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Some time ago, I decided to channel three decades of working as an EP in a dysfunctional, sick health care system into producing a film that would explore the perverse incentives that drive it. What I found was a (non)system that is beyond broken. It’s dumb! It costs too much, access is problematic, and our results, by any measure of public health, are poor. Along the way, I found that equally bright people who agreed on the elements of the problem come to wildly divergent conclusions about how to fix it. In the following discussion, I will start with “the facts”, explicitly state my core values, and offer the framework for a solution.
 
The “Facts” as I See Them

1) Advances in technology give us better tools to diagnose and treat more conditions with greater certainty. These expensive technologies must meet the measure of risk/benefit, but they are rarely held to the standard of cost/benefit.
2) Our extreme fear of liability dictates that physicians invoke all available technologies that decrease (even slightly) the chances of a bad outcome. Patients (customers) demand perfection and we spare no costs in our attempts to deliver it.
3) The absence of a universal (electronic) medical record is problematic in coordinating patient care. Tests are duplicated. Mistakes are made. Information gets lost. Every facility spends a lot of money inventing wheels that don’t spin with each other.
4) Because of the wide income gap between primary care providers (PCP’s) and specialists, the former are disappearing at an alarming rate.
5) The dwindling supply of PCP’s manifests as fragmented care. Many people take too many medications. Often, no provider takes responsibility for the big picture. We do an admirable job of treating organ systems and a poor job treating people.
6) The mass marketing of prescription drugs amplifies the demand for “me too” drugs. They are rarely better than cheaper generics.
7) Since most premiums are tax deductible, health insurance companies are actually subsidized by the taxpayer to make a profit by cherry picking the healthy patients and “pit spitting” the sick ones. At every opportunity, they dump the total cost of caring for ill patients back on the taxpayer. The abundance of competing insurance companies adds a lot (25%?) to total cost without adding anything to health.
8) When people have serious progressive chronic and acute life-threatening diseases, we do a poor job helping them navigate the end-of-life decision tree with grace and wisdom… often leading to increased cost and greater suffering.
9) We spend more than twice as much per capita on health care than most of our international competitors. For all of the above reasons, the relative and total cost is increasing at an unsustainable rate.
10) The government (taxpayer) is already spending 60 cents of every health care dollar. Because of the recent economic turmoil (and our rekindled zeal for universal access), the public portion of spending is going to increase, probably dramatically.
11) Nobody is responsible for asking the question “How do we get the most health and the least suffering for the public (taxpayer) dollars we spend on health care?”

Your “solution” will depend on your core values. For clarity of argument, I will list mine. Yours may differ.

1) Access to basic health care is a right. What is “basic” is debatable, but it surely includes immunizations, well baby checks, appropriate appendectomies, and indicated cardiac catheterizations.
2) Public money should be spent in the spirit of social justice. (Example? Everybody in this country deserves free education through 12th grade. If the school district is short of funds, it cuts services to all by cutting programs like art and music. We don’t create arbitrary groups of deserving poor who receive it and undeserving poor who don’t. That’s what we are currently doing in health care.)
3) There is no inherent “goodness” or higher value in a free (open) marketplace. Don’t misunderstand. I love the marketplace when it comes to computers, golf clubs, and gin. Unfortunately, in health care, it doesn’t work so well. Why? The suppliers (that would be us) have far too much control over the demand, which is extremely elastic. Example? A good predictor of relative Medicare costs in the last year of your life is how many ICU beds you have in your community. More beds, more cost. Oops! That’s backwards.
4) There is no good reason that some specialists make 2-4 times the income of primary care providers. Yes, I know they undergo extra training, however, the huge debt that medical students accumulate amount to one or two years of the difference in yearly income between a family physician and an orthopedic surgeon. Perhaps the extra years of training could be understood as the penalty they must pay for not having to do primary care.
5) Public dollars are a precious, limited resource. People can do whatever they want with their private dollars.
6) Limited resources, in the context of elastic demand, necessarily means rationing. We should do so rationally.

Given those facts and values, when I am Tsar of the health care system, this is what it will look like, starting with medical education.

First, we provide free medical education for all doctors and nurse practitioners, with significant resources devoted to training more of the latter. This “gift” comes with three to four years of mandatory post-graduate public service. No buy out clause. In addition, we tell prospective medical students that if they want to make more that $350k/yr, they should do something else. How did I arrive at this arbitrary number? On one hand, it’s less than some specialist are making. On the other, it’s an unfathomably large amount of money for Joe Sixpack. I know “salary caps,” as some will characterize this, are problematic. We must provide incentives to get physicians to work harder at times and, frankly, I am not sure what to do about that. Physician income will be zero sum, with PCP’s making more and some specialists making less. I am confident that the pool of bright, qualified, motivated candidates will be more than sufficient.

