Introduction
Section titled “Introduction”What are we trying to accomplish? Care for the poor? Reduce overall cost? Reduce infant mortality? Let's approach these problems directly, by examining the grounds in which they grow. I do not believe one change, even to a single-payer payment system, has any hope of really improving our system. Improvement must be incremental. You need to consider all the other factors in society. You don't go from a horse carriage to a jet airliner without changing an entire transportation system.
Separate family practice education from pharmaceutical and specialty influence
Section titled “Separate family practice education from pharmaceutical and specialty influence”Your family doctor works very hard to bring you quality medical care at the most reasonable cost. She does this in a social and medical climate that values medical specialists more than family doctors. Yet, general medical practice requires a comprehensive knowledge of a far greater variety of illnesses than does any specialty. It requires greater judgment to balance the often conflicting information given out by these various specialists. The challenges of motivating patients to change, of dealing with family systems, and of helping people over a period of years and decades fall on the shoulders of family doctors, not the specialists.
Family doctors are trained in large part by specialists, as well as by seasoned family practitioners. We are as reluctant to argue with those specialists, as would the furniture maker be loath to contradict the man who spent a lifetime perfecting the drawer pull. But we need to lose the illusion we have that he who knows the liver best has superiority over he who deals with the whole person.
We must also free our educational systems from the need for support from pharmaceutical companies. This is an expensive subsidy, for entire generations of physicians become thus convinced that all illness is best approached through a pharmaceutical means. Yes, yes, yes, many people find that a tablet a day is a more workable means to reduce their risk of heart attack than is a better diet or exercise. Yet the physician must have the depth of knowledge to let the patient know what options for treatment exist.
In our office, people can see what we do and when they feel the need for our advice, they ask for it. Health is not so much a product of X-ray machines and needles. These are just tools. The fundamental healing force is the will and effort of the physician and the patient, working together. Our medical educational systems must be redesigned with this major truth in mind.
Re-Energize Public Health Efforts
Section titled “Re-Energize Public Health Efforts”Public health is the name we give to health measures delivered to society as a whole. Public health has provided more benefit to society than anything we physicians have done for individual patients. The horrendous tuberculosis epidemics of the 1800's and the plagues of the preceding few hundred years are no longer with us. Antibiotics are not the reason. Public health workers reduced the death rates with campaigns for clear air and water, better housing, safe workplaces and workhours, garbage collection, and other hygienic measures.
Public health workers ended the spread of SARS a few years ago, continually work in disaster preparedness, oversee vaccination programs, ensure food safety, and identify and interrupt epidemic illness.
Public health, however, is the Cinderella of the health care world, chronically starved for funds and almost invisible in the media.
Like all our infrastructure, public health provides huge benefits for each of us; disease prevented is better than disease treated. Yet public health appears on the political radar screen only in times of catastrophe.
We need to
- adequately fund existing public health efforts
- strengthen efforts to reduce environmental toxins that cause disease
- implement new public health techniques such as community-wide treatment of high blood pressure and high cholesterol to prevent stroke and heart attack
- require businesses that use public airwaves to broadcast public health educational material
Infant Mortality
Section titled “Infant Mortality”Because infant mortality is greatest among poorer families, we need to address the problems of the underclass. Single-payer medicine will not restore the family, reduce drug abuse, bring doctors into rural Alabama, or end wife-beating. Helping people of all talents enter the workforce should be our primary goal. We need to make our political and legal system work as well for the ordinary person as it does for the super-educated and the super-intelligent. We need to declare the war on poverty and the war on drugs lost. Let's think a bit, put our hypocrisy to one side, and start over.
Separate health insurance from employment
Section titled “Separate health insurance from employment”Give individuals the same rights a corporation has to purchase health insurance with pre-tax dollars. Don't tie health insurance to the employer.
Improve medical licensing
Section titled “Improve medical licensing”Currently a doctor or other health care provider is given a license to practice after meeting certain requirements. Most states require that doctor to participate in continuing education; 25 hours a year is a common requirement. Much of this education is sponsored by pharmaceutical companies.
Beyond this, I would like to see the licensing agencies take a more active role in monitoring physicians. The best way would be to send undercover investigators to each physician in the role of patient. These people could identify physicians who record procedures they did not perform, or who fail in diagnostic and treatment challenges, or who otherwise require more supervision or re-evaluation of licensure. Yes, the AMA will cry that this tramples a physician's civil rights. Yet, commercial airline pilots are routinely required to demonstrate competence. Why shouldn't a physician?
