I believe that there are still many ethical and professional American physicians and many intelligent American patients who are capable of, in an alliance of patients and physicians, doing “the right things”. Their combined clout is being underestimated in the current healthcare reform debate.
Efforts to control American medical costs date from at least 1932. With few exceptions, they have failed. Health care reform, 2009 politics-style, is again in trouble over cost control. It would be such a shame if we once again fail to cover the uninsured because of hang-ups over costs.
Physician decisions drive the majority of expenditures in the US health care system. American health care costs will never be controlled until most physicians are no longer paid fees for specific services. The lure of economic incentives to provide unnecessary or unproven care, or even that known to be ineffective, drives many physicians to make the lucrative choice. Hospitals and especially academic medical centers are also motivated to profit from many expensive procedures. Alternative payment forms used in integrated multispecialty delivery systems such as those at Geisinger, Mayo, and Kaiser Permanente are far more efficient and effective.
Fee-for-service incentives are a key reason why at least 30% of the $2.5 trillion expended annually for American health care is unnecessary. Eliminating that waste could save $750 billion annually with no harm to patient outcomes.
Currently several House and Senate bills include various proposals to lower costs. But they are tepid at best, in danger of being bought out by special interests at worst.
So, what can we in the USA do RIGHT NOW to begin to cut health care costs?
An alliance of informed patients and physicians can widely apply recently learned comparative effectiveness science to big ticket items, saving vast sums while improving quality of care.
- Intensive medical therapy should be substituted for coronary artery bypass grafting (currently around 500,000 procedures annually) for many patients with established coronary artery disease, saving many billions of dollars annually.
- The same for invasive angioplasty and stenting (currently around 1,000,000 procedures per year) saving tens of billions of dollars annually.
- Most non-indicated PSA screening for prostate cancer should be stopped. Radical surgery as the usual treatment for most prostate cancers should cease since it causes more harm than good. Billions saved here.
- Screening mammography in women under 50 who have no clinical indication should be stopped and for those over 50 sharply curtailed, since it now seems to lead to at least as much harm as good. More billions saved.
- CAT scans and MRIs are impressive art forms and can be useful clinically. However, their use is unnecessary much of the time to guide correct therapeutic decisions. Such expensive diagnostic tests should not be paid for on a case by case basis but grouped along with other diagnostic tests, by some capitated or packaged method that is use-neutral. More billions saved.
- We must stop paying huge sums to clinical oncologists and their institutions for administering chemotherapeutic false hope, along with real suffering from adverse effects, to patients with widespread metastatic cancer. More billions saved.
- Death, which comes to us all, should be as dignified and free from pain and suffering as possible. We should stop paying physicians and institutions to prolong dying with false hope, bravado, and intensive therapy which only adds to their profit margin. Such behavior is almost unthinkable and yet is commonplace. More billions saved.
Why might many physicians, their patients and their institutions suddenly now change these established behaviors? Patriotism, recognition of new science, stewardship, and the economic survival of the America we love. No legislation is necessary to effect these huge savings. Physicians, patients, and their institutions need only take a good hard look in the mirror and then follow the medical science that most benefits patients and the public health at lowest cost. Academic medical centers should take the lead, rather than continuing to teach new doctors to “take the money and run”.
Physicians can re-affirm their professionalism and patients their rights, with sound ethical behavior without undue concern for meeting revenue needs. The interests of the patients and the public must again supersede the self interest of the learned professional.
George D. Lundberg MD, is former Editor in Chief of Medscape, eMedicine, and the Journal of the American Medical Association. He’s now President and Chair of the Board of The Lundberg Institute
As a physician who practiced both in Canada and the U.S. I can say that, were ancillary re-imbursement to be removed from physician services, along with improving Tort reform, and increasing physician EM re-imbursement, then a public system would be more sensible for all involved whereby physicians make decisions based on objective facts, not some bureaucrat or not influenced by profit.
lESS WE FORGET, physicians , by improving people’s health and preventing bad medical outcomes, increase
national productivity and hence improve the economy, much less everything else that goes along with good health!
I feel preventative medicine will go a long way in the long term health of our population.
Hi Guys
We can easily fix the healthcare system, all of us working together. Let’s look at the details.
Let’s make people responsible for their care. They pay for services out of a MSA type fund that comes from their taxes. They use the money wisely, live healthy, they get money back at the end of the year, like a refund from the IRS. If they have an unhealthy lifestyle and use the medical system more, they don’t get a refund or have to pay more from their taxes. People will choose healthcare resources wisely and use the medical system wisely. They are in control.
Lets make everyone work who can. This will increase the amount of people paying into the system so taxes can go down.
Lets have tort reform. All the money from lawsuits goes to the patients. The lawyers are paid costs and a small retainer. People filing frivolous suits should be made to pay the costs for both parties in the lawsuit.
We need the typical american values if we are to solve these problems-Honesty, Dynamism, Courage. Let’s solve this problem.
Mahesh Kuthuru, MD
mkuthuru@gmail.com
My wife was diagnosed with high-grade breast cancer in an asymptomatic breast cancer screen via mammography. She was well less than fifty at the time of diagnosis. She successfully underwent chemotherapy, mastectomy with reconstruction. Her care was handled by talented surgeons and her oncologist.