On the administrative side, we pool all the public money (Medicare, Medicaid, Public Employees, Veterans, SCHIP, subsidies to private insurance…) along with some percentage of the private insurance premiums that we are currently spending on health care. This one giant risk pool, administered by a quasi-governmental organization, will cover everybody and treat them all equally. Using the Oregon Health Plan as a model, we rank diagnosis/treatments based on cost effectiveness with the goal of advancing health and alleviating the most suffering. Immunizations and prenatal visits will be near the top of the list. Farther down the list will be managing diabetes and removing inflamed gall bladders. Everybody receives those services. Interventions that are marginally effective and extremely expensive, like proton beam radiation treatments for old men with prostate cancer, will be at the bottom. This public insurance company pays for treatments for everybody down to the level that the budget permits. If you want it and “we” can’t afford it, you can still get it but you must pay for it on your own. Vintage Americana.

We rekindle the National Center for Health Care Technology (establish by Congress in 1978, killed in 1981) to assess medical technology for safety and cost effectiveness We educate the public and fund ethics committees in hospitals with the goal of doing a better job helping people approach the end of life with maturity. We disallow the mass marketing of prescription drugs, even if it requires a constitutional amendment.

There are some beneficial unintended consequence of centralization. Since we aren’t trying to hide information from insurance companies, “privacy” will be less of a barrier in developing a national electronic medical record. Since everybody is covered forever, malpractice suits to cover “future costs” will be moot, making substantive liability reform more likely. Additionally, if the taxpayer is clearly responsible for the cost of keeping the community healthy, we will be motivated to better regulate other industries (Drug? Food? Tobacco?) that are engaged in behaviors that are detrimental to our health and increase “our” health care costs. That is already happening in much of the European Community.

This “solution” can be fairly described as publicly financed, privately delivered health care. To those equally bright or even brighter people who believe we need less government involvement and more free markets, I ask:

Is access to basic health care a right?

Are we going to spend more or less taxpayer money on health care in the future?

When people who can’t afford care get very sick (in part because they don’t have adequate access to routine care), do we care for them, and who pays for that care if not all of us? How does your free market accommodate this?

Without more centralization, how are you going to control the multiple drivers on cost listed earlier?

Since our public health care dollars (like all other resources) are limited, how do you propose we ration these resources rationally?

Is social justice just a phrase thrown around by fruitcake socialists or is there a moral imperative to using public money, equitably and efficiently, for the public good?



Paul Hochfeld is the Producer/Director of the recent film Health, Money and Fear, which can be viewed at his web site, www.ourailinghealthcare.com
 

Comments   

# Get the government out!!!Terence J. Alost, MD FAAEM 2008-12-03 18:12
While the essay is well thought out, it leaves out several things:

1. When the government runs something, it is a given that it will be more expensive and less efficient.

2. To reduce costs, there has to be a system to get the lawyers off of our backs. (Neither presidential candidate even touched on this topic.)

3. People need to be responsible for their bad health care choices: smoking, poor diet, dangerous lifestyles, sedentary life styles. In a universal system, where you get health care no matter what, what is the dis-incentive to smoking, drinking and eating all that you want. It is not fair for careful healthy people to subsidize reckless, foolish, careless people.
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# government insurance, NOT government careMichael P Halasy, PA-C, MPAS 2008-12-03 22:44
Excellent topic.

I agree with the other comment above.

Our healthcare system is badly broken, and the problems are many. Turning a deaf ear, is not only not an option, it is no longer feasible or ethical.

I agree that the income disparity between PCP's and specialist's is unfortunate, but I see a different path, with NP's and PA's assuming the majority of primary care responsibility in this country, and MD's performing specialty care.

We also need to visit malpractice reform, end of life issues and care (Does an 80 year old really need dialysis?), and we need to change the culture of expectation in this country. This will take time.

Unfortunately, americans eat too much, drink too much, smoke too much, and exercize far too little. This will also need to be addressed, and perhaps a tax incentive, or credit given to individuals who maintain good health to offset the "subsidization" that will occur.

It's an excellent, and poignant topic, but needs careful and deliberate discussion before change can truly occur. Otherwise, a hasty, and haphazard shift could be worse for everyone involved.

