Monday, October 01, 2007

Fixing American Healthcare

"If Martians were to come to Earth and study the US federal budget, they would immediately see (given their entirely objective, completely apolitical, incinerate-entire-cultures-now-and-ask-questions-later natures) that the main job of the now-defunct US government has not been defense, regulating interstate commerce, social welfare, law enforcement, administration of justice, research, the arts, or any combination of these. Instead, they would see the main job of the federal government – judging from the amounts spent on Medicare, Medicaid, Social Security, federal pensions, and veterans’ benefits- had been to take money away from the young and give it to the old.”

- Richard M. Fogoros, MD

Ask any physician how they would fix healthcare delivery in the United States today, most will tell you it can’t be fixed. The challenges and complexities of the system are so complex, so dysfunctional, and so bureaucratic that real change is impossible. There are just too many rich and powerful diametrically-opposed interests set to thwart any attempt by well-meaning doctors or policy-makers to restore any modicum of sanity to the healthcare juggernaut that is the American healthcare system today. And few of us can see the forest for the trees.

But like Phoenix rising from the ashes, Dr. Richard Fogoros’ (of the Covert Rationing Blog-fame) new book, Fixing American Healthcare: Wonkonians, Gekkonians, and the Grand Unification Theory of Healthcare (Publish or Perish DBS, Pittsburg) offers a 50,000-foot jet-stream view of the forces that have shaped our current American healthcare system. Dr. Fogoros provides a framework from which to appreciate these forces: his graphical “Grand Unification Theory of Healthcare.” Using this construct, he demonstrates the interplay between the needs of the individual and the needs of society as a whole that have led to our current health care predicaments. Fogoros demonstrates why our prior attempts at reining in healthcare costs through the establishment of managed care and governmental efforts to combat fraud have been largely ineffective while eroding patients’ and physicians’ confidence in the system.

But most important, Fogoros' insights pull back the curtain on the Great and Powerful Oz that is manipulating and degrading the vital doctor-patient relationship: covert rationing of healthcare. It is the covert rationing of healthcare, he argues, that corrupts everything it touches. Anyone who has had a medical procedure denied by an insurer, a reimbursement claim delayed by a payor, struggled with red tape, or been left to fend for themselves to negotiate the healthcare hierarcy, knows covert rationing.

Fogoros exposes the synergies and contradictions of two schools of thought on how to manage the ever-escalating costs of healthcare: (1) the free-market approach supported by many physicians, healthcare executives, and insurers (Gekkonians) who want to let the market decide the best approach to healthcare without respect to cost, and (2) a centralized regulatory approach supported by governmental regulators, politicians, public health officials, and policy mavens (Wonkonians) who believe greed is the problem and are hell-bent on limiting expenses through regulation and elimination of waste, fraud and abuse. His insights expose the limitations of either approach when they confront America's unrealistic expectations of a "no limits" approach to healthcare through the use of expensive technologies and therapies to prolong life at all cost and the entitlement-to-care philosophy generated by a third party payment system through "Tooth Fairy" economics.

Interestingly, Fogoros does not discuss the need for tort reform to limit the costs of healthcare. Rather, through personal experiences and sound research, Fogoros offers another solution that will require a paradigm shift in philosophy of healthcare delivery: overt (and publically-vetted) rationing of healthcare designed at its outset to triage the limited resources available for healthcare delivery to the most people for the most good. He guides us to a fundamental understanding of why this seemingly restricted course will serve to re-establish the doctor-patient relationship and once again empower patients in their healthcare decision process. To do otherwise, he argues, will surely invite fiscal disaster for our children or grandchildren.

This book is a must-read for physicians, hospital administrators, government regulators, and policy pundits that want to understand the complicated interplays affecting our healthcare delivery in America today. It is refreshing that it offers a solution, not just a rant.

But most important, as patients ourselves, we need to arm ourselves with the knowledge of the current system so we can begin to reshape the healthcare climate to reestablish us as the ultimate arbiters of healthcare policy and resource decisions.

For after all, knowledge is power.


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