Note:  I first published this op ed for physicians in the Winter 2008-09 as a newsletter column during my term as Connecticut Governor of the American College of Physicians.  I received so much positive feedback that it was republished in minimally revised form by Connecticut Medicine (the peer-reviewed journal of the Connecticut State Medical Society)  in 2009 [Conn Med 73(6):355-358, 2009].  While some of this content is dated in light of Heath Care Reform (Obamacare) and the “meaningful use” IT subsidies contained within the 2008 economic stimulus package, much still remains relevant today.   -EMM

Five Basic Tenets for Health Care Reform

As this is my final column as your Governor, I thought that I would invoke your forbearance and exploit the “bully pulpit” of both my position and this newsletter to present you with my personal thoughts about health care reform. I do not pretend to know how to pragmatically solve the health care crisis nor do I feel that I have discovered a new blueprint for the future. Rather, after many years involved in medical leadership and political advocacy, both at my hospital and through the American College of Physicians, I have developed some ideas, hopefully informed, about the fundamental principles upon which I believe an efficient, high quality and functional health care system should be structured. Unfortunately, I have to concede at the outset that from a political perspective and taken together, these principles are completely impractical. Given the positions of the two major political parties in the United States, I do not see a realistic, politically pragmatic path to reach the goals that I am about to enunciate. Nevertheless, I cannot help but articulate the principles, however politically naive, with the hope that the political landscape will change at some time in the future and that which is politically impossible today becomes feasible in the future.

Firstly, with health care expenditures currently totaling 16% of the United States GDP, I believe that it is safe to assume that there are sufficient dollars currently being devoted to health care in the United States to create and sustain a truly excellent universal health care system. Japan, with the longest average life expectancy in the world (83 years) and the second lowest infant mortality (2.8 per 1,000 live births) spends only 7.9% of its GDP on health care, only half of the U.S. rate. In absolute dollars, Japan’s annual per capita health care spending is only 38% ($2,690) of that in the United States ($7,026). The United States leads the entire world both in the percentage of GDP and the annual per capita dollars spent on health care and yet our overall health outcomes rank in the middle. While it is also true that the United States leads the world in medical research and technology, research costs consume only 2% of the health care dollar. Therefore, I do not think that it is necessary to add more money to the “pot” to achieve a quality, universal system. I would suggest that if we restructure our health care system on the following five pillars, that system would be capable of providing excellent care to all of our citizens and yet still maintain our leadership in research and technology and require no increase in the level of funding. These fundamental principles are:

            Universal Access: We simply must provide (and appropriately fund) universal access to health care for all of our citizens. Since I believe that we have agreed as a society that health care is an inherent right and not a privilege, the principle of universal access is the simplest and most basic. In our current system, all patients ultimately do receive care, but the care that they receive is neither high quality nor timely nor efficient. We have evolved a hodgepodge of disparate mechanisms to provide care for the underserved, mechanisms that actually serve them quite poorly and cost us substantially more than a universal system. Our dysfunctional and piecemeal approach forces us to provide care during the most expensive, acute exacerbations and end stages of disease, disease that often could and should have been managed chronically or even prevented. Also, currently hospitals must charge their commercial payers substantially more than their costs in order to cross subsidize the care of their uninsured and the Medicaid poor (who are not even covered at a break-even point by Medicaid payments). Private physicians eschew Medicaid patients (for which payments also generally do not cover office costs) and reluctantly care for many of them on a pro bono basis in under funded, poorly organized hospital-based clinics. In order to maintain their bottom lines, hospitals are forced to develop and aggressively promote high margin clinical programs and services, chosen primarily on profit potential rather than social good. It should not be the responsibility of hospitals and physicians alone to figure out how to take care of the poor.  The current reality results in parochial, ad hoc, inefficient and incomplete solutions. It is the responsibility of all of us, as a society and as a country, to shoulder this responsibility. This means developing a health insurance system that provides universal access (and adequate funding) for every member of our society. The problem of the uninsured has been “pushed down” onto the health care providers, exploiting our professional ethics and using the tools of unfunded legislative mandates and regulatory requirements. However, access cannot be solved by providers at the front lines; we must address this issue together, as an informed and progressive society, at the highest level of our government.

