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Feature: Who Defines Quality Care?  
 
President Obama has let the country know that he expects Congress to give him a health care reform bill to sign by the August recess. Whether that will happen or not remains to be seen. But recent polls are starting to show that, while Mr. Obama’s personal scores remain high, people are not as sure as they once were that he is handling the economy and the deficit properly. Democrats could get cold feet if they think that major changes would not be well received by the public. In California, for example, a Democrat-controlled state house considered a universal health care bill and then voted it down out of fear that it would bankrupt the state. The ‘public option’ for national health care reform could face similar resistance when congress attempts to find ways to pay the $1.5 trillion price tag. After all, 70 percent of America already has health care coverage. They just think it’s too expensive.
 
So regardless of what we happens in August, one thing is for certain: the cost of medicine is out of control. Last year, spending for health care in the US reached $2.4 trillion, 4.3 times the amount spent on national defense. That’s 17 percent of the gross domestic product. And while the rate of increase has slowed in recent years, it still rose 6.9 percent in 2008, twice the national rate of inflation. And with employers covering a smaller portion of the tab, employees saw their portion rise at 12 percent more than in 2007. Since 1999, employer-based health insurance premiums have increased 120 percent while inflation has risen 44 percent and wages have risen 29 percent.
 
Add to that bleak picture the fact that there are 47+ million uninsured Americans who want to be added to the health care reform bill and you wind up with huge problem. How do we provide quality medical care for the nation without breaking the bank? Politicians will talk about preventive medicine helping to lower the medical bills, but they are the only ones who believe this happy talk. The rest of us know that preventive medicine means more medicine, not less. Wider use of breast screening will cost more, not less. More meds for hypercholesterolemia will cost more, not less. Preventive medicine is a misnomer. We don’t prevent disease, we delay it. If patients live to be 90 instead of 70, they will still want to spend it all in order to live to be 91.
 
Another approach to lowering the nation’s health care bill, one that is the opposite of preventive medicine, is rationing, particularly in the elderly population. Everyone knows that a disproportionate amount of the total health care outlay goes toward the last year of life. So why don’t we just take off that last year and save a bundle? Like thirsty people in a lifeboat eyeing the weakest one to throw overboard, some are eyeing the aged as the first to go. The problem with that reasoning is that the graying population is rising, not falling, and so is their voting power. Moreover, we all hope to be “aging Americans” someday. So, while we must balance the health care needs of the young and the old, don’t look for everyone to get excited about cutting off granny’s food or oxygen in order to save money.
 
Realistically there are only two basic approaches to lowering the nation’s health care bill. We can pay doctors and hospitals less and/or we can become more efficient.
 
To show how the first doesn’t work we must only look to the Medicare Sustainable Growth Rate (SGR) formula that was created a few years ago for the purpose of restraining the rise in physicians’ fees. The idea was that if fees rose faster than inflation, the doctors would give it back the following year in the form of a rate cut. Two things happened. Congress never sufficiently enforced the cuts and physicians found a way to get around the system by coding differently or shifting the cost of the cuts to private insurers. Now we’re at a point where Medicare wants to cut fees a whopping 21%. Private insurers are not in a position to take up all the slack. If there was a massive shift from private insurers to a Medicare-like system, which would happen if a subsidized Medicare-like option was open to the under-65 crowd, physicians would see a dramatic cut in compensation per patient. We would have to see more patients or see our incomes drop. Work harder to make less. And the double whammy would be that, because we are all in the higher income brackets, we would be paying higher taxes to support this system.
 
One would assume that physicians would rise united in opposition to such a change. In fact, it looked as if the AMA had finally found its voice when its president, Dr. Nancy Nielsen, was recently quoted by the New York Times: “we absolutely oppose government control of health care decisions or mandatory physician participation in any insurance plan.” However, the next day, the AMA backpedaled, stating that the New York Times story created a false impression  about the AMA’s position. Further news releases by the AMA detailed some of the issues that they would take up at the upcoming convention. Health care reform legislation was only one among many other ‘important’ issues, such the use of tasers by law enforcement and flu protection measures for airlines. Needless to say, physicians are not encouraged by such feckless national leadership.
 
