Some 30 to 50% of the medicine practiced in this country is essentially useless subjecting many to unnecessary risk, morbidity and even death to say nothing of the attendant financial damage to the patient and society. The only logical explanations for this are: A. ignorance on the part of physicians; B. financial interests and incentives; C. perceived “protection” from the legal system and D. patient pressure.

What has developed over the last half century are adversarial relationships among some major social structures e.g. the medical system, the government, the legal system, the insurance industry. These relationships have soured the attitude of many great physicians to the point where they freely admit they are not enjoying themselves anymore and continue in practice just to make a living while anticipating as early a retirement as possible. The physicians most affected are the disillusioned ones that entered practice for all the right reasons; the ones who practice purely as a business venture are not so affected. Roadblocks are viewed as just a “cost” of doing business.

The end result of all this is the quality of medical care is deteriorating, the cost increasing, the number of applications to medical schools falling, and patients are slowly being forced to relinquish their freedom to choose. Our current approach of burdening medicine with mountains of paperwork, protocols, rules and regulations is only making things more complex, unmanageable, impersonal and expensive.

Worst of all is that we are hemorrhaging primary care providers at a rate faster than we are making them. Major players such as General Motors, Toyota, IBM and GE look at countries with similar health outcomes that we have such as Belgium and Denmark and duly note they spend 1/3^rd the cost per person on healthcare. The major difference is they have MUCH better primary care delivery than we have.

The key problems are:

1)    How are we going to pay for our medical care?

2)    How are we going to protect doctors from frivolous law suites?

3)    How are we going to limit unnecessary, wasteful medical care?

4)    How are we going to improve the quality of care?

5)    How are we going to reconstitute our primary care system?

How Are We Going to Pay For Our Medical Care?

Medical care is always going to be inherently expensive. It takes highly trained people and expensive technology to provide the best medical care. As individuals, what we are interested in is getting the best value per dollar spent which means not having to pay for unnecessary medicine, someone else’s medicine, and elements associated with medicine (like insurance bureaucracy and frivolous law suits) that have nothing to do with quality medical care.

The medical system can be divided into two distinct compartments: primary care and secondary care. Primary care is what you should be getting from your family’s personal physician. It is relatively inexpensive and should serve as an entry point to the rest of the medical system, which is secondary care. Secondary care is very expensive. The concept behind health insurance is to protect our financial welfare not your medical welfare. Primary care never gets that expensive; secondary care easily can get that expensive.

We buy insurance to protect ourselves from the expense of secondary medicine. The insurance companies-with some help from the federal government-devised the notion of using primary medicine to control the utilization of secondary medicine. They realized, appropriately I might add, that much of the medical care dispensed by this system was unnecessary. Guess what? It didn’t work.

Just as much, if not more, unnecessary medicine is practiced today as 20 years ago. Now, on top of this, we have the bureaucratic expense generated by this approach—which is staggering. What we have been handed is privatized socialized medicine. But worse still, in addition to the financial downside, is the destruction of quality primary care which, in turn, makes all the other problems far more damaging. And so, we have a vicious circle. If, instead, primary care doctors were appropriately trained and were allowed the time to develop the quality relationships they should have with their patients much of the unnecessary medicine and all of the unnecessary bureaucracy could disappear. Insurance premiums could drop as much as 30%

With today’s system in order for a primary care doctor to earn $50 someone somewhere has to spend $200.00 Modern primary care doctors have to see more than 15 people a day just to pay the bills the end result being that most of them are seeing more than they can appropriately handle. If they don’t overbook they starve. So, what they tend to do is dump problems which they could easily handle on higher cost providers just to keep the traffic flowing. If you get rid of all the bureaucratic nonsense, primary care can be practiced in a far less expensive manner. A doctor can make a very reasonable living seeing no more than 14 patients daily and those 14 patients get much more attention, better care, and many more viable reasons to have confidence in their doctor. The end result is much less drift to higher cost providers like emergency rooms. So, solution number one is to GET THE INSURANCE COMPANIES OUT OF PRIMARY CARE.

