Monday, September 04, 2006

Medicare Crisis - What to Do?

I have to congratulate the Chicago Tribune for posting this editorial on Saturday. I'm not sure where I was, but I missed it initially. The editorial does a reasonable job at exposing the real impending crisis facing our largest health care 'provider' for millions of seniors. But the commentary regarding suggestions for correcting the crisis, unfortunately, falls flat.
There are ideas for repairing this system. First of all, reimburse doctors based on the effectiveness of their service, not just the volume of service. At present, the system pays a set fee whenever a particular service is performed. This creates an incentive for doctors to order more procedures per patient without much accountability as to whether the procedure is necessary or effective. Rewards for procedures that work best, not those that cost the most, would help to remedy what ails the current system.
Perhaps it was space limitations. Perhaps it was a myopic perspective that health care can be commoditized. I'm not sure. But certainly the incentive for more procedures is not just driven by ever-lower reimbursement for physicians. The threat of litigation to the physician who does not call a consultant or order every conceivable test as a "rule out" cannot be overemphasized.

I have often thought about the issue of "transparency" in health care. I have even remarked about it in prior postings. But how on earth do we expect to classify the infinite permutations of disease manifestations that confront physicians each day and gauge "effectiveness?" It is this variability that keeps our job of caring for patients interesting and challenging. It is also this variability that defines us a experts in our chosen field. And I dare say that I have never seen two patients who present the same way - even when the they are eventually discovered to have the same disease process as a prior patient. Recall that each disease never exists in an isolated state. It presents amongst the medical milieau that came before it - with all the individuality of a person's prior disease processes and confounding psychologies already in play.

Just watch the TV series House sometime to appreciate this variability and difficulty. Are the doctors trying to discover the root cause of an illness "effective" when they order 30 tests to make a diagnosis? If they end up being correct, some would say they were effective, but if they are wrong and miss the boat, are they "ineffective" or performing a logical exclusionary test? Who will decide?

The Tribune also commented on the increased use of MRI's:
Charges for physician-related services and hospital outpatient services have continued to skyrocket. Use of magnetic resonance imaging (MRI), for example, and other high-cost high-tech imaging techniques has more than doubled in the last five years, Medicare officials say.
With MRI, the imaging is unparalleled - the opportunity to exclude malicious processes better than other imaging modalities - but it costs more. Is ordering this test rather than a cross-table lateral xray of the cervical spine more "effective" after head trauma? Perhaps. But is it "effective" at saving money? This is less clear. If a subtle diagnosis were missed because only a conventional xray was obtained, what will be the long-term costs to the patient and the physician in terms of disability and potential litigation? Unfortunately, Americans do not accept fallibility in medicine. We are expected to always get it right, no matter what. Is this not the tacit message of the series House?

These issues get even more complicated when one considers the elderly. Recently a well-publicized example might help illustrate the point. In August, 2005, Pulitzer Prize-winning oral historian Studs Terkel underwent open heart surgery at the age of 93 here in Chicago. Gratefully, he survived the surgery. As did his wit and brilliance. But were the doctors "effectively" spending health care dollars? Chicago's writers, historians, and literaries would argue they were. Life insurance actuarial curves might suggest otherwise.

So here we are. Left wondering. Many bright minds and think tanks are wrestling with these issues, many with political aspirations at heart in the short term. And these issues are by no means simple. But they must be wrestled. And soon. But transparency might not be the best way out, because if people could see the real costs... all of 'em... and then be left to pay the bill directly, without any third party insurance "provider" at all... just the patient and the doctor and no middle men fighting it out "mano-a-mano"... they would be left to realize they couldn't afford it. Healthcare and all of its wonderful technology is just too damn expensive for the average man, woman or child in America.

And guess what... that's why this is such a mess.

But in prior years this was not uncommon. The doctor often took care of patients that could not afford his services. But doctors and their patients would reach an agreement ahead of time - perhaps barter a skill instead for the care rendered. Non-monetary renumeration. And things worked out.


Perhaps the part about getting rid of the middle men, maybe this is where we should look...


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