Our political cycles, unfortunately, do not lend themselves to the necessary timeline that will be required.
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# DONatalie Painter 2008-12-04 12:01
While the article has many valid suggestions, I'd like to add one more. While health care may be a right, it also comes with a responsibility. That responsibility should be maintained if one is to gain full rewards from a publicly run program. Specifically, maintaining a non-smoking, no illicit drug-using body should be a requirement to receive certain benefits. If you don't comply, your benefit pay is lowered. This falls under the idea that patients need to also take some responsibility in their own wellness.
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# My two private centsDaniel Ridelman, MD 2008-12-06 15:12
If we let the government run the healthcare in this country, we will find ourselves fighting a loosing battle against a "super-corporat ion" that controls everything in the health care industry, inculding salaries. When you employ the vast majority of the health care force, you can certainly pay them as much as you want, as your employees won't have any employement alternative. Next thing you know, salaries go down and doctors and nurses have to regroup into unions to compensate the unopposed weight of the government. I've seen it happen and it ain't pretty. Not to mention what I call the "reverse Midas touch", where everything that the government touches turns to, well, something a lot less shiny than gold.
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# emergency physicianpaul hochfeld 2008-12-06 18:24
Is the purpose of the health care system to pay physicians maximally, or to provide health for our neighbors and pay providers adequately to motivate qualified people to go through the training they must endure and subsequently care for their families? How much is enough?
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# brilliant and provocativeRob Stone, MD 2008-12-18 04:56
Dr Paul Hochfeld's "If I was health care tsar..." is brilliant and provocative, and I applaud EPMonthly for starting their series on health care reform with this essay.

Dr Hochfeld noted that "The abundance of competing insurance companies adds a lot (25%?) to total cost without adding anything to health." To that I would add that health insurance premiums have doubled in the last 8 years, while co-pays and deductibles have risen at the same time[1]. All this has increased barriers to care for the insured, not to mention all the problems accessing care that the uninsured have. And it turns out that the insured are the ones who end up declaring bankruptcy and being foreclosed upon.[2]
Private for-profit health insurance is the biggest cause of our current crisis, and I don’t see why we should invite the insurance companies to be a part of the solution. This is another place where “The Market” has failed us. The US spends six times more on average for health care administration and overhead than the other developed countries (the OECD).[3] We have the craziest patchwork quilt of a health care financing “system” in the world, and it is simply broken.

Think about it. How do for-profit insurance companies make a profit for their shareholders and pay their executives multimillion dollar salaries? They collect money (premiums) from healthy people and figure out ways to avoid paying out money for sick people. It’s as simple as that. That’s the only way they can make a profit, and so all their creative and innovative thinking goes into becoming more efficient at not paying for sick people.

I went to medical school to TAKE CARE OF SICK PEOPLE. Not to avoid taking care of sick people.

Let’s phase these huge for-profit insurance companies out and replace them with some sort of government financed but privately delivered (single payer) system. Let’s figure out how to take care of EVERYONE. That’s what we’ve been doing in the ED’s for a long time. It’s time the entire system joined up with us.
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# Is health care really a "right"?Chris Pinderski, MD, FACEP 2009-01-07 13:06
I read Dr. Hochfield's article and disagree with him on a very significant point. He opines that healthcare is a "right" which is a concerning position to take. Healthcare is not delivered by inanimate objects but rather by dedicated professionals who commit their personal time to healthcare system. I submit that no one has the "right" to anyone else's personal time.

Using his position, I therefore would have the "right" to sleep in Dr. Hochfield's house, use his car and eat his food anytime I want since he uses his personal time to earn those things and it should be my "right" to use them. So would anyone else. Because personal time would now be a "right"of others to use, why stop at healthcare?

I agree that the healthcare system has serious issues but calling healthcare a "right" is ridiculous.
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# Hochfeld misses the pointTodd Arkava, MD 2009-01-12 04:04
People do not have a right to health care. Dr Hochfeld claims that “access to basic health care is a right,” but then goes on to say that certain physician services are included in that right. There is no way that a person can have a right that infringes on the rights of other people. These are called positive rights, and are morally flawed. A person can have a negative right- the right to be free from harm by another person, but health care requires that other people provide goods and services. If I have a right to health care, the doctors, nurses, pharmacies, and drug companies will have to give me their product and service for free, which infringes on their right to be compensated for their labor. What do you want to do to people who refuse to give away their work for free? Steal money from them in fines? Put them in a cage? Once you force someone to work for free, that person has become a slave, which is prohibited by our Constitution. Claiming that people should have a right to health care is akin to saying people should have a right to food and therefore all restaurants and grocery stores must give their products and services away for free. Is the government going to pay for these things? How will they ration those dollars and determine who is deserving? Will they also throw money at another commission with a top-heavy bureaucracy? What if a physician does not want that money with all those strings attached? Is he or she free to make those decisions, or is the doctor forced to provide that service on penalty of being fined or jailed? The socialist system cannot work without threats of violence. Am I the only one who finds that troublesome?

