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Wishful Thinking On Healthcare Reform

Healthcare Reform Won’t Come From Within 

Countdown to Healthcare Reform

America’s doctors are being exhorted to assume healthcare reform leadership roles in expediting payment reforms and system transparency.

In considering why I find this so unlikely, I remembered a tactless comment I made back in  my days as a regional health planner when presenting my case to a state regulatory board. 

In the midst of my presentation, I said something about getting a group of doctors to agree on something – anything, really – was like herding cats. The sole doctor on the board responded that he agreed with my presentation but wished I hadn’t made the herding cats comment. Of course, I immediately responded “So do I” and we all had a good chuckle.

But there’s continuing relevance in the medical profession’s history of stubborn non-conformity, especially as calls are made anew to enlist their collective  leadership in making healthcare reform more effective – whether in implementing Obamacare’s components or beyond.

The Good Doctors Weigh In 

Dr. Zeke Emanuel – a major architect of Obamacare – and Dr. Donald Berwick, former head of Medicare and Medicaid at the federal level, have both gone on record to encourage their physician audiences to take up the cudgel of healthcare reform.

This is likely to prove as effective as President Obama lecturing the NRA about their need to be reasonable in accepting prudent gun control measures.

Consider, for example, the list of vital healthcare reform ingredients Dr. Emmanuel laid out to his physician audience as reported by MedPage Today:

“‘We need to take the responsibility now as a group in pushing for payment change,’ Emanuel said. ‘It’s the only way we can facilitate the transformation and re-engineering that the system needs and we need to care about.’…

“He called on physicians to ‘get our house in order’ and ‘collectively campaign’ for these changes…

“If physicians take the lead, they can enhance their autonomy and design the delivery system they want, but that system will also assign them financial risk…

“‘I see no way of getting out of that,’ he warned. ‘It’s not a dilemma. It’s just the inherent nature of what it means to assume autonomy.’…

“Emanuel highlighted six elements that must underline payment and delivery reform efforts:

  • Focus on cost value

  • Focus on the patient

  • Work in clinical teams, not as individuals

  • Reorganize delivery systems

  • Standardize processes

  • Ensure price and quality transparency 

“While some providers have bemoaned consolidation in healthcare, physicians need other people in teams helping provide care, as well as a good infrastructure of information systems. ‘We need a big infrastructure to be able to deliver high-quality care going forward,’ Emanuel said…

“Transparency is inevitable and will happen faster than doctors think, he said, despite some opposition…

 “‘You need to know who’s doing well in terms of quality so you can make referrals,’ Emanuel said. ‘You need to know who is doing well in terms of price, so that when we change the price system you can actually make it reasonable’.”

What Defensive Medicine Tells Us

Sounds perfectly reasonable, doesn’t it?  Who could argue with such an obvious call-to-action?

And it would be perfectly reasonable if it didn’t fly in the face of all the evidence we have about how doctors actually practice medicine in America (see Our Healthcare Sucks).

Yes, some of that will change when their payment incentives slowly change as healthcare reform takes root. But the evidence we have about actual physician behavior in America shows it to be mostly self-centered and income-driven.

Exhibit 1 is the prevalent practice of defensive medicine. I’ve written before about Obamacare’s failure to incorporate meaningful malpractice reform measures in its healthcare reform package (see “Obamacare 2.0 – Fixing Medical Malpractice“).

But the medical profession’s near-universal response to the threat of medical malpractice claims is to knowingly violate their own codes of ethics by putting their patients in harm’s way with unneeded medical interventions to protect themselves from feared litigation.

However it’s rationalized, this morally bankrupt practice is all you need to know to assess how likely it is these same folks will rise to the high-sounding entreaties calling on them to lead, rather than resist, healthcare reform. The irony, of course, is these measures are essential to their continuing viability as a profession that’s on the verge of pricing itself out of business.

There’s no need for an Exhibit 2 – Exhibit 1 says it all.

More Wishful Thinking

As for Dr. Berwick, the former Medicare chief, here’s how Medpage Today reported on his recent talk to the Association of Health Care Journalists:

“There is widespread agreement that the current health system is broken, consuming far too much of the nation’s budget while delivering fragmented, uncoordinated, and often poor care….

“It will take greater social and political will to unseat the forces that maintain the status quo of the country’s healthcare delivery system, he said. ‘We can fix it … it can be done. Probably not outside-in, but inside-out,’ Berwick explained. ‘Will it happen? I don’t know.’…

“But he pointed out that based on his 30 years of experience in healthcare reform, the people who are best equipped to remake the system are those that give care. However, this effort will require the cooperation of the public, providers, politicians, and, of course, insurance companies….

“‘The question is, will the insurance system migrate fast enough to the kind of financing arrangements that will allow us to move toward totally integrated care?’ Berwick said.”

So Dr. Berwick ends up laying it on the insurance companies to impose changed payment incentives that will force doctors to practice differently. Somehow that doesn’t sound like the kind of physician-led change he was describing – perhaps because he knows in his heart-of-hearts that the medical profession is the leading force for maintaining the status quo. Their record-breaking spending on political lobbying bears this out in spades.

With “Leadership” Like This…

My thought is that where Dr. Berwick chose to land his final argument – along with his “I don’t know” when answering his own question about whether healthcare can actually be fixed from within – reveals his recognition that the medical profession is inherently incapable of rising to the challenge of leading on healthcare reform.

But both doctors realize they need to at least make the case for physicians to abandon their intransigent resistance to constructive change. Then they can say they were warned they needed to act or be acted upon. I suspect both doctors are sophisticated enough to know their messages fall on deaf ears.

I’ve written about this before, too (see “Can Docs Ever Lead On Healthcare Reform?“).

In that post I note the American Medical Association’s decision to adopt the Medicare voucher plan voters overwhelmingly rejected in last year’s presidential election. I also suggested this is about as far removed as possible from the kind of payment reforms and transparency that Drs. Emanuel and Berwick describe.

Instead, it’s a cynical attempt to actually strengthen fee-for-service payments – with their inherent conflicts-of-interests for doctors and their patients – by weakening Medicare and putting more seniors at greater personal financial risk.

If this is an example of the medical profession “leading” on healthcare reform, I’ll take changes imposed from without – thanks just the same.

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