Dr. Dennis Gottfried: The Wrong Debate

The argument rages on as Republicans and Democrats, liberals and conservatives decide how to finance our overpriced medical system. Will America adopt extended government coverage through a Medicare type program to compete with private insurers, will we maintain primarily a private system with some type of accommodations for the uninsured, or will we find a new, yet to be defined, blend of the private and public sectors? The pressure is on to do something — anything — by the end of the summer.

In this confusion certain realities are known to all. Everyone understands, for example, that the 17% of our GNP we spend on health care — 50% higher than any other country in the world and growing each year — is unsustainable no matter who pays for it. They also understand that this exorbitant price tag hurts our entire economy and is responsible, at least in part, for the 47 million Americans who have no health coverage. Most politicians are also aware that, when objective criteria of health quality are measured, our American health care system consistently rates as one of the worst of any developed country. The WHO recently ranked our system as only 37th in the world, a hard pill for most Americans to swallow. Yet little is being offered to correct the root causes of this cost-quality disconnect, and in fact most political suggestions, no matter how well-meaning, promise only to make the situation worse.

Providing care for the uninsured is a high national priority. Since they lack insurance and are required to pay out of pocket for doctor visits and prescriptions, they understandably avoid medical treatment and spend far less on medical care than the average American. With insurance they would be more likely to use medical resources and overall health care costs would rise. Another national health priority is for more preventive medicine, a policy that could improve the quality of care but one that would come with an additional expense for office visits, tests, medications, and procedures. Electronic record keeping, a major part of all proposed health care proposals, is generally regarded as cost neutral — neither saving nor costing much — and a measure which would have little impact on quality. And although expanding a primary care base is a cornerstone of every health proposal, the suggested ways to accomplish this are unrealistic. One proposed way is by increasing reimbursement for primary care doctors. This will narrow the income gap between primary care doctors and specialists and lure more young doctors into primary care, but where will the money come from? The major measure, however, is increasing the number of primary care doctors to increase medical school positions by 30%. Already the number of incoming medical students, which has held steady at about 16,000 yearly for the past four decades, has been increased to about 19,000 this year with the intention of being further increased to 21,000 over the next few years. The idea behind this move is that each year, after the new American medical school graduates and 9,000 foreign graduates who come here each year, fill all the specialty training position throughout America in fields like cardiology, anesthesia or orthopedics, more additional doctors will remain who can filter down into primary care. The overall effect of this measure is painfully easy to predict. Sure there will be more accessible primary care doctors, but nationally there will be the same number of specialists and overall there will be an increase of the physician population. Since the law of supply and demand does not apply in health care-doctors, to a large extent they create their own demand — there will be more office visits and needless tests and procedures. The cost-quality disconnect will worsen.

The net result of all these proposals is that medical cost will rise. Although worthy social goals might be achieved — the uninsured will be insured and primary care will be expanded — the price tag will be high, in the trillions of dollars. Government, which will be forced to underwrite much of the price tag, will necessarily be forced to cut reimbursement to doctors and hospitals. Doctors, in turn, will schedule a greater number of shorter appointments with their patients and marginally needed procedures (remember, doctors create their own demand) to preserve their income. Hospitals, on their part, have fewer options to maintain their income and will be forced to shorten hospital stays for sick patients and to lay off personnel in order to survive.Both measures compromise quality. The scenario is painfully obvious.

The ongoing national health care debate we are having is the wrong debate! Suppose, instead of our being primarily concerned with paying for our overpriced, under-performing health care system, we focus on why our system is the way it is. Maybe by correcting the causes of our cost-quality disconnect we can actually create an affordable system. It won’t be easy, guaranteed, and the steps needed to do so will be attacked from both the right and the left.

We as a society want to believe that all medical decisions are made with the patient’s best interests at heart although, at times, less noble factors play a role in determining what tests to order, what procedures to recommend, and what medications to prescribe. American medicine is big business. Doctors, hospitals, medical device manufacturers, and pharmaceutical companies have strong economic motives to provide excessive treatments that often provide no or little benefit. Patients, in turn, have expectations from their doctors often based on little science. Doctor’s frequently acquiesce to patients’ demands even when the medical care is more expensive, even when the care is not better, and sometimes even when the care is worse. Reimbursement for medical treatment should be based on sound medical evidence but what constitutes sound evidence need to be determined in a timely objective fashion, and preferably outside of direct political influence. Such measures have already been adopted in most developed countries that enjoy better health care system than ours. Some might argue that this measure constitutes rationing. But to those objectors I would urge you to come observe a medical office. We physicians daily make clinical decisions based on the type of insurance of the patient, based on our office’s ability to obtain pre-authorization from insurers, based on patient’s demands, and based on avoiding malpractice exposure. Those patients on state subsidized insurance are often rationed right out of town whereas those with good insurance sometimes end up providing a feeding frenzy for less than scrupulous practitioners. Requiring medical reimbursements for treatments and procedures to be based on scientific accountability, even with its imperfections, would constitute a major step to improve quality and control costs.

Expanding our primary care base also requires some central planning rather than just throwing more doctors into the mix. Our present system is top heavy with 70% of our doctors practicing as specialists. America doesn’t need more doctors; it just needs a different distribution. Medical education programs that train specialists need to be adjusted to reflect our true national needs for otherwise our specialist glut will continue. These changes won’t happen by the end of the summer!

Malpractice also needs to be radically changed and maybe taken entirely out of the court system. Estimates of $200 billion spent yearly on defensive medicine probably underestimate its true cost since the threat of malpractice weighs in on most medical decisions day-in and day-out. Again, I urge any doubter to observe a practicing doctor’s office.

Consumer advocacy groups like the American Cancer Society, the American Heart Association, and medical specialty societies need to be given less influence on legislating medical policies since these myopic groups frequently represent their constituency and fail to see the whole medical picture. Legislated medical mandates often make the medical situation worse.

If we truly want to heal American medicine, the political debate has to change from how we are going to pay for our overpriced, under-performing health care system to how we can provide high quality, efficient, cost effective medicine. Although members of both parties might find the new debate more difficult, continuing on our present path is impossible and solutions that avoid the difficult decisions are only doomed for failure.


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