Many EPs might feel that the best we can hope for is a stalemate, to end up with a watered down health care bill that only reduces physician pay a little while retaining the current basic structure. This would only delay the problem once again. And once again, physicians and hospitals will adjust by coding differently in an effort to maintain compensation levels. 
 
What about becoming a more efficient system? In May, The Bloomberg Press reported that President Obama received pledges from groups representing the insurance industry, hospitals, pharmaceutical companies and a union representing one million health care workers to reduce health care costs by $2 trillion over ten years. One pundit called such voluntary pledges “fairy dust”. And to some degree, that may be true. Who would believe statements like the one made by Dennis Rivera, health care chairman of the Service Employees International Union (SEIU), who said that the savings would come from “creating a system of wellness, where we now have a system of illness.”
 
The responsibility lies with physicians, who are the decision-makers and who drive most of the costs of health care. Only physicians can implement appropriate cost-efficient strategies that have major multiplying effects downstream without lowering the quality of care. 
 
End-of-life care represents a good case in point. Many patients and physicians rightfully fear that a top down universal health plan will institute broad stroke policies that ration care given to the healthy elderly in the name of cost efficiency. One medical ethicist from Canada appalled many readers by stating that the elderly had a “duty to die”. On the other side of the issue, physicians know of thousands of elderly who live demented, meaningless, even painful lives, who are maintained at the cost of billions to the system. Who is in a position to find the balance? Quality care at the appropriate cost will occur when physicians take the time to have open and honest conversations with patients and families to lead them to responsible humane decisions. Such care is not technology driven. It is a return to the essence of medicine. In emergency medicine, it means that we must have effective tools to communicate with the physicians caring for the elderly to assure that such conversations have taken place. The result will be appropriate care for those who can benefit from it and humane care for those who are not likely to benefit. The down-stream cost savings of these simple strategies could be enormous.
 
Much has been written about the waste of over-testing and over-treatment. By some estimates, the nation’s health bill could be lowered by as much as 30%, more than enough to cover every person in America, by simply conquering this one issue. But this problem is multifactorial. First, there is the issue of not repeating previous tests and treatments the patient has received. Electronic medical records may help this by creating a single source for patient information. The second issue is perceived medical liability protection. No physician is going to order fewer chest CTs for possible pulmonary emboli, regardless of the current clinical decision rule, unless use of that CDR is an absolute protection from a claim of liability in the event of a rare bad outcome. And Congress is not likely to give us that kind of protection without total control. Furthermore, President Obama recently stated, during an address to the AMA, that he has no plans to alter medicolegal system. Fortunately, there is still much savings to be had that doesn’t involve any increase in liability exposure. This is the low hanging fruit of cost savings. Take for example the ordering of chest radiographs. One hundred and fifty million chest X-rays are performed every year in the US at a cost of $11 billion. Could we be more selective? Knee radiographs with no history suggesting a fracture cost Medicare $63 ($45 for the test, and $18 for the reading). If just one knee film was eliminated each day in each of the nation’s 4000 EDs, it would save over $91 million. The same math is true for urinalysis, nasal bone films, throat cultures and uric acid levels. The tests we order that add no value to the patient substantially contributes to the problem. So why do we do it? “It’s protocol.” “It’s ordered by triage.” “It allows me to code a higher level of service.” “The box I check is a panel, including a whole lot of tests.” The bottom line is this. Whether Congress succeeds in overhauling the health care system, partially or dramatically, the success of any reform depends on physicians. If Congress simply tries to cut compensation, quality will fall, and patients will suffer. But if physicians commit themselves to cutting waste, costs could drop dramatically while quality remains the best in the world. 
 

Comments   

# ER DocAbqaiq 2009-07-13 06:32
Whilst all of the above discussion is interesting, there is not one mention of looking at other healthcare systems that do not spend the same percentage of GDP on healthcare, yet have better healthcare metrics than ours. We need to think 'out of the box' on this issue and realize there is a fundamental structural problem in the way the system self promotes. We must surely be able to learn from other countries' healthcare approaches, without getting bogged down on the term 'socialized medicine.'
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