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Further thoughts on health care: What became of cost control?
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Last month, I discussed an analysis by Dr. Atul Gawande regarding the widely disparate per person Medicare costs in various parts of the country, which appeared in the June 1, 2009, issue of The New Yorker. This month, I’ll discuss further an article by Dr. Abraham Verghese that appeared as an essay in The Wall Street Journal on June 20, 2009.
As some of you will be aware, Dr. Verghese is “one of us” — an infectious disease physician — who, owing to his abundant knowledge and skill, as well as his articulate and perceptive speech and writings, has quickly risen through the academic ranks and is now professor and senior associate chair of medicine at Stanford University. In his essay, titled “The Myth of Prevention,” he offers his critique of President Obama’s healthcare reform plans.
Dr. Verghese began by discussing the rightfully famous painting by Sir Luke Fildes titled “The Doctor,” which illustrated a physician at the bedside of a dying child, gazing intently at him, with the parents silently looking on with helpless concern in the background. This was painted in the late 19th Century and there was little the physician could do except to support the child — and his parents — as best he could, until death or recovery. It was an illustration of what Dr. Verghese referred to as “the sacred bond between doctor and patient.”
A sacred bond
When was the last time you heard the practice of medicine referred to as “a sacred bond”? For many of us, the answer will be “never.” Rather, the practice of medicine is most often referred to as a business, subject to the same vicissitudes as any other business in a capitalistic society. It is infrequently referred to as even a profession — let alone a sacred bond. Medicine is also often referred to in unflattering terms describing physicians’ seeming preoccupation with acquiring wealth.
All the more unusual, therefore, was that when President Obama appeared before the AMA convention to describe his reform plans, he was applauded warmly — or at least politely. One comment that was not applauded was the president’s reference to “a system of incentives where the more tests and services are provided, the more money we pay.”
Dr. Verghese went on to describe his greatest problem with the Obama health care reform plan: the President’s belief that better preventive care will achieve substantial savings to the health care system and help cover the incremental costs of reform. Dr. Verghese examined that projection and concluded that it is likely not true. Certainly an increased emphasis on preventive health care is overdue and would be welcome. Attention to diet, exercise, immunizations, lipid profiles and many other preventive measures are sorely lacking. But it is highly unlikely that such care, however welcome, will ultimately generate the billions of dollars in savings necessary to pay for universal coverage, perhaps the most expensive feature of the president’s plan.
Dr. Verghese went on to describe his belief that the only way the government can control costs is through its vast purchasing power, to achieve concessions on physician fees, hospital services and yes, on the price of drugs. Administrative costs could be controlled by using the Medicare model, with its 3% overhead, and disallowing private insurers from cherry-picking patients.
Little wonder that the Congressional Budget Office blew the whistle on the President’s plan a few weeks ago, pointing out that their cost projections would result eventually in bankrupting the country. Note also that the AMA still officially supports the president’s plan, a sure sign that there is not yet significant cost control built in.
Two “Perspective” articles, published online on July 29, 2009, in The New England Journal of Medicine, discuss these issues further in rather blunt terms. The first, by Dr. Robert Steinbrook, titled “The End of Fee-for Service Medicine? Proposals for Payment Reform in Massachusetts,” (10.1056/NEJMp0906556) relates that a special commission on health care payment has proposed that the Massachusetts health care program effectively terminate the present system of fee-for-service medicine and replace it with a system of risk-adjusted capitation and pay for performance, with a strong emphasis on the primary care disciplines. A series of “accountable care organizations” would be created, composed of hospitals, physicians and other providers working in concert, that accept responsibility for all or most of the care that their patients might need. Such organizations are not at all new, and were described further by Dr. Gawande in his New Yorker article.
Kaiser-Permanente, in all its locations, is probably the best known example of an “accountable care organization,” but there are smaller ones in many geographic areas as well. This would represent a huge step in health care reform and, if adopted and successful, would certainly stimulate the formation of other such “accountable care organization.”
The second article, titled “Cost Control: Time to Get Serious,” by Dr. Daniel Callahan, (10.1056/NEJMp0905630) suggests that neither the President nor Congress has yet seriously confronted the cost-control issue. He points out the basic dilemma: Cost controls likely to be effective will not be politically acceptable; the reverse is also true: What is politically acceptable will not likely be effective.
Incremental steps
The (my) answer: Cost control must be done in incremental steps, small though they be, perhaps over a 10- to 25-year-period. This would require a level of political commitment that, frankly, we have rarely, if ever, seen in this country short of wartime mobilization efforts – a level that would transcend presidents, congresses and political parties. If it can be done in Massachusetts, however, there is yet hope for the rest of us. Medicine (ie, physicians), must become much less entrepreneurial and much more “professional.” That might well include abandonment of the almost sacrosanct fee-for-service model. Unless medicine can recapture, at least to some extent, “the sacred bond,” medicine will truly have “lost its soul” (Dr. Atul Gawande). It’s not at all a pleasant prospect.