Health Care Reform.

Reforming healthcare while ignoring the physicians.

If physicians, who after all drive healthcare, were asked how they would reform the system, they may come up with somewhat different set of proposals that are being debated.

High on the list would be stringent transformation of the health insurance industry, malpractice reform and reeducation of physicians in giving up defensive medicine in favor of practice based on evidence based guidelines. This would truly improve the health care system and arguably attain substantial cost savings.

Physicians would debunk the myth that US has the best health care system in the world that should be left alone. It is also not as bad as some statistics tend to show. US physicians are well trained, Hospitals are equipped with star wars technology, medical and surgical protocols are exemplary and followed by the rest of the world. If criteria like life expectancy, infant and child mortality and cost effective care are used as parameters US is lower than many developed countries. No Canadian or Brit or French would like to migrate to the US for health care; unless they could afford it.

The main problem our healthcare is the huge rich/poor, rural/urban and inner city/suburb divide. There are North side Hospitals in Chicago that are so well appointed they rival five star Hotels and others in the South side that look like they are in a poor country in a different continent. The healthcare system suffers from an ethical deficit not a dearth of god medicine. No system that leaves millions of its citizens unprotected can be called a good system
The insurance industry makeover must include simplifying rules reducing phone calls and paper work that accounts for 7% of healthcare expenses. Many physician practices have one or more associates devoting their time simply dealing with paper work generated by many and confusing rules. For hospitals this administrative load is exponentially greater. Avarice of insurance companies has resulted in a diabolically complex system with multiple and confusing plans.

There are in network and out of network options to consider (your favorite physician may be out of network and therefore out of reach) and pre authorization even for PPO plans is common place. Current insurance plans may accurately be described as schemes that have more to do with increasing corporate profit and less with providing health care.

The “pre existing condition” clause and loss of coverage when individuals move to a different job are other examples of egregious Insurance behavior that health care reform proposals aim to eliminate and are universally embraced by care givers and care receivers alike.

Insurance companies, if they wish to do business, should be mandated to offer a simple, economical, no questions asked, basic plan. This frill free plan would provide for catastrophic coverage, hospitalizations and routine preventive care. The premiums for this type of plan may be subsidized by the federal government. This along with expanded Medicare eligibility and appropriate funding of Medicaid would eliminate the need for the “Public Option.” Expanded coverage would result in timely health maintenance, fewer visits to emergency room with significant cost savings.

Malpractice reform is a necessity not a luxury. The current malpractice system is corrosive, penalizes the caregivers directly and the patients indirectly. It is common to hear in discussions among physicians phrases like “It is not indicated medically but for medico-legal reasons it would be prudent to run the test.” That is not good medicine. Physicians are not suggesting getting rid of malpractice system but making it fair and balanced. Freedom from the ever present terror of the malpractice suit would allow the physicians to practice medicine the way it should be.

At the very end of the speech on health care reform to the joint session of Congress President Obama mentioned the words physicians had been waiting eagerly to hear; “malpractice reform.” But the statements that followed left many scratching their heads in puzzlement as there were few specifics mentioned; “move forward on a range of ideas about how to put patient safety first and let doctors focus on practicing medicine.” It seemed like a gesture to appease rather than a commitment to do anything substantive.

President Obama remarked “I don't believe malpractice reform is a silver bullet” and added, “I have talked to enough doctors to know that defensive medicine may be contributing to unnecessary costs.” President Obama is right malpractice reform is not a silver bullet and may not result in much direct cost saving but it will result in an assurance to the care receivers that they may not be subjected to excessive tests and much needed peace of mind for the care givers. What is distressing is that the malpractice issue has been reduced to largely economic question when it is primarily a matter that affects physicians as humans with feelings and vulnerabilities. There is no other country in the world where physicians practice their craft under GREATER DURESS than in the US. People tend to forget that a malpractice suit not only threatens their livelihood and life savings but cause untold emotional stress. Many experienced physicians have retired early or moved from sates like Illinois to states like Indiana that have instituted reasonable malpractice reform that we can learn form and improve upon. President Obama may have talked to many doctors but has he listened to any?

As a part of reform physicians would be retrained to practicing Evidence Based Medicine, and not defensive medicine; this arguably would result in large cost savings. Educating physicians in moving away from defensive medicine that is partly driven by fear of a malpractice suit, partly bad habits inculcated over years and partly patient expectation of a perfect outcome is a cultural shift of seismic proportions.

But it can be done.

Increasingly carefully crafted evidence based guidelines are published by societies in the discipline. Physicians would argue evaluating their performance on practicing Evidence Based Medicine rather than outcomes alone as suggested by President Obama is a better option. Outcomes depend on many and complex variables and would be problematic to use as the only way of judging good care. Caregivers who take on patients with higher acuity and complexity may have lower outcomes. Physicians and hospitals may start screening for patients with lesser acuity. Another part of the education process would be encouraging patients to enquire about guidelines in place in a practice or hospital for managing a particular illness and how is their efficacy being assessed.

Americans are compassionate group and have an admirable history of caring for their neighbors and regardless of party affiliation. They have seen too many horror stories of friends and family whose lives have fallen apart because of a serious or chronic illness; I know they will support a sensible and compassionate health care reform. But successful reform depends on listening to physician concerns.

Javeed Akhter, a physician practicing in the Chicago area, is a free lance writer.