            Computerized Health Information Integration: This is the “simplest” pillar of health care reform, one on which everyone appears to agree. The potential value of computerized health information integration is obvious to all of us who take care of patients – less duplication of testing, the availability of a complete medical history and accurate medication list across all venues of care, fewer errors, lower costs etc. However, my concern is the means by which the insurance industry and the federal government are attempting to capitalize information technology implementation within the health care system. Like the problems of the uninsured and the underserved, this issue is being “pushed down” directly onto health care providers, expecting us, in this severely resource constrained environment, to fund the creation of a $156 billion technology infrastructure and support annual operating costs of $48 billion (Kaushal et al., Ann Int Med 143: 165-173, 2005) out of the very limited positive margins we are currently achieving. Computerized health information integration will provide a social good that accrues to the entire society. It is therefore also a societal responsibility and society (i.e. government) should fund it. It has been estimated that physicians who install electronic medical records in their offices will reap only 20% of the financial benefits of such a system. However, physicians (and hospitals) are being asked to bear nearly 100% of the costs. This is not fair, it is not right and it is not economically realistic.

            Rational payments to hospitals and physicians: Internists realize, perhaps better than anyone, how irrational and inequitable our current payment system is. An internist consulting on a complex elderly patient with multiple chronic, life threatening diseases will be paid, for an hour’s worth of difficult cognitive work and thoughtful patient/family interaction, only a small fraction (i.e. 10-20%) of what a radiologist or proceduralist will be paid, for the same amount of physician work and time. Hospitals receive from Medicare approximately 30 fold more reimbursement (exclusive of the equipment cost) for the placement of an intra-cardiac defibrillator than for providing a patient with comprehensive diabetes education over 10 one hour sessions with a trained diabetes nurse. It is no wonder that medical students are choosing radiology over general internal medicine for their specialty training and that hospitals are choosing to develop imaging centers, bariatric surgery programs and interventional cardiovascular centers rather than geriatrics and diabetes programs. Indeed, the free market works and we have created a medical marketplace in the United States that rewards procedures and technology while discouraging cognitive services, longitudinal disease management and face-to-face patient contact with physicians. This dysfunctional payment system, as an unintended consequence, undermines the availability of desirable and very necessary clinical services (geriatrics, psychiatry, primary care etc.) as well as threatens the future composition of the physician workforce. We must rationalize payments to hospitals and physicians to create effectively a flat “playing field” in which no one type of program or service or procedure is inherently more profitable than another, and in which an hour of physician’s time reading images or performing procedures is reimbursed at a rate comparable to an hour performing cognitive work and interacting with patients. Were we to do so, I believe that we as a society would purchase more of those elements of health care (i.e. specific services) that are really required to serve the public good (and generate positive health outcomes) and fewer of those that are largely driven by high marginal profits.

