Fixing the Healthcare Mess

As a retired physician, I am aghast at the state of the art in my chosen field. There is no doubt that marvelous tools exist to diagnose and treat as never before, but at what cost? And who can take advantage of them?

The cost of drugs is too great. Primary care is spotty and hard to reach. Specialty care is a cottage industry. Politicians haven't a clue. Health Insurance is an oxymoron.

As I see it, there are three main areas of attack: funding, motivation and organization. Listen up, then please respond. Together we can start to deal with this farrago.

Let's start with motivation, which will lead into funding. Let me state from the outset that I believe that the majority of my colleagues are motivated to heal the sick and many, even at the risk of financial setbacks. However, the whole issue of motivation is on its head. All the major forces in healthcare motivate the physician and surgeon to perform. See patients, do tests and procedures. That's where the money is.

The word doctor comes from the Latin "docere", to teach. Not to perform. Teaching patients and other laypersons is widely neglected in the field, and poorly motivated, if at all. Yet the best weapon we have in Medicine is the informed patient.

Therefore, to begin the correction process, we need to address this error in approach. We need to motivate our professionals to teach. And there is no more powerful motivator than money. I have a suggestion on how this might be accomplished.

First of all, diminish the reward for doing to be equalled or surpassed by the reward for teaching. This will accomplish the admirable goal of having the physician pay more attention to what his patient understands about his body, its troubles, and his options.

Each physician would receive a base yearly stipend determined by his years of training, years of experience and the inherent risks of his field (i.e., neurosurgery would be paid at a higher rate than dermatology). On top of this, a bonus system would increase the stipend based on three criteria: maintenance of continuing education, patient satisfaction, and hours of practice.

Continuing education would be revamped. Isolated courses would be downplayed and ongoing, home-based, programmed learning substituted, with frequent pop quizzes for credit, and periodic reviews. The subjects for the programs would be chosen by each physician based on her actual clinical encounters. What she sees most often and what he feels most in need of study. However, the program would be structured to include eventually the broad scope of the field.
Scores on the quizzes and reviews would be determinants for the bonus.

Patients would receive from the office at each visit a confidential questionnare, to be mailed to a secure site, on their degree of satisfaction with the visit. They would be clearly led to understand that the physician's income depended on their submitting the questionnaire. This would lead to a form of passive rating of the visit. Non-submission would be a subtle criticism. Beloved doctors would get a higher percentage of responses. On the questionnaire would be such questions as "Were you seen in a timely fashion? Were the staff friendly? Did you understand what you were told? Were you given the opportunity to ask questions? Did you feel rushed? Were you given materials to refresh your memory? On a scale of 1-10, how satisfied were you with the visit?" The ratings would be analyzed and the bonus adjusted according to the answers and the percentage of submissions.

The physician would be invited to submit his hours of operation, including study time, and this self-rating would be checked by the payor against objective measures such as number of patients seen coupled with patient satisfaction, submisison of quiz results, and the like. A bonus would be paid but there would be a maximum time allowed for increased reimbursement to discourage burn-out.

There would be reimbursement for doing procedures, but it would be scaled down to discourage doing them for their own sake. The reimbursement for doing should never equal, let alone exceed, that for teaching.

The result of this approach should be that of empowering the patient to make more rational decisions, and reducing the moral bullying that goes on in so many medical and surgical offices. The patronization that says "I am the expert here, so do what I say". This should reduce the all-too-frequent occurrence of expensive and marginal medical adventures and therefore the cost of care.

Next, we should do away with the whole concept of "health insurance". An underwriter once pointed out to me a simple truth in the insurance business in the form of an aphorism: "never insure against the inevitable". This introduces the concept of "actuarial risk". To put it simply, if something is likely to happen, it is financially unwise to insure against it. That is not to say that one shouldn't plan for it and prepare for it. But insurance is a special kind of preparation that is designed and engineered to reduce the burden of infrequent to rare occurrences, such as tornadoes, forest fires, car crashes and the like. Not health care. Especially not preventive medicine.

In the insurance model, if you are insured against an occurrence, you and your fellow subscribers pay a stipend to an agency each month and then if you are hit with a disaster, funds are disbursed to pay for reparation. In the health insurance industry, you pay the stipend, but then turn around and collect with each medical encourter, which is far from uncommon. This has the result that you pay the health insurer to cover your office visit and tests plus the cost of administration. So if the administrative cost, is --say-- 20%, you end up paying $120 for every $100 of care you receive. This is definitely not in your best interest.

So do away with "health insurance" and substitute a more direct and less costly way to pay for care. I like the model of "health savings accounts" in which each patient sets aside income to cover the cost of health care, and each patient decides how it is to be spent. But, this model needs much tweaking. Many, if not most people will not be willing to spend their own money for preventive care, unless they are taught its importance and the cost of ignoring it is made crystal clear. This requires education and motivation, and those cost money. Perhaps a hybrid model would work. Doctor income would come from a public pool and procedures would be paid from health savings, with a catastrophic insurance backup. That is, you pay for your mammogram, but if you get hit by a truck or require a liver transplant, insurance covers it. I need feedback on this from wiser heads.

As to the cost of drugs, there is a simple and effective remedy: outlaw advertising of all prescription drugs. This includes TV ads and pharmaceutical reps in doctor's offices and medical meetings. A large percentage of the cost of drugs is in marketing. When the choice of a drug comes from -- as it should -- the results of objective controlled studies done by disinterested third parties, plus recommendations of expert panels when such studies are missing or inadequate, the cost will plummet. Pharmaceutical companies will spend their income on research and development, instead. If the profit motive leads (as it has recently) to disincentives to create certain classes of medication, such as antibiotics, a public utility would be created to develop them.

I want to hear contrary or supplemental ideas and will debate them gladly and enthusiastically with anyone. But no ad hominem arguments will be entertained!