention doctor would be lower insurance premiums. This boils down to making the right to sue something you have to pay for. Your doctor's reward for holding down costs would be lower malpractice rates, and reduced likelihood of being sued.

5. As an alternative to increasing taxes, a network of health care charities should be fostered by various financial incentives, to help those who need an even greater safety net than the system, even as reformed above would provide for. If people don't want to incur more costs through taxes to pay for the care of those who are sicker than themselves, let them voluntarily provide funds through charitable gifts that could be used for those how experience catastrophic illnesses that make their health care costs jump suddenly and dramatically. The difference could be made up in taxes, at the discretion of the individual states. This gives people more local control of their health care budget.

Too much care for too many people and too little of the kind of care that is needed are all parts of the problem. Doctors thrive on the perpetuation of ill health. How about rewarding them for improving health, rather than maintaining disease? As part of my first proposal, I would add that the health care costs generated in a practice (on a per patient basis) from year to year should be monitored, and doctors should be rewarded for reducing their per patient annual costs with higher reimbursement rates. For example, if a doctor has 1000 patients in his practice and generates costs of $1,000,000 total, for all of his patients (including the cost of referrals), and the following year, he reduces that to $990,000, for the same number of patients, his reimbursement rates would increase slightly. If they went up to $1,010,000 the following year (measured in inflation adjusted dollars), his reimbursements would go down for the following year. Naturally, the amount of increased revenue the doctor would be entitled to for reducing costs to his patients would have to be less than the amount saved, in order for the system to save money. However, this system would motivate doctors to think more before ordering tests, making referrals, or ordering expensive drugs. Some would argue that doctors must be free from these kinds of considerations. They must think only of what's best for the patients. I would counter that when you are in the jungle, you must think of what you have with you, not what the high tech options in another environment could do for you. We are now in a kind of jungle, since we see now that what we thought was available is actually a chimera. It will disappear just as Bear Stearns or Lehman brothers almost did, and just as the glaciers are doing, if we ignore the effects of over-consumption.

Some would say that by introducing financial incentives, doctors will reject sick patients, just as insurance companies have been doing for years. But this should not happen, since a patient who consumes a lot of resources can still help the doctor to increase his reimbursement if he cuts that patient's annual costs from say $50,000 to $49,000. Also, while it is true that doctors may find themselves in awkward positions at times, doctors personal interests are at least counterbalanced by a desire to help their patients and avoid vulnerability to lawsuits from delivering inadequate care. Besides, who would you rather have making decisions about what you can receive for treatment, government bureaucrats, insurance companies, or doctors themselves?

If patients were to be rewarded with lower insurance rates, or tax breaks for reducing their utilization of health care resources, this would encourage people to take more responsibility for their health. It would mean that people who choose more expensive options would have to pay for what they get. Isn't paying for what you recieve fair? Some may say that this discriminates against those with congenital or other "no-fault" illnesses. Individuals who reduce their health care consumption annually would receive financial benefits, whether they came down from $100,000/year to $95,000 per year, or from $2000 to $1900. This way people with congenital illness or other "no fault" would not be discriminated against because they need expensive treatments just to survive. And people with low costs would have an incentive to keep their costs low by not smoking, not using drugs, and exercising. It is known that at least 50% of health problems are caused by behavior and as such are modifiable without the need for conventional medical treatment.

Many physicians will look at less care as worse care. The notion is that you get what you pay for. However, studies on regional Medicare spending show that regions that have higher spending have no better health in their populations than regions with higher spending. Also, the notion that more spending results in better health is illogical. The healthier people are, the less their health care costs should be. The sicker they are, the more costs they will incur. This type of convoluted logic is itself a product of a diseased system, one that understands only disease and not health.

How does alternative medicine fall into all of this, you may wonder? Health care reform is very doctor-centric, and ignores the reality that large numbers of our population see practitioners of alternative medicine including chiropracters, naturopaths, acupuncturists, and so on. The numbers of these alternative health care practitioners are considerable. As a practitioner of alternative medicine myself, I am of course sympathetic to those who wish health care reform not to leave out these practitioners, and those who benefit from their work. Many fear that by expanding coverage to these practitioners, the health care costs of the country would just be increased further. I would propose only that these practitioners be judged by the same standards as physicians and other more conventional health care practitioners, nurse practitioners, physician's assistants, physical therapists and so on -- namely that their reimbursement rates be adjusted according to whether their patients show an increase or decrease in their collective health care expenditures for the time during which they were in treatment. This tends to reward those practitioners who are helping their patients be healthier and take away from those who are worsening or at least failing to improve the health of their patients.

In sum, we need to make doctors and patients more responsible for the health care costs they generate, support primary care, reduce built in medical education debts and malpractice costs that drive up the costs of care, add to the workforce that can affordably treat the uninsured and indigent, and let any treatment that helps hold down costs be justly rewarded. These are the kinds of proposals which I believe will move the system and those that it serves in the direction of health.