To Control Health Care Costs, We Need to Change the System

I used to be a pediatrician. My decision to leave medicine was an agonizing one, but the familiar litany of reasons– too much paperwork, malpractice threats, etc – just skim the surface of the truth. It is difficult for doctors to speak freely about some of our concerns while we have patients in our care.  Now I can speak freely.
The Senate’s recent approval of a health care reform measure has been described as an “overhaul” of our system.  It is not.  We are long overdue in providing coverage to all Americans, but this legislation does little to fix the system itself. If we are serious about pursuing excellent primary care medicine, and controlling costs, we need to be honest about the disincentives our current system creates.  We need to recognize the stranglehold that third-party payers have on our health care, how these forces make their way into the exam room, into the conversations between doctor and patient, influencing clinical decisions, outcomes, and cost.
Health insurers and employers, who have been shifting health costs to individuals at an alarming rate, try to justify this shift by telling us that forcing patients to be savvy consumers – to getting one’s money’s worth –will improve care.  This is simply not true. When the patient’s best interest blurs into customer satisfaction, the medical waters get muddied.  Nowhere is this more obvious to a pediatrician than in the evaluation of viral illnesses, like a cold. It takes much longer to explain to parents the natural course of the illness, symptomatic measures to use, and what signs to watch for, than it does to write a prescription. Often, by the time you get to the part that even cold medicines are generally useless, you have lost them.
“So, Doctor, are you telling me I just paid a $25 copay for nothing?”
It would be hard to overstate the tremendous pressure on a pediatrician – psychological as well as financial –to “do something,” even against her best medical judgment.  In our consumer approach to health care, what used to require reassurance from a trusted pediatrician, now demands intervention. That insistence on intervention – whether it be antibiotics, over-the-counter meds, or lab tests, drives up costs and compromises care.  Sadly, though, it is often that intervention that is likely to send a parent off feeling that they did, indeed, get their money’s worth.
Well-child care is another example of how misplaced resources, driven by reimbursement patterns and consumerism, drive up the cost of health care. Well-insured patients often feel entitled to boutique medicine, in which almost every aspect of child rearing – naps, toilet training, when to start strained carrots – deserves the full attention of a board-certified pediatrician. As a result, pediatricians spend a large part of their day doing things that do not require a physician’s expertise. The slightly humorous truth about pediatricians is that we often get our child-rearing information from the same childcare books that we recommended to our parents, or even from the magazines in our waiting rooms.  It would make so much more sense if pediatricians, in addition to focusing on complex illness and its management, for which we are trained, at great cost, were also specifically trained to coordinate teams of nurses and nurse practitioners, nutritionists, counselors and educators to do what they do best, in keeping with current best practice guidelines for well child care.  The problem is that our current reimbursement system, better suited for wart removals than safety education, won’t pay appropriately for this. Insurers, and many health consumers, view the teamwork approach as a lower and unacceptable tier of care. So pediatricians go through the charade of holding their hands over the phone as they ask their nurse colleagues questions about car seats and baby spoons, and get doctor-sized reimbursements to discuss the pros and cons of naps. Lots of cost with minimal benefit.
There’s another reason not to bring every aspect of child rearing to the top of the medical pyramid.  When health care begins and ends with the person wielding a prescription pad, the natural trend is towards a lower threshold for treating common conditions:  the “you go to Midas, you get a muffler” phenomenon.  So when spit up lands in a doctor’s exam room, it has a way of acquiring syllables – as in gastroesophageal reflux – and tends to morph into a reimbursable condition that can be treated by a brilliantly marketed drug.  Doctors are built to fix problems.  We are most effective when we focus on pathology that is clear, and when science, not marketing, drives therapy.
The darker side of the doctor/diagnosis mismatch is that pediatricians are also pressured to treat serious conditions for which we are inadequately trained or equipped.  We treat adolescent depression, diagnose learning disorders and tilt at the windmill of obesity, often against our better judgment, because we are the only professionals that are getting reimbursed to do so.  If we don’t step up to the plate, our patients have nowhere to turn.
We do need to “overhaul” health care; we need a system that is not based on trying to squeeze clinical practice into a shape that insurance companies will pay for.  Standards for excellent medical practice must be set by groups of medical experts who, shielded from the marketplace, base their recommendations on sound science, and a commitment to the patient’s best interest.  Once these standards and strategies are identified and prioritized, then the work of cost effective delivery begins. This is so basic, that it is difficult to believe the extent to which it has been sidelined in discussions of reform. By stepping out of the shadow of insurers and pharmaceutical companies, medical leaders can guide us all on a rational, teamwork approach to health care that will reach all Americans, trim wasteful spending, and finally be worthy of our considerable talents and resources.

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