Understand the American Medical Association
Section titled “Understand the American Medical Association”We need to recognize that the AMA promotes the interests of its member physicians, who comprise only a quarter of all US physicians. The AMA, at least in recent memory, has a poor track record of promoting the interests of anyone else. Currently, for example, the AMA is opposing licensure of naturopathic physicians.
Increase use of health savings accounts
Section titled “Increase use of health savings accounts”Health Savings Accounts are the best way for us to have maximum control over our health care choices at minimum expense. These combine
- the Health Savings Account itself, into which you put pre-tax dollars
- an insurance policy to cover major medical expenses, also paid with pre-tax dollars
You may use the Health Savings Account to spend on your regular medical and dental expenses, including medications. You add to the account each year. The account gains interest tax-free. Unused amounts carry over from year to year. Should any money be left at retirement, it can be transferred into your IRA. The insurance policy covers catastrophic medical expenses that exceed the amount in your Health Savings Account.1
Critics of this program called it a savings plan for the wealthy. Events proved them wrong, as 40 percent of Health Savings Accounts are being started by previously uninsured individuals.
Get rational about care of the indigent
Section titled “Get rational about care of the indigent”Every aid organization in the world knows that highest goal is to enable people to care for themselves, to "teach them to fish instead of giving them a fish." There are many uninsured people who might find a government-subsidized or sponsored Health Savings Account empowering. By giving that person a stake in the cost of medical care, there is a high probability the net taxpayer cost would be less than with any other plan. Study after study shows that when a person's job goes away, so does their health. We must improve our policies regarding the indigent. We need to empower people and hold them responsible as well.
Allow providers to provide discounted care
Section titled “Allow providers to provide discounted care”Medicare pays the hospital about 30 percent of what the "rack rate" is. If the hospital charges the uninsured patient less than the "rack rate", then Medicare pays less. Solution: allow the hospital to give patients fair rates without suffering a Medicare penalty.
Similarly with physicians, if a physician gives a Medicare patient free or discounted care, Medicare can (and has) viewed that as fraud.2
Patients must be aware of prices before buying
Section titled “Patients must be aware of prices before buying”Require all doctors and hospitals to publish the price of all medical services.
Patients must have ready access to medical records
Section titled “Patients must have ready access to medical records”Physicians can and sometimes do destroy patient records after the required waiting period of seven years. Patients often have repeat testing because previously obtained tests are not available. Costs often increase when laboratory reports, operation reports, and hospital summaries are not available to subsequent physicians. Patients often have to wait long periods of time before receiving requested medical records. This has to end.
Patients must be able to have knowledge of physicians and other health care providers
Section titled “Patients must be able to have knowledge of physicians and other health care providers”The internet often gives us consumer ratings of vendors, such as on Ebay, so that we may know what we are likely to encounter. We need to require providers to allow patient evaluation via the internet, for all to see. Some physicians have sued when their ratings are low. This must end.
Allow lawyer-free care to those who choose wish
Section titled “Allow lawyer-free care to those who choose wish”Washington State's Department of Social and Health Services spends millions of dollars a year in payments to attorneys for malpractice claims. (And an equal amount goes to patients.) Senator Patty Murray proposes qualified malpractice liability relief to physicians with a high Medicare and Medicaid caseload.3 Were you ill, would you or would you not wish the option of a low-cost medical facility, even if lawsuit-free?
Allow insurance companies to sell "no-frills" health insurance
Section titled “Allow insurance companies to sell "no-frills" health insurance”Most states will not let you buy "no frills" insurance, instead choosing to require coverage for things like hairpieces in Minnesota and alternative care in Washington State. Personally, I'd prefer the choice of insuring only for standard medical care.
Re-invent the pharmacy
Section titled “Re-invent the pharmacy”Allow pharmacists to streamline the process of dispensing drugs. If federal regulations have affected pharmacies similarly to their effect on physicians and hospitals, there must be dozens of ways to reduce pharmacy costs and improve service.
Decentralize where possible
Section titled “Decentralize where possible”Allow the individual states to govern marijuana use, euthanasia, and other local medical issues.
Restore public funding of research
Section titled “Restore public funding of research”Increase public support of medical research so that we can get big pharma's thumb off the research scale.
Give insurance companies power to save your money
Section titled “Give insurance companies power to save your money”Allow insurance companies to choose which doctors they wish to deal with. Some doctors are very good at milking the system. The insurance companies don't wish needlessly to get between you and your doctor, but they should have the ability to provide health care at the most reasonable cost. They are in a position to know which doctors are most cost-effective. Recently a major Washington insurer tried to weed out its clunkers. Unfortunately the de-selected physicians complained and your money wasn't saved. The Washington State Medical Association supported the de-selected doctors, asking that the insurance company use different criteria for their process.