As soon as you ask any entity, be it the government or an insurer, to cover the cost of any service, along will come rules, stipulations and suffocating bureaucracy. You now also have to cover the overhead and profit expectations of that entity. The end result is that a $50 office visit winds up costing $200. People have to stop looking for insurance that pays for everything and start looking at maintaining control over their health expenditure by moving to high deductible plans which are generally much cheaper and return primary dollar control to the patient. The newly enacted Health Savings Plans are icing on the cake. Now you can take the deductible and place it tax free in an IRA form which you can pay for all qualified medical expenses without penalty. What you don’t spend stays in the account and accrues tax free. All employers have the choice of obtaining such plans for their employees. Employees need to exert political pressure on their employers to do so.

Doctors are part of the problem. We let it go this far in spite of knowing that the current system is destroying primary care. I for one am getting sick and tired of hearing other doctors complain. If you don’t like what has happened, FIX IT. Nobody is forcing doctors to sign these ridiculous insurance contracts. They tend to feel if they don’t sign on they will never get any patients. There are huge numbers of people who have grown tired of the HMO scene. They are actively looking for other options but those options start and end with us doctors. We need to be offering them alternatives. If we don’t there won’t be any alternatives available. People join my practice because I offer a viable alternative. Pretty soon, I’ll have to close the practice to new patients and there is not one, single other physician practicing this way in the area in spite of so many doctors feeling disillusioned. Doctors unite!  Do the right thing and the world will beat a path to your door. People, if you like what I’m doing tell your doctor about it. Tell him or her you wish they would do the same.

People always ask me about the 40 million uninsured in this country who are presented by the politicians as being somehow disadvantaged and in terrible danger. As my Great Grandmother was fond of saying, the BS is flying now! The Elderly have Medicare, the truly poor have Medicaid. Anyone who presents to an ER will be treated regardless of their ability to pay.  A visit to most primary care doctors cost perhaps $50 - $75.00. The 40 million uninsured are, for the most part, young working individuals, some between jobs, many self-employed, who CHOOSE not to purchase insurance because- after all- they are healthy and never need a doctor and would rather spend the money on something else—like a TV set.  The problem is that a certain percentage of them do get sick and wind up costing the rest of us a bunch of money. They are using the medical system but not contributing to it. The solution is simple. We make auto insurance mandatory. We need to make health insurance mandatory. But first we have to open the insurance industry to real competition by nationalizing it and getting the prices down. We can actually get rid of the Medicaid system and subsidize the insurance of those making less than a certain income. Will this bring everyone into the medical system? Heck no. I know several Wealthy men in their 50’s who refuse to buy insurance, and refuse to see a doctor for routine care. Only when they have a heart attack will they present to the medical system. Fortunately, they have enough money to cover the expense if they survive.

What about “Universal Healthcare”? You think medicine is bad now?  Over the years I have known numerous Canadian doctors who moved to the US. I have also seen numerous Canadians come to the US for healthcare. I know of ZERO American doctors who have moved to Canada and I know of ZERO patients who have gone to Canada for healthcare, although they do go up there for cheaper drugs.  Just recently I was offered a job running a private hospital just south of Shang Hai, China.  The Chinese hate their public health system and their fast-growing middle class is demanding private alternatives. They also love American doctors. The Chinese government is now donating parcels of inner city land to businessmen for the construction of private hospitals.

One way or another medicine has to be paid for either directly, via insurance companies or via taxation. As individuals, we want to maintain as much control over the situation as we can. The best way of keeping costs down is people being aware of the expense of the services they are utilizing so they do not use them unnecessarily and to keep involvement of other institutions to a minimum. We want to buy medical care, not bureaucracy, and the overhead and profit of insurance companies and the pharmaceutical industry.

