Checks and balances in health reform

What follows are ten thoughts on checks and balances in health reform.

I am writing from Oak Ridge, Tennessee, where I am attending a high school class reunion. My son Spencer, a nationally known poet and a candidate for the Episcopal priesthood, is with me. He is checking on my past, and I am trying to provide balance so he can understand his father’s legacy.

There were 251 in our graduating class. Two of us became physicians. I have been fielding questions about health reform and other health care matters. Our class is equally split between Democrats and Republicans, and I’ve been talking about checks and balances between the two parties and other participants in the health reform battle.

1. Democrats and Republicans. Democrats won the first round with passage of the health bill. But two thirds of Americans still oppose the bill, and it is a long way between 2010 and 2020. Obama is spending $125 million in a pre-November PR blitz to sell the good parts of the bill. Democrats control the spending and sending of checks for now but come November, if Republicans take back the House, they may begin to cut off health reform checks.

2. The President vs Congress. It has become clear the President has very short political coat tails, and endangered Democratic politicians are not rushing in to ask the President to campaign for them.

3. Centralized vs Limited Government.
A recent Gallup polls indicate most Americans think government is “too liberal,” and resistance to excessive government spending and too much federal debt, now $13 trillion, is palpable and growing each passing day.

4. Specialists vs Primary Care Physicians.
Two thirds of American doctors are specialists. That is the way Americans seem to like it. Despite all the rhetoric about primary care shortages, the health bill did little to correct the situation, and 98% of medical students are voting with their feet by becoming specialists. Universal coverage without universal coverage to primary care doctors may be meaningless.

5. Proceduralists vs Cognitive Doctors. Americans prefer doctors who do something concrete to physicians who advice caution, watchful waiting, and conservative therapies. We remain a nation of doers. We prefer action to inaction, and specialists who do what they are trained to do.

6. Government vs Market Reforms.
The health bill is heavily skewed towards government reform. Market reforms, e.g, health saving accounts, be damned. This is generally presented as government benevolence vs. market greed. In short, it is better to spend other people’s money rather than your own.

7. Doctors vs Consumers. This is often characterized as the Health 2.0 or patient-centric care vs. doctor-directed care. The idea is that the Internet will empower consumers to challenge their doctors,become equal partners in the decision making, and separate the the good doctors and hospitals from the bad. Not a bad idea, but patients still trust doctors more than outside sources.

8. the Old vs the Young. Politically the Medicare crowd dislikes the bill because it cuts $585 billion from Medicare, and through the individual mandates, the young and haalthy must buy coverage at the same rates as others to support the old and sick.

9. Hospitals vs Doctors. To make the Medicare budget balance, government will have to cut hospital and doctor pay. Since hospitals and doctors often compete for the same piece of pie, this will upset the competitive equilibrium between hospitals and doctors and will force them to collaborate.

10. Inpatient vs Outpatients. Two forces are at work here: one centripetal forces driving consolidation of care into large institutions; and two, centrifugal forces, pulling consumers and patients into ambulatory settings and to home care. The two forces can be complimentary, but don’t count on it. Hospital administrator and physician egos are strong, and so are incentives to control care and cash flow.

Richard Reece is the author of Obama, Doctors, and Health Reform and blogs at medinnovationblog.

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  • Michael F. Mirochna, MD

    You couldn’t be more correct about the nation of do-ers.

  • Bev McCartt

    You’re probably correct about ppl liking “do-ers” as opposed to “thinkers”. BUT the biggest drawback is the lack of partnership between the doctor and patient. I have “fired” specialists who treat me as if I haven’t an active brain cell and refuse to even consider alternative or less invasive procedures. I’ve also walked away from doctors whose only specialty seems to be writing prescriptions without any notion or care of pharmaceutical management. As for healthcare reform, I don’t have insurance, & with my precarious health (congestive heart failure) unlikely to be insured any time soon. All my medical care is self-pay, cash only. But I support the Affordable Care Act – small steps, not giant leaps, are what propel society forward. The unwillingness to compromise, the intractability of all the parties involved is discouraging – because with each argument, with each stalling tactic and legal maneuver/block a person who could have been helped will die. Perhaps we need specialists who treat people, not just symptoms.

  • Steven Reznick MD FACP

    While there needs to be checks and balances in health care reform there appears to be little if any. On a regular basis I receive on line advertising for the World Health Congress to be held in Washington , DC this coming spring. It is one of many ” meetings” set up to discuss health care reform. It is targeting large employers, health care systems and hospitals along with attorneys and policy makers. The cost to attend is an extraordinary $1500 if you get all the discounts. The roster of speakers contains not one practicing physician,, not one physician in the private practice of medicine, not one organization representing physicians. The speakers are Congressmen and women, directors of nationally recognized insurance companies, CEO’s of Fortune 500 companies and two or three employed physician medical directors of large insurance companies. There is certainly no input or advocacy by patients or practicing physicians. At least this is a public session of the kidnapping of medicine by employers and insurance companies from patients and doctors and more transparent than the many back room deals being made each day in exchange for campaign contributions.
    To say that Americans prefer doctors who are doers rather than thinkers forgets the ACP White Paper of the 1980′s which suggested that specialty medical physicians are internists and can provide the primary care needs of the nation. Unfortunately when a patient called with a cough and a fever or just general malaise , they were in the cath lab or endoscopy suite or OR and too busy to provide the services their specialty society claimed they were going to provide. They didnt believe they needed generalists and said they would be replaced by ” physician extenders.” It wasnt long however before physician assistants and nurse practitioners realized that there was more revenue in specialty care than in primary care and they too left family practice and IM in droves. Where did patients end up,in an acute care hospital emergency department. To say Americans prefer doers rather than thinkers ignores the way medical schools and subspecialty societies have done away with most general medical rotations instead fast tracking students and young doctors into their specialty training with little or no experience or understanding of the complexity of problems their colleagues in other areas of medicine deal with. To say that Americans prefer doers rather than thinkers forgets that when new procedures and technologies are introduced to American medicine it is a small group of experts who gather to set the reimbursement rate for the procedure with no thoughts on its true market value and caring little about the fact that if their procedure drives up total costs that money will be taken from someone else’s share of the reimbursement pot. When after many years of being reimbursed at this extraordinarily high rate for the procedure, the value and reimbursement for the procedure is adjusted downward, they circle the wagons and use their income and influence to fight the changes tooth and nail ( that is not to say that any specialty should have to take the reduction in reimbursement cardiology did this last year.)
    Dr Reece I congratulate you on your long and dedicated career as a specialty physician. I congratulate you on raising a responsible child to be a model citizen entering the clergy. I am not sure that the checks and balances you propose exist in the health care debate.

  • BobBapaso

    Dr Reznick, thanks for the update.

    Checks and balances will only be real when we all pay for our care out of our own pockets, or our Healthcare Savings Accounts.

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