Deal more intelligently with medical errors
Section titled “Deal more intelligently with medical errors”Rationalize the way we deal with poor medical outcomes. We need to end the medical malpractice lottery and replace it with special medical courts to rule on medical errors and fairly compensate the patients. Next, we need to allow medical licensing boards to evaluate physicians who have erred and take appropriate action to protect patients.4
Stop the child abuse cycle
Section titled “Stop the child abuse cycle”Huge amounts of money are expended on people using methamphetamine and other "terminal" drugs. Even more money is spent caring for the children they beat up. We must stop returning these children to these families. The political impulse that "people are victims" leads to society's abandonment of these children. The political idea that "people can't be held responsible for their actions" poisons our society, especially in welfare states such as Great Britain. Read Life at the Bottom by Theodore Dalrymple.
Take a cold, hard look at medical technology
Section titled “Take a cold, hard look at medical technology”Provide for a neutral forum for medical technology assessment. This could provide the ability to separate agreed upon information from controversial information, as does Wikipedia. That forum allows for discussion of controversy on subsidiary pages. It could also provide evaluation of health care information sources, in the same way that people evaluate books and products at Amazon.com.
Richard A. Deyo, MD, in Hope or Hype: The Obsession with Medical Advances and the High Cost of False Promises points out that new medical technologies, including pharmaceuticals, increase the cost of medical care by selling methods that often do not prove cost-effective, or effective at all. For example, the FDA doesn't require new drugs to face head-to-head comparisons with older drugs. It should. Sometimes the older drugs are more effective. Hydrochlorothiazide (HCTZ) for hypertension is one example of an older drug that reduces mortality as well or better than the newer models.
Use the power of the internet
Section titled “Use the power of the internet”Allow responsible use of the internet to provide health care and information, allowing physicians and patients to maintain contact and care relationships across state lines. For example, entrepreneurs could engage, 24/7, experienced specialists of all types to answer questions over the internet, an endeavor that would not be cost-effective on a state-by-state basis (which is all current licensing laws would allow.) Digital imaging, and patient possession of all their medical records, would improve the quality of this service. This may require changes in state and federal regulations.
Allow new categories of care providers
Section titled “Allow new categories of care providers”Create a range of new medical training levels and specialties. For example, a fully qualified gastroenterologist with a certain amount of experience should be allowed to train and supervise nurse practitioners or physician assistants to perform colonoscopy or endoscopy. The gastroenterologist would have to be on site to provide supervision, oversight, and care for any complications.
This would introduce needed competition into the medical marketplace. For example, you may notice how even the price of high-tech procedures such as LASIK has become much less expensive with competition. We could see the same thing with many surgical procedures if, and only if, there is a reason to compete, as there has been with the LASIK procedure.
Change medical training
Section titled “Change medical training”Allow people to enter the health care field with some initial training, then study to improve their skills and responsibilities while performing appropriate health care tasks under supervision. The military "corpsman" program should be thus emulated, with scholarships to academic medical training for those advancing in skill and wishing to work in underserved areas.
Get real about marginal benefits
Section titled “Get real about marginal benefits”If you break your arm, that $200 X-ray provides a great benefit, as does the $300 emergency evaluation to be sure you've damaged no nerves or blood vessels, and to determine what kind of treatment is required. The initial cast or splint is valuable. After that, each dollar spent on orthopedic or other care brings less value. The second or third X-ray helps that orthopedic surgeon avoid a lawsuit, and physical therapy beyond a few visits helps you get back to full performance sooner, but again, less value per dollar spent.
Similarly with a skin cancer, those initial bucks at the dermatologist bring a lot of value. Go back every year for a routine follow-up that your family doc does anyway at your annual check-up, and those dermatologic dollars go straight down the drain.
Some economists estimate that about the first 70 cents of each health care dollar bring some value, and the last 30 cents are entirely wasted.5 I think they are being generous.
We all understand the cost-benefit curve in everyday life, because we're writing the checks.
Spending that last 30 cents is much easier when it is someone else's money. Physicians can spend it to avoid lawsuits, to increase income, or just to make their lives easier. Patients can encourage us to spend it because of reluctance to face emotional issues, or from anxiety. "My cousin was just diagnosed with multiple sclerosis. Do you think I should see a neurologist?"
Reform the FDA
Section titled “Reform the FDA”Make the process of approving drugs up to date and fair. Remove the political component.