Dr Hochfeld makes the argument that the suppliers of health care have too much control over the demand. I agree with him, and this is where the free market could take over. Why does it cost $800 for someone to come to the ER for an uncomplicated broken arm or laceration repair? Why can’t someone spend 6 months to be trained in simple procedures and make a living in his or her own private clinic? No, there is no medical degree being given, but they can let the free market determine if they are doing a good job. They have a great incentive in that they will go out of business if they do shoddy work. Before you suggest a regulatory body to oversee this industry, think about how much the costs will go up to fund the bureaucrats in this endeavor. We are trying to keep costs down, and the free market is very good at that job. I am sure these people would be happy to receive $50 for minor cuts and breaks, and they could even use dangerous drugs like: lidocaine, tetanus boosters, and cephalexin. We have a monopoly on services in this industry, and the free market cannot exist without competition. What would hospitals do to compete with this new sector? They would have to lower prices. If a person wanted a thorough physician evaluation, he or she could choose to pay more. Much in the same way you decide what to eat for dinner or what type of television to buy, cost plays a role. People make decisions about their health based on cost all the time (types of food, cigarettes, alcohol, saturated fats, etc).

No central body can ration health care dollars because no one can predict market pressures and respond to consumer demands as rapidly or as efficiently as the free market. In order for our system to work in the free market, we would have to remove the current restrictions that allow for monopoly privilege of physician services.

Finally, on the issue of care for those who need it and can’t afford it, I bring up the absurd notion of “charity.” We are all human beings, and most of us in this line of work have compassion. Personally, I donate a large amount of money to charities every year; charities that I feel do an excellent job. For those of you who think the government is the best charity to handle this endeavor, look at how carefully they handle your money and how efficiently they produce things like new roads and highways. Do you want more “evidence-bas ed” medicine like blood cultures in uncomplicated pneumonia? (Hopefully the sarcasm came through in those comments). The free market would do a much better job of caring for sick people than our current socialist system. Wouldn’t it be great PR for a hospital to have an entire charity wing? I think a doctor would acquire many more patients when it became known that he or she spent even one day per month doing free care. Of course, the legal system would have to be drastically revamped in my world, but that is a topic for another time.

When the system you propose requires that you use a word of violence like Tsar, it is time to rethink that system.
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# Good Start, Fundamental FlawsWhiteCoat 2009-01-14 16:46
I applaud Dr. Hochfeld for continuing the discussion on how to improve the status of the "House of Medicine." All of the ideas floating around need to be vetted and EP Monthly is doing a great job at bringing the ideas forward.
Salary caps on physicians in Canada restricted access to medical care. At the end of each quarter, most physicians met the cap and just left to go on vacation until the new quarter started. In the end, the Canadian government was forced to lift the caps to improve access to care. Caps won't work. We need a modified free market approach to medicine.
Agree with multiple other commenters that medical care is not, and will never be a "right." Think of the logistics involved if medical care *were* a right. Do you have the "right" to the *best* "basic" medical care? If so, can you sue if you only get average care? Do you have the right to timely care or is it OK to put you on a ten-year waiting list to get your constitutionall y guaranteed liver transplant? You'll probably die waiting for the care, but you're care isn't being denied, mind you - just delayed until the big ... single ... payor you propose decides to provide the care for you. Doesn't this scenario sound similar to other countries who have socialized medicine now?
On the other hand, I like the ideas of requiring people to become responsible for their own health. I also believe that "rationing" medical care - either through delay in receiving services or through providing services only to those who can pay for those services - will become a necessary evil in whatever system we choose ... oops ... make that "in whatever system that is chosen for us."
Fast care, quality care, free care - pick any two.
That's the last issue I have with your proposal. The "Golden Rule" is universal and won't change. He who has the "gold" makes the "rules." Look at the VA system. Think extra hard before you advocate enacting that system, with all its inefficiencies, into practice all over the country.
I'd be interested in comments about proposals I have made on EP Monthly's new blog "WhiteCoat's Call Room."
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