Would a Universal healthcare system insure healthcare for all? Heck no. Many, like the wealthy men above will still choose not to use medicine appropriately like they choose not to wear seat belts. I might also add that politics in medicine was what got us into this HMO mess. Politics and medicine do not mix. Medical problems do not and should not have political or financial solutions. We need a constitutional amendment for the separation of medicine and state. I do believe the government has an important role in controlling the healthcare financing field. Legislation such a the creation of HSA’s is an elegant way of creating market alternatives that greatly benefit the individual and put pressure on the insurers to come up with cost-effective alternatives without eroding personal freedoms. Sometimes we are forced by human behavior to become more forceful for the benefit of all. Making health insurance mandatory is such an example. This seems drastic but I see no alternative.

How Are We Going To Protect Doctors From Frivolous Law Suites?

Doctors are a very different group of people. Much of the professional and business world operates on an adversarial basis. Such is the competitive nature of our society. But Doctors are supposed to be empathetic and work in cooperation with patients and the rest of the medical system. They are notoriously bad businessmen and better for it, I might add. Unfortunately, they do not handle the adversarial world of law and business very well.  They become insecure and defensive. The end result is an obsession with the potential of a lawsuit which often results in more concern for personal, legal welfare than for the medical welfare of the patient. Expensive and frequently risky defensive medicine is the product of this obsession. The cost of defensive medicine (in addition to the cost of defending against frivolous law suites) can, and will, damage our economy if it is allowed to continue.

80% of medical malpractice cases fail but the cost of defending against them is huge. Many lawyers knowingly take bad cases hoping to jerk a settlement out of the defendant. Insurers and doctors frequently settle just to make the problem go away instead of fighting for what is right.  If we do not want adversarial businessman doctors we are going to have to do something to protect them from this nonsense. Limiting the awards a plaintiff can get is NOT the solution. There are people who are seriously damaged by our medical system and they deserve to collect whatever thy can get. The real solution is to filter out the frivolous cases so that they do not cost us an arm and a leg and doctors can be confident that they will not be inappropriately abused by the legal system.

Doctors should be excused from the civilian legal system. Instead of doing jury duty they should be required to sit several days out of the year on panels reviewing medical malpractice claims. All medical malpractice claims should be brought before these panels and all cases with merit can proceed normally through the legal system, cases without merit dropped immediately without recourse.  Can you see the trial lawyers going for this? Unfortunately for them there is no other solution to this problem so, as a society we are simply going to have to shove it down their throats. What about the constitution? Doctors have a right to be tried by a jury of their peers. Their peers are other doctors and only other doctors.  If everyone is worried about doctors “guarding the hen house” the panels can be supervised by judges and specific guidelines creating to divert abuse.

How Are We Going To Limit Unnecessary And Wasteful Medical Care?

First, we need to enact the above mentioned arbitration panels, but defensive medicine is only part of the problem. The medical system has a way of inappropriately spinning its own wheels—usually for monetary reasons. PSA’s are a great example of this. An assumption was made that a PSA test could be used to screen for prostate cancer and save lives.  Prostate cancer is the number one cancer killer of nonsmoking males so we are talking about a huge market and billions of potential income yearly. Problem is that its use became widespread based purely on an UNPROVEN assumption. Many of us are quite certain given the current data that we are harming more men than we are helping.  Shouldn’t we prove all testing scientifically before we use them on the public at large?

Anybody heard of Be Well Body Scan? This is a company that markets a whole body scan. They suggest that if you have a normal scan you are in good health and have nothing to worry about. There goes the BS again. First of all, every scanner we use has its limits of resolution. At some point a cancer is so small the scanner can’t see it. So, having a “normal” scan does not mean you do not have cancer; it only means that at the point the scan was taken there wasn’t a cancer big enough to see. Worse, in a number of patients you will see abnormalities that can’t be explained. Financially and legally the Doctor is now obligated to further work up the abnormality subjecting the patient to further radiation, surgical procedures, risk and expense. Over 95% of these abnormalities will be totally benign. Ignorance is bliss.

