Don Parsons, MD: Herding health care’s sacred cows and bulls
In the pasture of health care we have a large herd of Sacred Cows, untouchable lest the entire herd collapse without their sacrifice. Among these cows are a few Sacred Bulls, so essential that many observers regard them as the sine qua non, integral to “American” health care.
Among the Sacred Cows are such well-known and widely accepted cud chewers as solo practice; the doctor as “the captain of the ship”; out-of-pocket payment for medical care and prescriptions; unlimited prescription authority rests only in the hands of doctors; high prescription prices; hospitals are places we go to die; we can’t make a diagnosis without extensive laboratory testing and imaging; every patient with a complaint must see a doctor in person, and probably a specialist for a second opinion; only MDs and DOs can practice medicine; doctors are allowed and expected to have illegible handwriting. If you want to test these inviolable principles, start your sentences with “In American medicine, it is true that ….” And end with “… and without that, our quality of medicine will suffer greatly.”
Yet we know that many of these Sacred Cows of medical care of past times have now changed. Solo practitioners are seeking employment or coming together in group practices. Teamwork medicine is gradually replacing the autonomy of the dominant physician. Many prescriptions are covered by insurance, and prescribing is safer now. We have hospices, home care and long-term care settings for dwindling or dying patients. At least some diagnoses can be made without a million-dollar workup. Doctors now have midwife, nurse practice, physician assistant, colleagues as well as psychologists, alternative medicine practitioners and others who provide excellent care. Computer-based records will soon make illegible handwriting irrelevant.
In this herd of Sacred Cows, there remains many principles and practices that define “American Medicine.” Let’s call some of them “Sacred Bulls” because they are so powerful politically, culturally and financially that we have a hard time conceiving of our health care system without them. Four big ones stand out. Unless these “Bulls” lose their manlihood or go away entirely, our health care “system” will continue its relentless advance toward collapse.
The first is fee-for-service medicine. This drives utilization of services, especially procedures that are more highly paid than evaluation and management of chronic disease, say. Most medical students now want to be procedural-based specialists, not primary care docs. Thus, the cost of medical care is ballooning due to a large and growing number of more and more expensive procedures of marginal value. Sometimes, unnecessary, inappropriate or questionable care is provided at great cost to somebody and at great risk of complications and harm to the patient. Under the new health reform law, with the emergence of bundled payments, accountable care organizations, medical homes, payment based on episodes of care, salaried physicians and other innovative payment mechanisms, we may be able to turn this Sacred Bull out to pasture in our lifetime.
The second Sacred Bull is for-profit health insurance, which relentlessly drives up the cost of gaining access to care, siphons off great chunks of money for the purposes of disputing and denying claims or rescinding policies, and obscenely enriches those who dream up ways to keep money in the treasury of the insurance establishment. Closely related are for-profit hospitals and other entities that are subject to fraud, waste and abuse. The recent health reform law requirement that insurance companies spend at least 80 percent of their revenue on medical care for their clients is helpful but is being fought by – you guessed it – the for-profit insurers.
Third in the herd of Bulls in the Sacred Herd is employer-based insurance. This concept came about during World War II when wage and price freezes made it difficult for employers to compete for scarce labor, so they invented “benefits” such as health coverage. We have seen the consequences of the down side of this practice in the current recession where many new unemployed, or even the employed (and their dependents) of struggling businesses have lost their coverage, now amounting to 59.1 million uninsured by latest CDC estimates – up from 46 million just four years ago. This sounds like a real death spiral. Unless we change this practice by either providing for portability of insurance that is not employer-based, or creating access to health care without insurance, such as through a single-payer system, we will bear the burden of a growing population of uninsured citizens. Aside from the moral question “Is this right?” – can we afford it?
The Fourth Bull is the notion that cure is better than prevention. Eat, drink and be merry, for tomorrow you can go to the medical establishment and get fixed. Over 50 percent of the burden of disease (morbidity and mortality) in our society stems from just three choices we make as individuals: whether we smoke, what we put in our mouths, and whether we exercise (see http://www.3four50.com). We have an expanding epidemic of childhood (and adult, for that matter) obesity, a preoccupation with sedentary jobs and leisurely pursuits, and 500,000 Americans dying each year from smoking-related illness-many times that number who are sick but not yet dead. Can we convince people to take responsibility for their own health?
And finally, if prevention of illness is an individual responsibility, prevention of hospital and doctor- and pharmaceutical-induced complications, infections, reactions, wrong site/wrong patient surgery must be accomplished. Sloppiness, carelessness, arrogance, ignorance in this age of computers, deafness to the patient and family, lousy teamwork and communication and handover of care, all must change and improve rapidly. This would be the very best form of addressing our malpractice liability problems: stop malpractice.
If the Sacred Bulls grow stronger, and the Sacred Herd grows larger, the strongest fences in our health care/medical care pasture will not keep them from stampeding and trampling our “American” health care system – not “the best in the world.”
Don Parsons lives in Dillon, is a retired general surgeon and Kaiser Permanente executive, a health policy and public health expert, serves on the Boards of Saint Anthony Summit Medical Center and the Community Care Clinic, and is executive director of the Colorado Patient Safety Coalition.
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