Split the responsibilities of the FDA into two parts. Right now the FDA approves drugs, then monitors safety. We should separate that, as do other agencies. For example, the US Federal Aviation Administration certifies new aircraft. The National Transportation Safety Board investigates accidents and decertifies aircraft if necessary. Similarly, the FDA should not be given the conflicting responsibilities of approving drugs for market and then having to second-guess itself.
The safety arm of the FDA could then involve itself with better post-marketing surveillance
Control anti-competitive behavior
Section titled “Control anti-competitive behavior”End restriction of the number of doctors trained. Under current practices, when the number practicing seems too high, the training programs6 will restrict their supply of orthopedic surgeons. We do not allow any other industry to monopolize a market in that way. We are paying a price for allowing certain medical specialty boards to restrict competition. If we end that, we will see the same kind of competition we see for dental service.
Rationalize federal health care regulations: Let Nurses Nurse, Not Complete Endless Paperwork
Section titled “Rationalize federal health care regulations: Let Nurses Nurse, Not Complete Endless Paperwork”If you go to the local hospital or nursing home, you'll find the nurses spending up to half their time completing reports, not serving patients. We need to entirely review and revamp medical regulations. Up to now, when someone cuts a corner or engages in fraud, the government response is less to punish that individual and more to add to the voluminous health care regulations. Result: slipshod work is ignored while the conscientious nurse ends up filling out more forms.
End Corporate Shenanigans
Section titled “End Corporate Shenanigans”Richard A. Deyo in Hope or Hype: The Obsession with Medical Advances and the High Cost of False Promise reports on a number of abuses.
- The National Sleep Foundation is an example of a purportedly health-oriented organization that is actually mainly funded by pharmaceutical companies. Prior to the release of Lunesta, the Foundation sponsored a "National Sleep Awareness Week" and other similar activities. Also, around that time, companies "assisted" physicians in preparation of articles bashing older sleeping agents. These articles appeared in reputable medical journals.
- Betty Dong, UCSF, agreed to study Synthroid for its manufacturer, Boots, Inc. Boots designed the protocol, monitored the project, but in the end all the different forms of thyroid replacement were found to be equivalent. Dong had contracted with company not to publish without permission, and so she did not. The company published the study with a conclusion favorable to themselves. When Boots sold Synthroid to Knoll Pharmaceuticals, Knoll relented and the actual facts were published in JAMA in 1997.
- There are similar stories about Herb Needleman, who studied the neurotoxicity of lead paint. And James Kahn, at UCSF, about an AIDS vaccine that was ineffective. And David Kern, who reported the lung toxicity of nylon flocking, and lost his job.
Recognize That Complex Regulations Favor the Large Corporations, Not Your Neighborhood Doctor
Section titled “Recognize That Complex Regulations Favor the Large Corporations, Not Your Neighborhood Doctor”When the federal government passes HIPAA, the "health privacy act" or complex OSHA regulations, all medical businesses must pay attorneys and/or consultants to be certain they are complying with these new regulations. The cost for Dr Welby is much higher, relatively, than it is for the Hospital Corporation of America. This is another reason so many local physicians work for the hospital district.
Require more realistic pharmaceutical ads
Section titled “Require more realistic pharmaceutical ads”Direct-to-consumer advertising is legal only in the US and New Zealand and ensures that a new drug is widely disseminated quickly. Most people do not know that the patent on a pharmaceutical agent begins to run immediately. It may take up to ten years to get that drug through the FDA, after which the company doesn't have much time left to recoup its investment. So I think they should be allowed to advertise. That said, we should require pre-approval of drug ads. Currently, by the time a campaign is judged to be misleading, it has run its cycle.
Redesign new drug approvals
Section titled “Redesign new drug approvals”Give conditional FDA approvals, and phase in use of new drugs.
The Art of Political Compromise
Section titled “The Art of Political Compromise”While interest groups chafe at some of these recommendations, there should be benefit for all. There should be enough "give" to compensate the "take."
Acknowledgement
Section titled “Acknowledgement”Joe Messerli at http://www.balancedpolitics.org/editorial-solution_to_health_care_crisis.htm provided the initial idea for this section.
1 Health Savings Accounts are available at Brent Shirley Insurance and other agencies.
2 http://www.chirobase.org/19Insurance/noope.html
3 http://murray.senate.gov/medmal/index.cfm
5 http://econlog.econlib.org/archives/2005/06/healthy_debate.html
6 US Federal Trade Commission, at http://www.ftc.gov/be/workshops/healthcare/nicholsonslides.pdf