The past failure of insurers and care providers to control medical costs challenges the Obama health care team to redesign health care to provide broader coverage while managing costs. If the past is any guide, they will fail just as certainly as those who went before. The problem is that those working on the new health care plans do not fully understand why existing plans failed over the past 30 years. The panoply of managed care ideas; HMO’s, rationing, pre-approvals, denial of benefits, denial of service, reduction in fees have all failed to reduce medical costs. If we wish to get past these failures, we need to think about seducing those who control the costs.
The phenomenology of health care shows that medical costs are a function of fees and utilization. Fees are what we pay for a medical service. Utilization denotes the variety of services available. Almost all medical services are performed or ordered by physicians. The ever spiraling cost of medical care amply demonstrates that coercive methods used by insurers and managed care proponents against physicians have failed to bring about the desired results.
If physicians cannot be coerced into cooperating, perhaps they can be seduced.
Seduction works when the seduced feel or believe that the rewards of being seduced outweigh the costs. Keeping it simple, what rewards can a health care plan use to seduce most if not all physicians and care providers?
— Let’s pay them fairly. Stop pushing down on the fees paid to physicians. After all, this is a relatively small part of the total health care cost. Let them actually make enough money to pay for their malpractice insurance premiums.
— Let them play god. Allow the physicians to determine the course of treatment without interference from the demons of payer pre-approval and denial of service.
— Pay them promptly. Don’t challenge or refuse to pay medical bills for services already provided. If physicians were auto mechanics they would put liens insurers.
What physician would not be seduced by these rewards? This is the medicine of their fathers and grandfathers (or mothers) when doctors belonged to the country clubs. There is, however, a price to pay; a cost to keep the rewards of this seduction. It’s a small cost, a bearable cost, a cost that will not diminish the physician’s independence or respect.
In joining this health care system, the care provider must agree to practice lean medicine as expressed in a simple, common sense, set of treatment guidelines. These are proven to work effectively in lowering medical costs yet have been accepted by thousands of physicians. For example, one of the guidelines states, “Be sparing in the use of tests and studies unless indicated by clinical findings”. This is not medical care rationing. The choice of obtaining expensive tests or studies is completely up to the physician. All that’s asked is that they ensure that clinical findings call for the tests.
Agreement is voluntary and willing compliance follows from the rewards of seduction. Critics may ask what happens if the physician does not practice lean medicine or follow the guidelines. In those cases, after consultation and discussion of the benefits, the physician will either correct the behavior or be dropped from the system. That is penalty enough. Another questioner might ask, “How do we know whether physicians are complying with the guidelines”. I believe that software already exists that could be easily modified to manage this health care system. It is true that all medical bills, reports, and payments would have to flow through this system to facilitate the management of care but that could have additional benefit by creating a cash flow that could help fund the system.
Finally, who are the payers in this system? Is it single payer, private insurers, or self insured employers? Actually, it could be all of these. The simplicity of the system is that it can be put in place with any type of medical insurance system. The insurer or payer would benefit from lower medical costs and needn’t bother with managing care.
Ultimately we would all benefit from this health care system. Lowering costs of health care by practicing lean medicine could save 30% to 50% over current medical costs. Patients would benefit by assurance that they would get appropriate care. Physicians can practice medicine, and insurers can add to their bottom line. There are no losers. But it all begins with seduction of physicians.