Furthermore, you subsidize people’s bad health behaviors this way. As an example, a 40 year old cigarette smoker is scared of getting lung cancer so, he or she gets one of these scans which appear normal. He or she then thinks it is OK for them to continue smoking! Warning, NEVER get a test done without discussing it with your personal physician first. The ONLY purpose behind marketing is to get your money regardless of whether or not it is in your best medical interest. Lay people are notoriously ignorant of medical issues and the complexity of medical decision making. The marketers know this and take advantage of it. Smart people do not go to court without their lawyer.  Don’t go to the medical system without your doctor.

Most medical care, both necessary and wasteful, is ordered by physicians. Doctors order and provide unnecessary medical care to defend themselves from the legal system, to make money, under direct pressure from the patient and, last of all, because they don’t know any better. Over the years medicine has become increasingly complicated but we still train doctors the way we did 50 years ago. Doctors now frequently come out of their training programs without enough experience to make them secure in modern practice. The end result is over ordering tests and unnecessary referrals. Family practice residencies are 3 year programs but they should be 5 year programs. Training goals need to be delineated specifically and procedural competence also documented. On the bright side, ongoing CME (continuing medical education) has become the norm and computers armed with updatable medical information programs as well as many internet sites have made the most up to date information on ANY medical issue available at our fingertips. Many uncertainties can be resolved with just a little research but many doctors simply don’t have the time for this. They are too busy seeing the 40 – 50 patients they need to cover overhead and make a living. If they are uncertain they just order some test or dump the patient on another physician. A primary care physician should see no more than 16 patients daily.

Much of the wasteful medical care provided today is by protocol. My favorites are the protocols for follow up of patients after cancer treatment. As an example, Lady X got breast cancer. It was removed but, unfortunately, two lymph nodes were positive for cancer. Appropriately, she received chemotherapy following surgery. She tolerated this well and six months later was doing well with no evidence of recurrent disease. At that point she should have been returned to her personal physician for routine follow up; however, both the surgeon and medical oncologist continued to see her every three months for several years. On occasion they would do blood work and a CT scan off this that or the other. Two weeks after her last visit to the oncologist her sister, a patient of mine brought her to my office; the patient was up visiting from Florida when she had what sounded like a seizure. Sure enough a cranial MRI demonstrated metastatic cancer in her brain.  She was very angry wondering why her doctors didn’t find it. I did not say anything about her previous care. The reality is metastatic breast cancer is essentially an incurable disease.  This patient was kept comfortable, her seizures controlled with medication and she passed on two months later. What those other doctors did was waist this patient’s time and society’s money looking for an incurable disease. She should have been out having fun, living her life, trying to distance herself from the breast cancer. Protocols for follow up of cancer patients have been developed by the American Cancer Society not for the welfare of patients but for the pocketbooks and legal protection of doctors. The problem for doctors is that many of these patients will eventually die from their cancers and the families will then go after the doctor. The doctor needs to be able to prove that he was practicing at the “standard of care”. I die laughing when I hear that term.  Frankly, there is no standard of care. Every patient is different. The same disease in 100 different people is 100 different diseases.  Unfortunately, the legal system has a big problem with diversity. Again, doctors do not belong in the civilian legal system.

In a nutshell the solutions for wasteful medicine are:

Better, longer training for Doctors

Evidence based treatment versus assumption based treatment.

Limit the use of protocol medicine.

Get the Marketing out of both the medical and pharmaceutical industries.

Enhance the ability of personal physicians to do their jobs correctly.

Remove doctors from the civilian legal system.

How Are We Going To Improve The Quality of Medical Care?

Medical care professionals are human beings with all the attendant benefits and limitations. Medical care is inherently complex requiring a great deal of careful thought, organization and manual dexterity. Quality care starts with quality education and training followed by continuing education and experience. Errors occur in medical practice all the time. Most are minor and go unnoticed but some can be catastrophic. There is no way to avoid all of them. Accidents and mistakes are part of life but they can be minimized by avoiding unnecessary complexity, procedural protocols where appropriate and not overworking the medical community.