           Overhaul/replacement of the medical malpractice system:  I realize that politicians and the public are tired of hearing from “rich doctors” who complain about rising and/or excessive malpractice premiums. Earlier in my career, I too was a bit of a cynic, believing that “defensive medicine” was overstated as a significant driver of unnecessary health care expenditures. However, as I have matured, I have witnessed (and experienced) a fundamental transformation in the perspective through which we as physicians approach the delivery of patient care, a transformation driven by the necessity to mitigate the pervasive risk of medical malpractice. During the past 25 years, there has been an insidious change in clinical practice by physicians who have shifted from doing that which we genuinely feel is best for our patients to frequently basing our clinical decisions (i.e. testing, hospitalization and even therapy) on that which first and foremost reduces medico-legal risk. Despite unambiguous research indicating that malpractice awards are driven largely by poor clinical outcomes rather than by physician negligence, politicians and the public continue to insist that access to essentially unlimited malpractice awards is required to keep us physicians “honest, i.e. to assure physician quality and reduce the risk of medical error. While for many years I had difficulty accepting the “lottery mentality” of the excessive malpractice awards driven largely by the emotions of lay jurors, I have gradually come to accept our implicit societal decision that an adverse medical outcome should be mitigated by some sort of financial remuneration for the unfortunate victim. However, I would propose that such remuneration should be provided through a society-wide, no fault insurance system program (similar to Workmen’s Compensation) rather than a medical negligence / malpractice system that punishes the involved physician. Some would argue that without the opportunity to prove medical negligence, the individual and society lose the opportunity to control the quality of medical practice and to hold physicians accountable for their clinical decisions. I would propose that we separate the administrative system that regulates physician quality and clinical practice, from that which rewards adverse medical outcomes. Regarding the former, I would have no problem supporting a much more rigorous system for medical licensure and licensure renewal; one which requires physician-specific quality reporting and review, recurrent testing and limited licenses (for those who do not maintain the level of quality necessary for independent, full practice). It is difficult to argue that we as physicians should not be completely qualified and competent throughout our careers. However, the medical malpractice system is working neither to assure physician quality nor to reduce medical error. It is only inexorably driving up the total costs of health care to a level that some Stanford economists (Daniel P. Kessler and Mark McClellan MD, 1996) estimate to be 5 to 9% of the entire health care budget. What a waste of money!

            Rational rationing: Finally, we get to the “R” word – rationing. Rationing is the “third rail” of health care reform – no one wants to touch it. Nevertheless, rationing is a necessary and inevitable component of any universal health care system for which there are finite resources available and in which the demand for services is functionally unlimited. For most products and services, rationing is not required because demand is constrained by an individual’s personal capacity to purchase those products and services. However, we as a society have agreed that health care is a “right” and that everyone should have access to all necessary health care services regardless of their personal economic circumstances. In our society, there is effectively no personal economic consequence for choosing to purchase health care services. While a lot of free market economists believe that creating personal accountability for the purchase of health care services will effectively limit the demand for health care, I do not agree. I believe that the “average” individual has neither the knowledge nor the temperament to routinely make the best (and most cost effective) health care decisions on their own behalf. The health care marketplace will never be rational and consumers are not capable of judging either quality or effectiveness. Rather, I believe that we as a society, aided by physicians, health care analysts and politicians, can and must address health care rationing publicly and make overt allocation decisions – prospectively, transparently, scientifically and effectively, on the basis of social “good”. We have to recognize that rationing is already taking place in the United States and among the other developed countries around the world. In the United States we ration passively, invisibly, and irrationally, allowing services to be allocated to our citizens based upon a mishmash of insurance products and an individual’s age, employment and economic situations. In Canada, health care is rationed by limiting access and centrally budgeting health care resources, producing long queues that reduce the utilization of many high demand and expensive services. Neither of these approaches allocates health care services rationally and thus neither serves its public well. Given the vast amount that we are already spending on health care in the United States, I do not believe that the rational rationing of health care will reduce anyone’s access to necessary and effective procedures and services. But, we have to critically evaluate that for which we do and do not provide funding, investing in only those procedures and services that truly improve meaningful health outcomes. We as physicians observe the squandering of health care resources every day – hundreds of thousands of dollars of ICU care for the tenth and terminal pneumonia of an elderly, malnourished COPD patient; demented, wizened patients sustained on dialysis because their families cannot make the decision to let them die; third line complex chemotherapy or extraordinarily expensive biologic therapy for the patient with metastatic cancer of the lung and essentially no prospect for incremental quality survival; complex back and disc surgery for pain that otherwise would have resolved with time and, countless other examples. Our society, focused intensely on the “rights” of the individual, is loath to make decisions that overtly restrict an individual’s right to choose anything on the health care smorgasboard, regardless of how expensive or ineffective. I believe that we cannot allow our cultural orientation towards the “rights” of the individual to undermine our capacity to create an affordable (and equally effective) health care system that serves our entire society. The right to effective health care should not be translated into the right to all possible health care nor the right to cost ineffective and futile health care. The alternatives to rational rationing are our current approach of de facto irrational rationing and/or financial insolvency of the health care system. We must accept that rationing is an inevitable, necessary and inherent part of all universal health care systems. Let’s ration deliberately and overtly, so that the choices we make are active and evidence-based, not passive. Let’s ration rationally, such that the rationing optimally benefits every one of us and results in universal access with quality, meaningful and effective health care for everyone.