My point: is my wife really such an outlier? Was it “worth it” to go and pay for that ‘asymptomatic’ patient’s mammogram? Do each of the above mentioned seven points have exceptions? There’s the rub. I find outliers and exceptions each week in my practice. Is it worth it? Perhaps not in the global perspective vis-a-vis health care costs, but try explaining that to someone you love.
There’s much talk of tort reform on this thread. However, a quick look at actual numbers shows that the total medical premium paid each year by doctors in the US amounts to $6.5 billion. That’s less than one half of one percent of the total healthcare spend.
We need to understand that the focus on malpractice originates in the legitimate frustration of doctors — but it is fueled by those with political objectives and is absolutely irrelevant to the struggle to control healthcare costs.
Andy – I don’t think the main reason for the focus on tort reform is the insurance premiums. It’s the lingering possibility that, at any time, a physician’s career (and possibly life) could be destroyed as a result of an honest mistake. That is a completely legitimate fear leading to unnecessary testing that dwarfs the figure you mentioned.
Shortly after turning 48, my mom was diagnosed with stage two breast cancer. We had no family history of cancer. My mom was fit, active, and ate a healthy diet. There was no reason to suspect she had cancer. She was diagnosed because of a routine mammogram.
She has been cancer free for six years. If she did not have that routine mammogram, I do not know if she would be here today.
From my personal experience, those mammograms for women under 50 don’t seem so frivolous.
Most people refuse to believe that routine cancer screening — mammography, psa, and even colonoscopy — offers little early detection benefit or improved outcome. Stopping the routine, non-indicated use of these screening exams saves billions.
At the age of 59 I went for my routine screening Mamogram, after 30 years and with no family history, and confident that all would be well. I was diagnosed with two (2) seperate cancers. I had surgery to remove my breast last May, and they found that the cancer had not invaded my lymphnodes, I was one of the lucky ones. Without health insurance, to pay for annual health screenings, I may not have caught this in time.
Thank god for my health care coverage. I wonder every day what I would have done had I not been so blessed!
Two of your recommendations would have likely meant that I would be sitting here complacently, unaware of an aggressive cancer in my breast. Like some of the other recent commenters, I was diagnosed with Stage 1 breast cancer at the age of 60 following a routine mammogram. I had no family history. After the initial biopsy, I had an MRI that showed two more suspicious areas. One was an additional smaller cancer. Because of the location of the lesion revealed by the MRI, the treatment was mastectomy rather than lumpectomy. I also had aggressive chemotherapy, and am now cancer-free (as shown by a recent PET scan).
Initial response by author:
I am gratified by the number and sincerity/quality of the discussion participants and their points. We all together can make a difference, although once an activity becomes economically successful, its continuance seems almost addicting to the players.
The strength of an anecdote is the extent to which the people involved really do believe that their treatment helped them. The weakness is that cannot ever know (without randomized controls) whether their experience was random or cause and effect.
We have known for many decades that many (probably most) prostate cancers do no harm to their hosts, regardless of therapy. We are now learning that many breast “cancers” self-destruct, but we do not yet know how to tell which unsuspected lesions that are discovered by screening mammography will disappear and which have the potential to kill. But we do know that much harm is done to many women by screening mammography and the actions that result therefrom.
George D Lundberg MD
President and Chair, http://www.lundberginstitute.org
Although I agree that mammography is overdone, you are unrealistic in expecting physicians practicing in the real world to follow your advice.
The ACOG recommends mammography as follows:
Age 40 – 49, every other year
Age 50 and up, every year
Let us suppose that an OB/GYN follows your advice and doesn’t order mammography according to ACOG recommendations. Let us further suppose that one of his/her patients develops a Stage II or higher breast CA – that is a virtual certainty given enough time.
I guarantee you two things:
1) The OB/GYN is at significant risk of being sued for malpractice and of losing the suit
2) You won’t be there sitting next to him during trial
Your advice is medico-legal malpractice.
As a practicing hospitalist, I am quite displeased when I read or hear current theories of why healthcare costs so much. As if the problem lies in “misplaced incentives” from hospital readmissions, or unnecessary procedures from physician profit motives. I suppose Obama & Pelosi are reviewing Ted Kennedy’s hospital admissions to find out which doctors & hospitals are merely looking to make a buck.
While I am sure there are some examples of said behaviors, the larger part of the problem is society itself. The same segments clammoring for added benefits/programs/universal healthcare, etc are often the same patients & family members that “want everything done” despite counseling & recommendations otherwise based on the clinical scenario. It’s easier for policy makers to fault the hospital or the doctor than to point the finger at unrealistic & demanding recipients of care, who expect someone else to pick up the tab. I would gladly order fewer tests & provide fewer services when I feel they were unnecessary or inappropriate, if the necessary changes in our system could be implemented. This would take things like tort reform with economic damage caps, “loser pays” rules, medical court reviews for merit of claims, and legal protection for providers to refuse unrealistic demands of patients/family members without fear of legal entanglements & costs. Until these things happen, everyone can just look forward to paying more & more for the healthcare demands of your fellow citizens. Defensive medicine at its unrecognized best. Thank goodness most of government is served by the interests of lawyers.
