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We’ve gotten away from the notion of real health care reform, I notice, and are just concentrating on insurance reform. But insurance reform doesn’t control costs, and doesn’t make Americans healthier. It just tinkers at the margins of a problem that also includes how doctors are reimbursed, what society should pay for, and what constitutes rationing.
Here are two terms that should be in the discussion, and don’t seem to be. People who really understand how the system works, like perhaps the Mayo Clinic, Kaiser Permanente, have said repeatedly that reimbursement and incentives should be changed so that our health care system is less of a sick care system. Learn these terms, in case someone gets smart and the discussion changes focus:
Outcomes-based medicine: paying the provider (doctors or hospital) for things that actually work, rather than for treatments the patient comes in requesting, treatments that are worth a lot of money when the provider bills the insurance company, or treatments that take place in settings owned by the provider (the MRI machine owned by the syndicate of doctors).
For a number of reasons, mostly financial, that come from the current pay structure of Medicare and insurance companies, providers have to “game the system” to survive. So there’s a tendency to do what Medicare will pay for (or United Health, or Cigna) rather than what has been demonstrated to work.
For example, exercise, low salt diets, biofeedback and meditation have been shown to control blood pressure, but no doctor is paid for prescribing them. Nor are doctors paid for talking to or educating patients. We could save tons of money for paying doctors to get all the blood pressure patients in their practices under control (no matter what it took) rather than paying them for office visits to monitor the pressure, drugs to control it, or tests to determine it. This would mean the labs, drug companies and doctors would have to work together to get the patient’s blood pressure under control –or nobody would be paid.
Certain conditions and diseases, mostly chronic, plague the population and soak up 2/3 of our health care costs. They can be brought under control, but only by changing the incentives for physicians, who are now paid to do MORE, not less.
Comparative effectiveness research: About thirty years ago, someone invented heart bypass surgery. It became immediately “the rage,” and hospitals developed elaborate surgical suites and cardiac surgeons became the big wage earners. Those were followed by the less invasive “stents,” which opened the blocked arteries and kept them open, and were cheaper. Stents were discovered by cardiologists who were pissed that they were losing business to cardiac surgeons. Thus was born the discipline of interventional cardiology.
Recently I read a study that compared patients with similar heart disease who had cardiac surgery to those who had interventional cardiology procedures (angioplasty), to people who were only using prescription drugs. And guess what? People with heart trouble didn’t live any longer whether they had heart bypass surgery, stents, or drugs! Do you understand what that means? For years hospitals have built expensive cardiovascular surgery suites for their cardiovascular surgeons to operate in because the procedures made both doctor and hospital so much money from insurance companies. The surgeons went wild when it was discovered that the same results could be gotten with stents, far less invasive and expensive. So the hospitals then built interventional cardiology labs. And now we are hearing that patients do just as well controlled by drugs.
Which could give way to a study that says diet and exercise are just as effective as any of the more expensive remedies if you stick with them.
Do you see where I’m going with this? Many of the problems that cost society big bucks come from lifestyle choices. OK, it’s impossible to make Americans exercise and lose weight. But now that we know prescription drugs are just as effective, perhaps we should stick to those as a standard of care.
The only way to change the system is to change the way doctors and hospitals are reimbursed, and give them more money if they keep patients well in the first place. For a medical community that is used to being reimbursed best when the patient gets to a crisis, this is a huge shift.
http://ushealthcrisis.com/2009/08/two-important-terms-for-health-care-reform/#more-356
Add a Comment1 Comments
Your article is pretty pointed and makes some generalized statements but does not cite any of the resources you have used. There are many studies which demonstrate that cardiac interventions have improved outcomes and saved lives compared to drug only therapy for patients with unstable angina or acute myocardial infarction. Even if there are studies out there showing drug therapy is close to as effective in some circumstances, there is simply far more evidence to state otherwise. I don't think any cardiologist would suggest simply giving medication to a patient undergoing an acute MI when a cardiac stent might actually prevent the infarct from progressing.
Physician payment makes up 8-10% of all health care costs. Even if you cut provider payment by 50%, you'll only decrease costs by 4-5%, hardly enough to blunt the rapid growth of health care expenditure. And you'll create access problems for people who need it most. I don't think cutting provider payments is the answer to our problems.
August 23, 2009 - 10:08amThis Comment