Successful healthcare reform is critical to the well-being of our nation. Who has the answers? As a rural family physician, I keep shouting in vain that they are backing the trailer up to the wrong barn. Reform proposals utilizing creative accounting keep conjuring up healthcare expenditure savings where they don’t exist, and even is we could attain this mythological information technology utopia, it will be mere cough medicine for our healthcare system’s pneumonia. It scares me to think that healthcare reform is being guided by myths.
Myths: Evidence based medicine, technology, Electronic Medical Records (EMR), quality improvement, universal healthcare coverage.
All these good concepts will prove incapable of solving our healthcare crisis. The fundamental flaw behind the proposals of presidents, politicians, pundits, policy makers and physicians is the notion that universal access to quality evidence based, measurable, mistake free medicine can prevent illness and death, cure the unhealthy and provide a safety net to save us if we fall from health. No one wants to hear the truth: the safety net at its best is riddled with holes. Policy makers are trying to assemble a toy on Christmas Eve without instructions, but even worse, they are operating under the assumption that this toy is supposed to fly rather than simply roll along the ground.
The major public health breakthroughs in order of decreasing benefit remain clean water, immunizations and antibiotics (overused and abused). If we cured all cancer it would increase the average American life span by only a year. Of course we should strive for the prevention and cure of cancer and availability of medications, but healthcare reform should place the highest priority on the doctor patient relationship.
No matter what we do, people will continue to suffer from illness; people will continue to die prematurely; tragedies will continue to occur at nearly the same rate as they occur today, but we cannot accept the public perception that healthcare doesn’t care.
Evidence based medicine is just a fancy term for what doctors have been doing already, using the best available evidence to make medical decisions. Giving it a name falsely implies that now we should practice based on fact rather than whatever we were doing before. That fact is that evidence based or not, half of what we believe to be scientifically proven will be proven wrong in five years. The fact is medicine is based on opinion, not fact. What percentage of human physiology, diagnosis, treatment and cure of illness do we know? 95%? 85%? Despite the fact that we may have cracked the human genome code, try 10% and you’d be closer to the truth. Surprised? Ask a doctor how does acupuncture work? How many lives per year do we save by PSA screening? (Answer: not enough.) Ask the woman who did everything right -annual exams, monthly self breast exams, regular mammograms, surgery and chemotherapy, but is dying of breast cancer.
To make a reform policy based on Evidence Based Medicine and expect it to improve our nation’s health or save money is like telling the hitters on the hapless 2008 Colorado Rockies to keep their eye on the ball. Good advice, but likely not innovative enough to win the Rockies a pennant in 2009?
Injecting billions of dollars for a health information technology utopia is like giving a big Christmas bonus for every shareholder of health information technology vendors, perhaps stimulating the economy, but failing to remedy the main problems within the healthcare system. The Obama stimulus package may speed development of health IT, enabling us to reduce inefficiency in finding and using health information, but the real problems such as our gross primary care shortage and deleterious incentives bred by our third party payer system remain immune to IT fixes.
EMR will be even more disappointing than it will be costly. What we eventually gain in efficiency, we will lose immediately in up coding. Doctors charge fees based on the amount of data supposedly gathered and processed during the visit. EMR makes it easier for doctors to document more data allowing for higher charges. Higher reimbursement for the same care may sound good for doctors but it’s bad for healthcare reform. EMR will result in check box medicine, three page notes (If you printed it out on paper) for 12 minute office visits and higher levels of office charges. The number of harmful mistakes due to lack of EMR is grossly overestimated. Sixty-five percent of patients seen in my clinic are relatively healthy, and I should be able to keep their records on 5 x 7 index cards. EMR may eliminate the need to flip through obese paper charts to find information, but it does not represent healthcare reform. Healthcare reform should eliminate the need for EMR.
My review of inpatient medical records reveals that roughly three out of every four sheets of paper seems to be placed in the chart to make it hard to find the useful information. Privacy statements, multiple copies of demographics sheets that contain the insurance carrier identification, copies of orders justifying the tests performed, consents for treatment and other useless papers clutter the chart. Notes in the outpatient chart originally served only as a reminder of what occurred during the visit. Instead the chart has become legal defense. If it is not written in the chart, the doctor did not consider, examine, ask or explain. The office notes have also evolved into justification for payment from insurance companies, Medicare and Medicaid. No longer do we tolerate succinct notes reading, “Strep throat. Penicillin. $4.” Perhaps we should. EMR professes to be healthcare salvation, like the amazing clean up machine that Dr. Seuss’s Cat in the Hat uses after he trashes the house. EMR may be progress, but it isn’t healthcare reform. The need for EMR is but the symptom of a trashed house.
Quality improvement mandates will not fix the problem. We can have either quality care, or the guarantee of quality care. We cannot have both. Medicine is such a cumbersome art to quantify, mandates to do so will use up so many resources proving and guaranteeing quality care, we won’t have enough resources left to care for people when the baby boomers hit the hospital doors. Hospitals should strive to continue to educate themselves and improve the quality of care, but the notion that a multitude of quality improvement initiatives will save five million lives per year is healthcare refantasy- not reform. The patient centered medical home is a good concept, but should physicians get paid extra for providing patient friendly ready access to quality care? Should your mechanic charge extra to fix your car on the day you need it? The American Academy of Family Physicians should encourage physicians to make their offices medical homes, but do not expect to solve our healthcare crisis by requiring doctors to document and prove quality care.