Thanks for very informative and revealing post.
For the most part, a sensible list, though a bit misty eyed – how many physicians are going to rein in a family’s desire to extend heroic measures to prolong life – especially when its highly profitable? Until and unless you change the fundamental incentives, you won’t change the fundamental trends.
On a more minor note, how exactly is it that if we stop charging for MRIs on a case by case basis, there will be fewer of them overall? You might bring costs down by increasing utilization rates, which means regulating the number of machines available to a given population. But again, that requires fundamental changes, the kind of practical stuff this article ignores.
“It’s the lingering possibility that, at any time, a physician’s career (and possibly life) could be destroyed as a result of an honest mistake.”
Deron, why is this different just for docs? Do you know any doc where this has happened? Here in NC Duke Hosp. put the wrong set of organs in a young girl for a heart/lung transplant. As far as I know all docs are still practising.
“That is a completely legitimate fear leading to unnecessary testing that dwarfs the figure you mentioned.”
Even in states with tort reform, as in Texas, this has not stopped rising medical costs – which shows me it has nothing to do with fear, only money. This article seems to say doc’s fear is no longer, but they now are angry at the medical board that oversees them. I guess docs will only be happy when they are not liable for anything.
http://blogs.wsj.com/health/2008/05/19/doctors-flock-to-texas-after-tort-reform/
I think that everybody is ignoring the 800lb gorilla in the room, and that is tort reform. Almost all PRACTICING physicians agree that what drives up medical costs is defensive medicine, driven by lawyers looking to get rich. As a practicing ER physician, I know that MOST of the tests I order are not designed to find the correct diagnosis, of which about 80 percent is a good history and physical, but rather defensive in nature, to rule out the 1 in 100 or 1 in 1000 chance of the presentations being a atypical presentation of something nasty. I routinely order expensive tests for this reason,a nd the truth is, it is better to spend the patients money on testing than for them to sue you and get to spend your money. Most practicing physician, whether they admit it or not, practice the same way.
It is amazing to hear the rhetoric about testing, and kickbacks as a cost of a and cause of ordering more tests. the truth is, most physicians dont get paid any extra no matter what tests they order or how many they order. I wold love to see some hard numbers on this, but unfortunately, since medicine is an art and a science, they would be impossible to come up with, as most of the time, it is ingrained in our training. This is why articles like the wsj piece underestimate costs, they are reliant on self reporting, and most physicians dont report defensive testing.
Until tort reform, and I mean real tort reform is established, no practitioner will be comfortable pointing at a patient and saying “you dont need this test because…”
Steve
Peter – I work closely with physicians on a daily basis and I can tell you that fear is a significant factor. Are there physicians who base their referrals on money? You bet. But there are fewer of them than you might think because contrary to the soundbites out there, not a lot of physicians own a stake in a testing facility. The ones that do have created this perception that hangs like a dark cloud over all physicians.
Thankfully, I don’t personally know any physicians that have suffered serious career damage, but I have read enough accounts of those that have in my career.
I don’t tout tort reform as the big cost saver that some do, but that doesn’t mean it isn’t necessary. I don’t think either of us knows enough about the situation in Texas to be able to diagnose their cost problems.
FYI: I just summarized the original posts and comments at http://curinghealthcare.blogspot.com/2009/08/quick-way-to-rein-in-medical-costs.html
Steve,
I am an internal medicine resident. I don’t mind good and fair tort reform but honestly I think that the threat of law suit are only partly responsible for unnecessary testing. We all know that we often order extra tests because we are less than confident or competent in our clinical thinking. Sometimes, we simply don’t have or take the time to think before we order. We can go a long way by instituting some educational reforms in our training programs and continue to devise and implement guidelines. Often times we physicians are very reluctant to change our practices even in the face of evidence. As you know, many of us go up in arms whenever someone suggest guidelines, let alone pre-printed forms. Changing physician behavior is a very difficult thing. I agree with good tort reform, but it is too often used as an excuse to take our eyes off the ball…
I understand, Val.
I can’t really blame the clinicians, however. A screwed up healthcare system with misaligned incentives, the belief that we clinicians can and should somehow know more than is human mind can handle (even when the evidence is clear), a strong desire for autonomy/independence (we don’t want to be told what to do), a tendency to rely on our experience coupled with the dearth of evolving personalized evidence-based guidelines, etc.—in addition to fear of lawsuits—I contend, reasons for such reluctance. But in the end, none of that really matters since we don’t have any other good options. So, I would argue that we’d be wise to learn to work together to create a new and improved model of healthcare focused on bringing high value to the consumer based on greatly expanded scientific evidence. And we ought to be active participants in garnering that evidence-based knowledge through widespread collaboration between clinicians of all disciplines and researchers. Yes, change—fear of the unknown—can be scary, inertia can be very tough to break, self-deception can blind us to how bad things really are, and even ego can get in the way of accepting new guidelines.
The combination of a badly broken system and the forces of human nature are responsible for the healthcare crisis. I’ve been studying this for decades and see no good alternative; we must change in meaningful ways or else we’ll be watching our healthcare system (and country) continue to implode!
