Reforming medicine from the inside out

Rather gloatingly, Hillary has indicated that healthcare reform is back on the table.  I’m familiar with the problems of the uninsured, I know about the benefits of and problems with Medicare, I know about skyrocketing drug prices, etc.  I can confidently argue both sides of each issue, since each side has good and bad points.  None of those, though, are the things I want to talk about.  I want to talk about how doctors have learned to use the system.  The following is a true story (swear to God) which happened to someone I know with premium health insurance.

My friend has a long history of ulcers.  A year or so ago, he started feeling sick with the typical symptoms of an ulcer.  He made an appointment to see his internal medicine doctor.  Now, if I were the doctor in  cost effective world, I would begin with non-invasive the blood test for H. pylori (although that’s not determinitive, since that bacteria isn’t the only thing that causes ulcers).  If it was positive, that would have dictated a straightforward treatment.  Even if there wasn’t any H. pylori, based on the patient’s symptoms and health history, I would have written a prescription for Prilosec (or just told my friend to buy it OTC) and said, “Let’s see what happens in a couple of weeks — and be sure to contact me immediately if you get worse, not better.”  If the symptoms went away, I would be pretty comfortable believing that I had correctly diagnosed my patient.  But that’s not what happened to my well-insured friend.  Here’s what happened:

He was told to make an appointment with a gastroenterologist for an endoscopy.  My friend met with the gastroenterologist before the endoscopy.  Ka-ching.  My friend went in for the endoscopy.  Ka-ching.  My friend, rather than receiving a phone call saying “You have an ulcer; take some Prilosec,” was required to go back to the doctor for a “hear the news” appointment.  My friend went back, was told he had an ulcer, and was given a prescription for Prilosec.  Ka-ching.  Six weeks later, my friend was told to have another endoscopy to ensure that the ulcer was actually gone (the cessation of all symptoms apparently being inadequate to prove this point).  My friend underwent another endoscopy.  Ka-ching.  My friend, rather than receiving a phone calling saying “You’re good to go,” was required to go back to the doctor for a “hear the news” appointment.  My friend went back, and happily learned that he was “good to go.”  Ka-ching.

Now, you can’t entirely blame the doctors for engaging in this kind of fantastic overreaching.  Between deadbeat patients, low Medicare payments, and obscenely high insurance premiums (so let’s all give a loud Bronx cheer for the plaintiffs’ bar), it’s completely logical for them to engage in entirely legal, professionally accepted behavior that helps fund their practices.  The problem for Americans, taxpayers and patients alike, is the role that little Medicare payment plays in this cycle.  Medicare payments are so low, in part, because there are so many demands on Medicare.  But there are so many demands on Medicare, in part, because the payments are so low that doctors have to maximize their number of Medicare contacts to make ends meet.

It would be easy enough to say that Medicare payments should be structured to reward physician efficiency.  That sounds good in theory, but the dismal HMO stories of the late 1980s and early 1990s demonstrate that, when medical efficiency is the criterion for a doctor’s financial remuneration, there are some who will, or feel forced to, give substandard care.  And that, of course, leads one into the whole icky, sticky question of what is adequate care, what is substandard, and what is gold standard — and who is entitled to or who should suffer from each of those standards?

My favorite model is the Kaiser model.  The doctors are salaried, so they have no incentive to go overboard to ramp up their income.  The expensive testing equipment is owned by the institution, so no one doctor feels compelled to give myriad unnecessary tests to pay for the cost of the equipment.  It’s no surprise to me, therefore, that Kaiser consistently rates as one of the better care providers in America.  It’s not perfect, of course.  First of all, no human-run institution is going to be perfect, and the medical profession has lots of room for error.  Second, because the physicians are salaried, some of the best and brightest may opt for the financial possibilities in private practice (and in elective and/or cosmetic surgery).  Nevertheless, system-wise, I think it’s the best thing going, because it minimizes the incentive for fraud, without destroying the doctors’ and nurses’ desire to do the best they can for the patients in their care.