Under pressure from Medicare and the other insurers hospitals have been forced to increase bureaucratic labor at the expense of healthcare labor. Hospitals have been subjected to exponentially increasing levels of bureaucracy at the same time their fees were cut by both Medicare and other insurers. The only place they had financial “wiggle room” was in healthcare labor cost. Worse, as admission criteria limited the admission of less sick patients, the admitted population has become sicker. The end result is that we have fewer healthcare personnel taking care of sicker patients.  Overworked people make more mistakes. In our offices, primary care doctors are forced into seeing more patients than they should to make a living. The end result is they spend less time with individual patients, patients are more frequently inconvenienced by long waits and the quality of the relationship between doctor and patient is such that the patient has little confidence in the doctor, is less likely to follow advice and more likely to wander unattended through the medical system generating unnecessary expense and risk.  Overworked, hurried doctors also make mistakes. We need to pay more for people and less for paper but the system has done just the opposite. As the error rate started increasing the medical system, under advice from outsiders, started creating protocols aimed at preventing the more common errors—further burying healthcare providers in paperwork.

In medicine things are frequently not as they seem. Intuition and common sense frequently lead one in the wrong direction. The average layperson thinking she/he can manage their own healthcare cruising around the internet is like Michael Jackson thinking he can defend himself in court without a lawyer.  People are best served by having a personal physician they have the utmost confidence in who they know for a fact has only their welfare at heart. People who have good relationships with their primary car doctors utilize secondary medicine far more effectively and efficiently. They get better medical care and generally spend much less getting it.

The problem is that attentive primary care doctors are getting harder and harder to find. The system has turned them into insurance bureaucrats. I firmly believe primary care practice under the conditions set forth by the insurance industry and the government is unethical. I did not go to medical school to support the financial welfare of insurance companies and Medicare. Doctors who sign these insurance contracts relinquish their role as patient advocates. This is just as much of a conflict of interest as if I sold drugs out of my office or referred testing to a lab that I owned. My patients know that the only issue front and center in my mind when I am dealing with them is their welfare. There is not anything else. Because I keep the number of patients to a manageable level I can be available for them 24/7 except when I’m out of town on vacation. Because I’m available, my patients always have advice they can trust at hand so they do not wind up in emergency rooms inappropriately and are not so easily diverted by marketing. When they need advice or just simply have a medical question I’m the first entity they call not the last. The end result is that my patients get better medical care, they perceive them selves as getting better medical care and, overall, they spend much less getting it.

To sum it all up, we can improve the quality of medicine by:

Paying for people not paper, we need more nurses and fewer paper pushers;

Reducing the complexity of care by limiting and re-designing bureaucracy;

Providing an environment in which primary care providers can function appropriately; Reimburse hospitals fairly for their services, making it possible for them to employ the appropriate number of nurses and personnel to do the job effectively.

As you may have noticed, I am very much against socialized medicine. Yet, it will take government involvement to aim this medical system in the right direction. Only the government can remedy the toxic effect our legal system has on medical care. Only the government can manipulate the insurance environment to provide greater competitiveness, lower pricing and product diversity. Only the government will subsidize the research needed to verify what structural changes we need to make in our medical system to improve healthcare delivery, lower cost, minimize wasteful care and improve quality. Historically doctors have not wanted to get involved in these subjects. They would rather develop fancy new surgical techniques or research new therapies. Doctors need to start thinking more about how we can make this medical system run better and create research protocols to prove our theories pointing the legislators in the right direction. Indeed, this type of research will benefit healthcare and the general population more than research on the newest designer drugs and scanners. People need to pay careful attention to political commentary and elect politicians who support malpractice reform, insurance reform, streamlining bureaucracy, and medical marketing reform. Politicians who advocate universal healthcare should be banished to Canada.

3/30/07

Dr Mike

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