Medical pools including practitioners of various specialties could help reduce costs considerably. There are many modalities, each practitioner claiming it’s the best.What about saving costs by consolidating “Back specialties”, including orthopedists,”pain management” specialists, physical therapists, personal trainers,acupuncturists,yoga specialists, meditation specialists etc.Transportation to consolidated centers could be managed by special medical vans, as we have in our area. Surely, eliminating so many offices with their expensive equipment would save millions.What about having trained counselors to help navigate the system? Many millions of dollars could be saved if this change is made.
Val,
I trained in Europe (Germany and alsio some time in France) and can tell you that in the US wheer I train/practice for a decade, I have met very many physicians absolutely scared by the threat of litigation.
It is not so much the amount of malpractice awards/settlements (as long as the doc’s property and house isn’t at stake which I believe is a rarity these days), the scary thing with litigation is the burden in terms of emotion (pride) and unpaid labour before and during trial.
Barry Carrol above has given a very nice and IMHO scientifically adequate summary of that strong intuitive truth that is so hard to quantify (as he explains).
Right now, a physician/resident has no incentive NOT to order tests, but many to order them (patients want thorough work up/pics). Residents can get reprimanded for forgetting/delaying something deemed important, but I can not remeber many if any instances where residents are scolded for wasting thousands of dollars (and during case based discussions an exams, considering zebra diagnoses are encouraged even if they are not really an option in the case at hand).
As long as the people in the US do not understand that they get very little true value for their health care bucks (getting close to a fifth of the GDP), US health care is doomed … and that’s the feeling that I get from the current discussions about death panels etc. anyway …
Leaving aside the medicolegal issues noted above, in practice it is likely difficult to “regulate” medical practice by suggesting guidelines given the amount of variability that currently exists in medical practice.
A (perhaps the) major issue that affects nonacademic practice will likely be incentivization-how our time is valued. So what is the problem here? Lets take point number 1. For “intensive medical therapy” to occur, primary providers have to be willing to spend the time to provide advice on lifestyle, diet, exercise, etc. I would hope they already do so-but in reality many do not. So make sure the incentive system focuses on quality, not quantity. If, say, pay was proportional to the % of patients reaching certain LDL goals (“pay for performance”), then primary providers would look a little more closely at achieving goal cholesterols. Something like bundled payments would lead to increased scrutiny of those getting CABG procedures.
By putting in a system with aligning incentives would be essential to achieving your suggested approaches. Getting more medical students to choose primary care wouldn’t hurt, either. But expecting practice to change by simply adding to primary care burdens under the current system we have is probably unrealistic.
My viewpoint is as a primary care provider/endocrinologist.
I am the son of a physician, a former pre-med student, and, as a Vietnam veteran, currently getting my medical care from the VA. Thus, I have a pretty good sense of what the author is trying to say. In my view, much of the health care industry plays shamelessly on people’s fears, and as a result is able to bill for work far beyond anything really useful. Since I have a pretty good background in biology, I find it fairly easy to guard against such fear mongering, and the VA has a similar institutional sense. They do not have any need to churn the account, and they do have real budget constraints, so they focus on good outcomes, and nothing else. Thus, I get what I consider quite good health care, it is absolutely guaranteed, and I don’t have to do any arguing with an insurance company. All I have to do to get all this, aside from being a veteran, is to be sensible about what is worth spending money on.
“Death, which comes to us all, should be as dignified and free from pain and suffering as possible. We should stop paying physicians and institutions to prolong dying with false hope, bravado, and intensive therapy which only adds to their profit margin. Such behavior is almost unthinkable and yet is commonplace. More billions saved.”
So, the answer is, instead of trying to preserve and extend life with a terminal illness, the final prescription should be for a gun to blow your brains out…….
Until is happens to you or a person you love, best you re-think this cost saving idiotic idea. You are beyond contempt.
Thought-provoking indeed. It is also a piece that reveals the excruciating set of choices we may have to make to bring costs under control. I read it dispassionately until I came to the part about false chemotherapeutic hope for widespread metastatic disease. I don’t know how the latter is defined, but I almost certain fit the definition. I’ve lived on “false chemotherapeutic hope” for almost 8 years, time enough to raise my children and become an e-patient activist. Clearly, the median is not the message, and for all those who are getting an extra few months of marginal quality of life, there are also those of us who are fighting a good fight, and living a good life. Perhaps this is also an equation the wisdom of patients will help us solve — patients who understand the tradeoffs and are empowered to value quality of life may surprise the powers that be with their clear-eyed assessment of their options. We should certainly not let the fear-mongering of certain ex-governors of Alaska deter us from encouraging those conversations.
Excellent comments Judy, thank you. It becomes obvious that the “ivory tower” experts are far removed from the real world. Best wishes for continuing your fight, and I can but hope my partner who has Liver Cancer stage 4 with perhaps a year to live at most, will be as fortunate as you have been. I presume that the writer is pleased with a prognosis of a year, thus saving him his tax dollars.
Algernon and Judy, I believe you misunderstand what Dr. Lundberg is referring to.