So, there you have it – my personal prescription for the principles on which health care reform should be based. Pie in the sky? You “betcha”! Politically impracticable? Absolutely! But, sensible and reasonable? I think so. Creating a universal system of health care at realistically achievable costs that provides quality outcomes for all is definitely within our reach and clearly within our budget. However, it will require major concessions from both sides of the political aisle and a change in how we as individuals view the balance between our personal “rights” and social benefit. We are at the beginning of a new political era – let us hope that our leaders have the courage to think “out of the box” and are willing break new ground in leading the United States to our shared (and elusive) goal of the best health care system in the world.

Note:  I first published this op ed for physicians in the Spring of 2007 as a newsletter column during my term as Connecticut Governor of the American College of Physicians.  It remains completely relevant today as healthcare remains in transition.   -EMM

It is no secret that many physicians are disgruntled and dissatisfied, and that the medical profession perceives itself as under siege. However, most of us as physicians don’t realize that our dissatisfaction does not arise simply from perceived Kafkaesque, malevolent external forces that include managed care, increasing bureaucracy, regulation, and governmental control. I would suggest that what is happening in health care is more fundamental, i.e. that we are in the midst of a seismic cultural transition in the practice of medicine, one that results in a clash between two completely different and separate worldviews, neither one of which is inherently evil or wrong. The problems and conflict derive from the fact that the “values” held by these two worldviews are largely incompatible; in fact, they are almost mutually exclusive.

I was first introduced to this concept when taking a course at the Harvard School of Public Health for physician leaders. Using the traditional business school approach, a real “case” was presented to the class of a modern company that produced small quantities of unique, fine art quality flatware. The employees of the company were indeed artisans, individually designing, producing and signing each piece, and personally controlling the production process for their handiwork from beginning to end. The beauty of the flatware was such that its popularity and demand grew to the point that the company decided to significantly expand production. A new management team was recruited and an “industrial” production model was implemented. In order to maintain quality and brand identity, designs were standardized, production steps were explicitly defined and segregated, individuals were assigned to specific production steps and measurements of consistency and quality were put in place. In other words, the company moved from a production process dependent on the work an elite group of highly skilled individuals to a mass production or assembly line model in which the system, not the individual, was determinant. Notably (and not unexpectedly), the artisan employees who were so responsible for the initial success of the company were extremely unhappy with this new production model. They rebelled and struggled against its implementation. Ultimately, they were unable to adapt to the new work paradigm and they left the organization. All the artisans were replaced by lower skill workers and the reconstituted company was extremely successful (and continues to flourish today).

This real business “case” is not unique but rather exemplifies what happened to countless industries in the early 1900s as the “industrial revolution” took hold. Prior to that time, most products were created by individual, highly skilled workers who controlled the entire production process from beginning to end. Production knowledge and skills were passed down from senior to junior workers via long apprenticeships. Skilled craftsmen belonged to exclusive guilds that were organized around their products and skills. The industrial revolution resulted in a complete paradigm shift in manufacturing during which the work of product production was totally reorganized and the guild system, as well as most of its craftsmen, were eliminated. This change led to an enormous increase in productivity and resulted in the high standard of living that we currently enjoy today.

