A Penny Saved

Amidst all of the furious negotiation going on on Capitol Hill, it is all too easy to forget that realistic health reform can (and must) occur without government intervention. As I mentioned to my colleague Dr. McGonigle, the other day, we could probably trim 25% off the health care budget if we could improve our non-technical, mundane medical diagnostic skills a notch or two. Instead of relying on a thorough history and patient and thoughtful physical examination, doctors and patients are too quick to rush to the MRI, the blood test, or the specialist referral. I doubt most physicians (I include myself) have anything more than the roughest idea how much these expensive evaluations tally in the end, but I suspect it would be thousands of dollars every day for the average primary care physician.

There are few incentives for the average doc to do so, however. It takes more time, more energy, more thinking, and results in fewer patients being seen per day to be more thorough, so as a result there is less revenue. In short, the system is rigged to perpetuate high remuneration for all corners of the medical suite -- the techies and the PCP's. The radiologists and pathologists love this system, since it creates a virtual torrent of business. The PCP's, who are already underpaid, feel they can't afford to do otherwise, and after all, it's the standard of care, isn't it? There is a sense of security that evolves that "everything that could be done" has been done. This sense of security is the same as the pleasant balminess of a warm day at the North Pole. To one who cares to think more about it, it means that a global apocalpyse is upon us, while to others it simply means respite from the cold.

These concerns are just a beginning. On a broader level our society breeds unhealth on epidemic levels by economic and social forces that help to celebrate the moral sicknesses of greed and turpitude. We see this in the food industry and the energy industry, most egregiously. Obesity, heart disease, cancer, and other chronic illnesses are becoming more common all the time, and a large proportion of these illnesses can be said to have an environmental component that is perpetuated by industry and the governmental supports that lie behind them. This would include eating too much refined and sugary food, food that creates pollutants that fouls our rivers, oceans, and the air we breathe, and results in downstream environmental illness. We could easily add to this the pharmaceutical industry, which also has added its products to our drinking water because of an inadequate waste disposal system, and the iatrogenic effects of medications. The pollutants that enter our air and water that come from carbon consumption cause a rise in respiratory illness and disturb the ecosystem. Our energy policies affect our political dealings in the middle east, which leads to wars, and death of our citizens pursuing these political-economic energy goals.

In short, it is hard, when talking about health care, to keep the topic on the health care system itself. Poverty, political maneuverings by the giants of industry, including the food industry, agribusiness, the coal and oil industries, the pharmaceutical industry and many other economic powers are linked in a massive juggernaut of illness production that helps to keep medical costs high.

We doctors spend most of our time cleaning up the mess this vast illness production system creates. And we sometimes do so in ways that contribute to it. Why do we spend our time this way instead of working to prevent illness in the first place? Are we ignorant, dumb, or just greedy? Most doctors, I believe want to do good. They want to be well paid, too, but they are willing to work hard for their money, even if working so hard isn't particularly good for their health, the health of their family relationships, or ultimately, even for their patients. I think that it comes down to there being few incentives to do the right thing, and every incentive to keep the system going as is, even as it careens towards disaster. To make a more frugal system, the system must change the rules of the game. It must incentivize salubrious behaviors on the part of the physician. And corporations must be incentivized to produce salubrious products. The system must be purged of the economic and social inequities that amount to a moral sickness. It's a dangerous self-deception to think that moral illness can flourish with no effect on physical or mental illness.

How can we incentivize doing the right thing? I can't say my vision is that broad. But I do know that it begins with acknowledging that we have incentivized the wrong thing.