I am a practicing physician (not an oncologist), and I am positive that re. chemo, he is referring to therapies that are comlpetely unproven or of absolutely marginal benefit. Keep in mind that a lot of agents come with almost certain side effects and may make QOL worse.
Re. end of life care, I have obsrved and have participated in useless efforts, “for” suffering patients in hopeless situations, and “for” patients with very limited or absent brain function.
rbar,
I think I agree with you completely. Defensive medicine and the fear of lawsuits are real. But even in your comments it’s only one of many factors in our medical culture that lead to waste and excessiveness. Ours is a situation where medical errors are too common (see the IOM report to err is human), American doctors resist JACHO, guidelines, or any oversight. Our autonomy is supreme. We actually don’t get sued for the overwhelming majority of mistakes we make. Something has to give. I believe the tort system in medicine is completely unfair and counterproductive and we should change it. Democrats are not honest about this, in my opinion. However, to claim that as central to the overall health care system is hyperbolic and quite self-centered on our part.
Do any of the people railing against malpractice suits as a root cause of health care costs ever read “Health Affairs” or for that matter the CBO report on US health care costs? Both of these rather thoroughly debunk the myth that either malpractice suits or defensive medicine have all that much to do with increased health care costs in this country. The 2005 “Health Affairs” piece by Gerard Anderson et al. is particularly helpful. When one looks at the US, UK, Canada, and Australia (all of which have similar legal systems but very different health care cost structures), the problems with the “tort reform solves health care” case become apparent.
I had trouble hearing and went for a hearing screening at my MD’s office. The loss on one side was so significant that she immediately sent me to an ENT and an audiologist, who in turn ordered an MRI. It turned out that I had an acoustic neuroma (clinically stable, thank God). I am being treated by a doctor at Mass Eye and Ear Infirmary in Boston, who has me undergo a contrast MRI every year to make sure that the AN has not grown. I see him rather than the local specialist because the local specialist would have had me undergoing surgery immediately, which in turn would have destroyed the remaining hearing in one ear.
What would happen to me under Dr. Lundberg’s system? This isn’t a theoretical situation. This is my life. Would I have been denied the MRI and simply given a hearing aid? Forced to see the local doctor and been rendered deaf on one side? Possibly lost my job due to the cost of surgery and finding a temp to do my job for the six weeks I would have been out of work, not to mention the increased insurance costs?
Yes, we have too many tests. But a vast amount of healthcare costs stems from drug company profits and insurance company bureaucracy. A Canadian-style single payer system would have allowed me to see the specialist and have my MRIs without referrals, without risking my job, and without being forced to see a doctor who tried to rush me into the operating room.
Single payer is the only solution.
I’d first like to reiterate that physicians’ fear of malpractice litigation is far from unfounded. My father is a primary care physician and was in court for three weeks this year at risk for losing his house for simply following the standard of care. He ultimately won the case but my guess is that others aren’t so fortunate.
Secondly, I think it’s all well and good to talk about incentivizing medical students to go into primary care but that’s a long shot as the system is now. As a first year medical student, I just completed my federal loan counseling where I learned that to be able to pay back my student loans over 25 years I will need to be making 300,000 a year once I complete my studies. While I have every intention of going into primary care anyway, I’ll apparently also need to win the lottery.
Kim,
I think I have read that piece and I believe it is wrong in several respects – in some details such as density of MRI machines (where it was admitted in the text that the US number might be too low because one facility can contain several MRIs), and wrong in the big picture because the crucial problem is not the malpractice premiums, but defensive medicine. Let me cite from Barry’s post above:
“It is true that defensive medicine is virtually impossible to quantify precisely because the motivation for ordering a given test or procedure can be part defensive medicine, part money driven and part trying to please patient demands and expectations. I have seen cost estimates for defensive medicine that range from the very low single digits to north of 10% of healthcare costs. Nobody knows for sure.”
I think it is probably higher than 10 %, but don’t forget, it’s rarely defensiveness alone, but also patient expectations, money driven medicine etc. that drive overutilization. It’s like saying: this marriage broke apart due to the lack of money (it’s usually more complicated than that) … several factors can be interwoven, and it may be hard to identify one clear culprit. Same with overutilization. However, I think that tort reform is a prerequisite in oder to curb overutilization, but alone it wouldn’t change much.
You will find a few health policy wonks (Ezra Klein for instance) stating that the tort system is irrelevant … but you will find very, very few physicians saying that, and this includes the well informed and progressive ones.
President Obama, we are tired of the Whitehouse trying to sell us health care reform. You know, I know and the American people know this is really about more government power and control. Our biggest problem has become our government! Stop! Just stop all this nonsense! Do not treat U.S. like we are stupid, ignorant morons! Join U.S.!
Do Not Sell Out “We the People” of the U.S.A.! We Trusted You!
President Obama, great Presidents do Great things! They have great Honor and Integrity! We know you can do it! “We the People” know the truth! We want to hear it from you! Please join U.S.! Tell the American people the Truth! Confess! Americans are forgiving! We feel if this took place, a renewed Spirit of Patriotism could spread through our government! The American people have never lost our Spirit of Patriotism! We never will! Join U.S.!
