In all the politics surrounding the town halls and the proposed legislation to overhaul our health system, we have backed away from the notion of real health care reform and see to be just concentrating on insurance reform. But insurance reform doesn’t control costs, and doesn’t make Americans healthier. It just tinkers at the margins of a problem that also includes how doctors are reimbursed, what society should pay for, and what constitutes rationing.
Here are two terms that should be in a discussion about reform, and don’t seem to be. People who really understand how the system works, like Mayo Clinic or Kaiser Permanente, have said repeatedly that reimbursement and incentives should be changed so our health care system is less of a sick care system.
Learn these terms, in case someone gets smart and the discussion changes focus:
Outcomes-based medicine: paying the provider (doctors or hospital) for things that actually work, rather than for treatments the patient comes in requesting, treatments that are worth a lot of money when the provider bills the insurance company, or treatments that take place in settings owned by the provider (the MRI machine owned by the syndicate of doctors).
For a number of reasons, mostly financial, that come from the current reimbursement structure of Medicare and private insurance companies, providers must “game the system” to survive. So there’s a tendency to do what Medicare will pay for (or Blue Cross, or Cigna) rather than what has been demonstrated to work.
For example, exercise, low salt diets, biofeedback and meditation have been shown to control blood pressure, but no doctor is paid for prescribing them. Nor are doctors paid in general for talking to or educating patients. We could easily cut costs by paying doctors to get all the blood pressure patients in their practices under control rather than paying them for office visits to monitor the pressure, drugs to control it, or tests to determine it. This would mean the labs, drug companies and doctors would have to work together to get the patient’s blood pressure under control –or nobody would be paid.
Certain conditions and diseases, mostly chronic like asthma, high blood pressure, diabetes and heart disease, plague two thirds of the population and soak up much of our health care money. These diseases and the costs that accompany them can be brought under control only by changing the incentives for physicians, who are now paid to do MORE, not less.
Comparative effectiveness research: About thirty years ago, heart bypass surgery was invented. It became immediately “the rage,” and hospitals developed elaborate surgical suites; cardiac surgeons became the highest earners. Then along came the less invasive “stents,” which opened the blocked arteries and kept them open, and were cheaper. Stents were discovered by cardiologists who were fearful that they were losing business to cardiac surgeons. Thus was born interventional cardiology.
Recently I read a study that compared patients with similar heart disease who had cardiac surgery to those who had interventional cardiology procedures (angioplasty), to people who were only using prescription drugs. And guess what? People with heart trouble didn’t live any longer whether they had heart bypass surgery, stents, or drugs! Do you understand what that means? For years hospitals have built expensive cardiovascular surgery suites for their cardiovascular surgeons to operate in because the procedures made both doctor and hospital so much money from insurance companies. The surgeons went wild when it was discovered that the same results could be gotten with stents, far less invasive and expensive. So the hospitals then built interventional cardiology labs. And now we are hearing that patients do just as well controlled by drugs.
Which could give way to a study that says diet and exercise are just as effective as any of the more expensive remedies if you stick with them.
Do you see where I’m going with this? Many of the problems that cost society dearly come from lifestyle choices. It’s impossible to make Americans exercise and lose weight. But now that we know prescription drugs are just as effective as more costly interventions, perhaps we should stick to those as a standard of care.
The only way to “bend the cost curve” is to change the way doctors and hospitals are reimbursed, and give them more money if they keep patients well in the first place. For a medical community that is used to being reimbursed best when the patient gets to a crisis, this is a huge shift. But the most savvy docs already know it is coming.