No matter how you spin it, we have one pile of money to take care of 300 million Americans. Universal healthcare coverage merely rearranges the piles, like rearranging the deck chairs on the Titanic. Having the wealthier pay higher healthcare costs to compensate for those who cannot pay, or having everyone pay higher premiums or funding it all through taxpayer dollars merely shifts the piles of money around. True healthcare reform must drastically reduce the cost of delivering care, so we can make the pile of money smaller. As our current massive luxurious healthcare system sinks to the ocean floor shall we start lining up deck chairs and assign seats by annual income? Now is the time for a whole lot of lifeboats- a whole lot of family physicians.
The river of time and nature
True healthcare reform must start with the simple realization that except for isolated lifesaving triumphs, all of healthcare is but a few stones thrown into the cruel and unforgiving river of time and nature. The tragedy would not be in the futility in attempting to dam that river. The tragedy would be to continue to sap our economy and still allow people to feel lost, alone, abandoned, hopeless and without even a rudder to choose their course down this river. The solution must mostly comfort and guide people on their voyage for a bargain price.
Fortunately the real goal should simply be to enable every American easy access to a caring human being who has a reasonable grasp of that 10% of medical knowledge to help guide that person through the system, through the river of time and nature. To at least place a hand on every person’s shoulder and say, “I don’t know what is going to happen, but I am going to do my very best to utilize all we know to help you. You will not be forgotten or lost in the shuffle. You will not be abandoned because of your inability to pay. I may make an honest mistake, but I will treat you as I would treat my own family.” Can’t we simply improve that access to our current system with improved healthcare coverage for the indigent, and subsidies for the lower class? Any rancher knows it is nearly impossible to herd 20 cows into a livestock trailer sitting in the middle of a pasture. Five, ten or even twenty cowboys cannot get the job done. It will be just as futile to try to herd 300 million Americans into such a healthcare system with five, ten or a thousand rules, incentives or subsidies. Perhaps I’m not smart enough to solve the healthcare crisis, but I know this, take a bucket of grain and one cowboy can lead the whole herd where he wants ‘em. Where do we want ‘em? Primary care.
The solution: An army of family physicians
We need an army of family physicians working with physician assistants and nurse practitioners. We will need the specialists to make this the greatest healthcare system in the world, but the family physician is ideally suited to save the American people from our broken system. I would generalize and choose all primary care physicians for the job, but family physicians have the advantage of being able to care for the whole family. They can do a quick free ear check on a child when mom comes in for her obstetric check. Family physicians can care for more for less.
We need a primary care based system, and any reform plan that attempts to rely on information technology and does not create a primary care dominant system will fail without question. How do we accomplish this? I believe it is a better incentive strategy to eliminate debt for newly trained family physicians than to spend federal dollars paying them more for services the rest of their careers. Make family physicians and their physician’s assistants and family nurse practitioners and possibly all primary care providers exempt from malpractice lawsuits. Absurd? Military physicians are exempt from malpractice suits and they are the physicians likely to care for the President of the United States. Drastic yes, but malpractice suits are an ineffective way of regulating physicians. Besides let’s face it, we are in a crisis situation here. Let the state board of Medical Examiners and the American Board of Family Medicine regulate and police the profession. Is lack of a monetary consolation to a victim of malpractice any more criminal than our current system where thousands of people feel lost and abandoned by the system every day? Politically impossible? Maybe, but is it really? What is the budgetary cost of such a move? $0.00. What are the risks? None really. What are the benefits? More physicians choosing to go into family medicine and primary care, helping to solve our primary care shortage.
Insurance should be for hospital care and specialty care. Primary outpatient care should be financed totally separately from inpatient and specialty care. You don’t buy insurance to cover oil changes on your car. People ideally should save in Health Savings accounts and pay directly for inevitable healthcare expenses. Enough family physicians can care for the majority of America’s health needs without Medicare, Medicaid or insurance. Family physicians won’t get rich, but they will have security and something they no longer enjoy- job satisfaction. Without malpractice threat they would no longer have to pay $20,000 per year for malpractice insurance. Without the hassle of third party payers, physicians could drastically reduce their overhead and administrative waste. They would continue to take care of the indigent for free, but now with an attitude of altruism rather than frustration. The new generation of family physicians is out there. I have seen them rotate through our clinic. They study in our schools and universities. They spend their vacations in third world countries where they feel they can help more human beings. Idealistic and bright, they burn with the desire to make a difference, one patient at a time, but without change, we surely will extinguish their flame with debt and all that distracts them from their patients.
Of course there is a lot more to successful healthcare reform. Preventive care will need to be encouraged if third party payers are no longer covering routine health maintenance. The problem of high drug costs can be solved. Primary care physicians in impoverished locations cannot be made to shoulder the brunt of the burden of indigent care. How do you address the problem of people trying to save money by avoiding necessary tests and treatment? But these are all problems with attainable solutions. The outlook is bright if we can expose the myths and clearly see what is real and important. Technology can help, but it is not our panacea. A variation of universal healthcare coverage demands consideration, but no matter what the solution, we must become primary care based and fulfill our fundamental obligation to take care of each other, young and old, rich and poor.