“Few men have virtue to withstand the highest bidder.” –George Washington
President Obama, You owe nothing to the manipulators who bought your way into office. Those people only used you! Americans do not want to use you. People have been using you and lying to you all your life.
You Have to Betray Them or Betray the U.S.A.! What’s Your Choice?
Look at the people of the United States. We are real! We are good people! We are intelligent and can think! The elitist mind is really small and weak! The elitist people are selfish and twisted. We just want a President with Honor and Integrity. This is your big chance to become the Greatest President of all time! You need to lead our government by example, with Honor and Integrity! President Obama just do the right thing!
Join “We the People” of the U.S.A.!
“Experience has shown that even under the best forms of government those entrusted with power have, in time, and by slow operations, perverted it into tyranny.” -Thomas Jefferson
President Obama:
Can you stand on your own?
Can you make your own decisions?
Can you be a man of Honor and Integrity?
If we have any other elected or appointed “public servant” leaders in our government who have any Honor or Integrity left inside them, they should come totally clean with “We the People”! If most of our leaders have any intestinal fortitude, then we should have a long line of them holding resignation papers in their hands or begging to ask our forgiveness! Do they no longer think they are accountable to U.S. and believe they can do whatever they please? They have developed a “spirit of insubordination” that has gotten way out of control! We no longer need employees working for us that practice malfeasance in office.
We need laws stating that any Representative, Senator or President that has the audacity to sign any bill without reading it and fully understanding it should go immediately to jail without any bond? We must raise the bar of Integrity and Honor for our employees! Elected or appointed “public servants” need to achieve a much higher standard. How did it get so low? If they are found guilty, a 30 year minimum sentences would not be out of line! This complete lack of responsibility is a very serious issue! It’s totally scandalous, outrages and just plain wrong! It’s Criminal!
We Must Never Again Allow Our Leaders to Have Unaccountable Trust! EVER!!!
People are corruptible! We must always question and watch very closely everything they do! Our Freedom, Our beloved Constitution, Our National Sovereignty, “We the People” and the fact that we are a Constitutional Republic is why the United States of America is the Greatest Nation in the World! Any bad truths about our Country are the slow results of the corruptible human nature of a few individuals! Power and wealth can corrupt a person if not kept in check! After we fix our current problems, and we will, we must put in play many more “checks and balances”. We must figure out a way to completely take away the opportunity of corruption! Nothing personal – but “We the People” must always come first and be protected!
http://www.tomdavidd.com/blog/
“We can all commiserate forever about how bad things have been, are, and will continue to be. But I don’t think that we can afford to wait for elections in order to have our say about putting a stop to this madness. Enough, already! Let’s start talking treason, prison, and death penalties for all malefactors in government who subvert, ignore, skirt and otherwise trash the Constitution of these United States of America. Those who have sworn to uphold the Constitution and have then ignored their oaths of office are guilty of perjury and malfeasance in office.” -Stephen A. Langford (personal communication to this author)
While the article oversimplifies medical care delivery and payment, much of this can be attributed to an author who, from the sound of it, does not actually treat the sick. Please feel free to correct me if I am in error, but following the dream of many MD’s today, Dr. George has found it more lucrative and less risky to leave caring for the sick to other less dignified “providers.”
In order to lower the cost of care, these costs must be studied, scientifically. Who spends the most? When, and for what disorder? This has already been done.
Now that this data is known (the elderly, at the end of life, for heart disease), we can make recommendations.
Dr.George’s desire that we experience death with “dignity and free from pain,” is so sophomorically wistful. The demand of the public is always “not me, not now.” The doctor is trained to say, “not on my watch.” And so it goes. Also FYI doctors run the very real risk of being prosecuted if they are too helpful with the “free from pain” bit.
In Dr. George’s perfect world, we would all not imitate our President’s smoking habit. We would resist the urge to overeat and under exercise. We would drive our highways without a “sip of beer.” We would not have unprotected sex with dozens of Hatian prostitutes, or trade group sex in a trailer for a hit of meth.
But alas, it isn’t Dr. George’s dream world. It isn’t that we resent paying top dollar for the best care in the world either. It is being asked to pay for the bad judgement of others that strikes us as unfair.
We also pay the multi-million dollar salaries of insurance company CEO’s and pay for tens of thousands of their employees who profit by COLLECTING PREMIUMS and DENYING CLAIMS. It is brilliant. Probably a great investment for some. But when $7000+ a year goes to my insurance, and precious little ever comes back to the doctor, I have to ask, are these healthcare dollars well-spent?
Hospitals play a key role. By hiding the true costs of care from the public and publishing outrageously inflated billing statements they can markup product 7000% and not blink. A “Dr. George” fix here would be TRANSPARENCY. Force hospitals to post a menu of services with cost + prices. Let the public see how little the insurance company is paying for that visit. While we’re at it, give each American citizen a healthcare account, $700 a year, every year. From it, vouchers can be withdrawn and used for healthcare. Don’t use it? Roll it over and add to it the next year. Saves the banks, puts consumers in control of their own spending. Forces healthcare providers to compete at price and transparency. I know, it is simple minded and idealistic. Wasn’t that the point of this article?
Dr. Lundberg … Your item might have more validity if you had shown the numbers from peer reviewed studies to back up your assertions. Without documentation its simply political positioning rhetoric.
Dr. Lundberg, and most of the respondents apparently never took Econ 101, or forgot what they were taught, or are in denial.
There is no consumer-provider free market. Neither the doctor nor the patient can get what they want and need because they have forfeited all the money to a third party.
Loss of consumer pricing power, as exists everywhere else in the economy, is absent here, obviously because all power rests with those who control all the money.
Why does this reality exist only in health care? Deep thinkers want an explanation. The road to good health care for all begins with the answer to the right question.
As for myself and my patients, we figured it out long ago. We returned to the free market, where consumers purchase what they need directly from the supplier, at a price agreed on between us, spending our own money. This is how every good and service is exchanged, except health care. Therein lies the problems.
The entire debate for us is irrelevant white noise. Nothing to do with us.
The solution is all around you, hiding out in the open.
I think that Dr. Lundberg’s opinion piece, and David Goldhill’s article, How American Health Care Killed My Father, in The Atlantic,(http://www.theatlantic.com/doc/200909/health-care) make eminent sense about how to control health insurance costs and improve health care. The first article is by an eminent physician who has seen the system over years from 30,000 feet; the second is by a businessman who has a functional sense of the economics of health insurance. Neither article mentions the words “conservative” or “progressive.” They are both pragmatic.
I would add that a public awareness campaign needs to start at once. The two main messages, per these two articles are:
* Many of us will live 8 to 10 decades. As we age we will need more and more medical interventions. Face the fact that we are all going to die some day. Recognize that thinking about, or saying the word “death,” is taboo in our culture. Determine what interventions you will want to take to prolong your life; balance that with expectations for your quality of life and your family’s needs for inheritance. Help change our culture’s expectation that each individual has a right to hope that her or his life will be saved by medical intervention.
* Remember when you realized that you had to save money to send your kids to college because it was clear that the costs for higher education were beginning to sky rocket? You saved and were able to pay for all or a part of their tuition. Health care’s costs are sky rocketing now. The best thing you can do for yourself and your family is to start a HSA now to pay for the health care that will be necessary as you and yours age.
******
It will be a hard sell. Physicians and patients are both mortals and, as Puck pointed out in A Midsummer Night’s Dream, “Lord what fools these mortals be.”
One of the main aspects in the increase in cost of healthcare is the way it is paid for through health insurance. No matter how much price control is added by physicians performing less procedures, the costs won’t be reduced until the patients are fiscally responsible for their own healthcare.
Exposition on why healthcare is significantly cheaper in developing countries:
http://hoothoothoot.wordpress.com/2009/08/28/obamacare-vs-indiacare/
I have been trying to make this point to members of Congress for the last month. They can think of nothing except expanding coverage, the big bad insurance companies as the problem and a public option as if any one or combination of those is the real problem. I recently placed an intersting article on my Blog
http://quinnscommentary.com/2009/08/27/i-agree-with-ezekiel-j-emanuel-md-phd/
related to an article that Exekial Emanuel wrote in the February 27, 2008 issue of JAMA. I think he has it right as well, but you hear very little about this even though he is the White House advisor on health care reform. Go figure
For healthcare reform to succeed, our country needs the right blend of principle and pragmatism, and it is foolish to prefer glorious defeat to an incremental victory. I contend that this requires (1) defining what we have to (ought to, should, must) do in order for our healthcare reform strategy be judged as principled and, at the same time, (2) defining what we can do in order for it to be judged as pragmatic. For an in-depth discussion, see this post on my blog titled “A Principled and Pragmatic Approach to Healthcare Reform” at http://curinghealthcare.blogspot.com/2009/08/principled-and-pragmatic-approach-to.html
rbar — picking up after some days on the discussion of “false chemotherapeutic hope” versus of course treating aggressively if there is any chance of a benefit. I wish I could share your confidence. However, I have lived in the cancer world too long not to have seen patients fighting for tx’s that are well known and widely used, but somehow do not meet the criteria of their insurance company for coverage. I have seen patients pulled off of a treatment at the first sign of progression, when other doctors would take a more incremental approach, possibly change dosage or schedule, and perhaps reap a few more precious months from a given therapy. I have seen my onc’s notes in my chart reflecting her belief that I was within weeks of death but (thankfully) open to trying a treatment for which we never thought I was eligible (that was six months ago). I offer these anecdotes not to try to find right or wrong, but to say that the choices are nuanced, complex, and yes, sometimes excrutiating. But it makes a lot more sense to me to be as open as possible about the very important issues of QOL, side effects, benefits vs. harms, etc., than to try to reduce it to some actuarial formula. In this regard, I have found the input of patients to be at least as valuable (usually more) than anything I’ve read on a package insert or heard from a provider, and I hope I’ve been able to share information that has given other patients and caregivers a chance to make truly informed choices.
Good points, Judy. The root problem, it seems to me, is that doctors often don’t know with a strong degree of certainty whether “chemotherapeutic hope” is false hope or if it is a valid & reasonable approach for a particular patient (like you). The same goes for many tests and procedures throughout the healthcare industry, i.e., we simply don’t know if they are worth the side-effects, cost, risk, etc.; if there are more cost-effective approaches that will have superior outcomes in terms of QOL, longevity, etc.; or if doing nothing is best. Lacking this knowledge causes all sorts of problems, which is made worse because our system pays more for doing more, not for doing best (i.e., it does not reward delivering high value to the patient/consumer).
The only long-term solution is to gain the knowledge we need. That doesn’t mean relying on some actuarial formula based on administrative data collected by insurance companies. It means working hard in collaborative research and practice networks across the globe to emerge that knowledge by analyzing comprehensive clinical outcomes data and then translating the resulting information into evolving evidence guidelines/protocols/pathways. In that way, we can focus on improving those guidelines over time by studying compliance rates and variance data depicting (a) when and why the guidelines are followed; (b) when they are not followed, why they aren’t; and (c) what the particular types of patients for whom the guideline works and for whom it doesn’t.
Over time, this would address the issue you raise. How best to do and use this research is what we ought to be debating!
Dr Lundberg identifies a number of things which should be targets for reduction in usage rates. Many, many more could be identified but Dr Lundberg does NOT identify an effective pathway to do so. Putting physicians on salary is NOT the answer. Removing incentives to work hard is NOT the answer. The Geisinger/Mayo/Cleveland examples are more driven by excellent physicians who broadly know best practices and have internal peer review than by the fee for service issue. In fact, each of these organizations do use productivity models which take into account fee-for-service activity, among other quality and productivity indicators. Changing how community, non-big-system physicians function is much, much more complex than putting folks on a non-fee-for-service system.
Achieving change has to track the following principles: incrementalism as drastic change is too disruptive in so many ways. Amplify and expand what already works. In this case, Clinical Practice Guidelines need to be expanded vastly, need a process of generation that is continuing, well organized, and frequently updated. As a new wrinkle, like the SureScripts model which incorporates medication management within EMRs, Clinical Practice Guidelines need to become an integral add-on to EMRs/EHRs. Since EMRs are still in relative infancy, NOW is the time to influence them to implement Clinical Practice Guidelines and NOW is the time to make all EMRs Health Data Vault based. NOW is the time to insist that EMRs ALL use standard MedCin codes for as much as possible in a manner which is efficiently usable. The Guidelines need to see MedCin codes for symptoms and physical findings within EMRs, need to see coded outcomes of tests, and integrate them automatically into a Guidelines structure. They should assist with diagnosis, prompt the physician to document more effectively in a manner which supports decisions. Guidelines evaluation of medical data should be able to look at the patient’s entire health record for coded symptom, physical finding, test, and procedure outcomes data. That means that many pieces of data which are now stored as prose will need to be stored as evaluable coded information. Cardiac ejection fraction, thus, needs a coded place and outcome format. COPD needs coded parameters. Liver dysfunction and renal impairment need to be quantified in code. And the coding needs to fit virtually invisibly with the way we are encouraging physicians to document. Demographics like age need to be considered. Then, guidelines can advise on whether prostate cancer should be observed, radiated, or operated and what the benefit/risks are which are pertinent to a specific patient. Then, guidelines can inform the family of the elderly diabetic with end stage renal disease that any coronary artery procedure has a very poor outcome potential.
For guidelines to be optimally effective in making care more appropriate, they must be an integral part of evaluating the medical record as it is being generated. Guidelines need to influence decisions as they are being made rather than being imposed hours to days later by faceless bureaucrats who demand “peer to peer” phone conferences before care will be covered. Current “peer to peer” is in fact not “peer to peer” as the person on the other end of the phone is commonly woefully under-informed. Current processes anger everyone generating excessive physician office costs.
Please work for solutions which fit the modern direction in medicine: integrate with what is happening, enhance it, use new directions as a tool to make cost-appropriate care a reality.
I agreed with Dr. Lundberg of the needs to make provision and provide healthcare coverage for the uninsured and underinsured. We still share the cost of caring for these people in Emergency room Department. Also to reduce the cost of healthcare, Physicians should reduce ordering duplicate and unnecessary diagnostic tests just to protect them from annoying law suits. Over-treatment is a big problem with cancer patients compare to other developed countries. It’s time for us to focus more on providing quality and cost-effective care.
Americans are ENTITLED to all of those wasteful treatment and behaviours. Just try to take the candy away from a spoiled child. Use reason? That is ineffective. It takes 5 times as long for me to explain to someone why they dont need an MRI than why they do. Their neighbor certainly is more knowledgeable.
Kaiser is in deep finacial trouble, not a good example.
Cooperatives DO NOT work, failed in Florida over ten years ago. Competition DOES WORK- Public Option IS a competition strategy.
As a healthcare provider I see way too many patients complaining of a sore throat or a cough they’ve had for less than a day. The number of patients coming in on a daily basis with normal aches and pains is astounding to me. Both the urgent care and I get paid for seeing these patients by insurance companies, so I suppose I shouldn’t complain…But these frivolous visits are a big part of what is driving up the cost of healthcare.