This reorganization of the work of production had several components. As described by Darius Rastegar¹, these included 1) dividing “work” into discrete (and simpler) tasks, 2) the evaluation and standardization of these tasks and 3) the rise of the managerial class to manage and control the production processes. All of these components, while necessary to achieve the overall goals of high productivity and efficiency, had their own negative consequences. Dividing up the production into simpler tasks required a less skilled workforce and, because of its repetitive character, the work itself became less intrinsically satisfying. Standardization and metrics, while assuring uniformity and at least a reproducible minimal level of quality, eliminated worker autonomy and emphasized “efficiency” and throughput over creativity. Finally, the rise of the managerial class further disempowered the workers and valued worker conformity and compliance over individual autonomy and personal excellence.  Nevertheless, it is difficult to argue that the industrial revolution was “bad”, even though it displaced skilled workers and eliminated many high skilled positions. And, it is equally difficult to maintain that there is not still inherent beauty and value in a carefully handcrafted product by a highly skilled artisan; beauty and value that far exceeds that available in mass manufactured products.

Health Care (now often called the health care industry) was almost a century late in coming to the party but is currently in the midst of its own industrial revolution. The medical industrial revolution is driven by many factors including the increasing complexity of medical knowledge, the rise of evidence based medicine, and public demands for greater transparency and quality with fewer medical errors. However, the fundamental force behind this transformation is economic; public demand for the production of health care “widgets” keeps rising (the appetite of the U.S. population for health care appears unlimited) but the cost of such production is effectively capped at the current level (i.e. 15% of the U.S. GDP). Consequently, the societal demand to improve the “efficiency” of producing health care widgets is irresistible. This requirement for substantially increased efficiency has resulted in the application of the industrial model to health care delivery and directly to doctors who were trained in and are disciples of the “old”, professional medical paradigm.

I would suggest that it is the clash of the cultural worldview of the medical profession with that of the purchasers and managers of health care (insurance companies, health administrators and government) that lies at the heart of so many physicians’ job dissatisfaction today. Physicians are the “artisans” who value such things as the doctor-patient relationship, empathy, continuity of care, individualization, personal commitment and accountability, education, professionalism, selflessness, autonomy and volunteerism. The industrial model values conformity, uniformity, efficiency, throughput, selfishness and compliance. (Capitalism is, in fact, built upon the foundation of avarice.) The conflict in which we currently find ourselves as doctors is that between the values of medical professionalism and those of capitalist commercialism.   Dr. Frank Davidoff wrote about this conflict², framing the worldviews somewhat differently. He described the physician worldview as the “guardian moral syndrome” and the industrial worldview as the “commercial moral syndrome”. Furthermore, he characterized the current health care system and its working relationship of physicians and managed care (with their conflicting worldviews) as a “monstrous hybrid”.

Certainly, Dr. Davidoff is correct in his characterization of the current state of the health care system and I believe we can agree that the existing model of health care can be only transitional. A more stable and satisfying (to patients and doctors alike) paradigm must emerge because health care (and doctoring) will not go away. Unlike the artisans’ culture of the pre-industrial age, the ethos of medicine cannot completely disappear because the “widgets” of health care cannot be completely uncoupled from our and our patients’ humanity. In fact, our patients are caught right in the middle of this cultural conflict, desiring to consume large quantities of “artisan quality” health care but at industrial, mass-produced prices. The ancient healers, the “medicine men” of antiquity understood the power and “value” of the artistic side of medicine. They recognized that the relief of human suffering and even healing could be achieved by the authority of the (time inefficient) doctor-patient relationship. Even today, with all the technological and pharmaceutical advances available to us, our patients still look to us for reassurance, relief of suffering and healing human interaction. There is no time efficient way to mass-produce these widgets of physician-patient healing and they have real value, even in an industrial, commercial context. But, neither can we physicians, in the context of the nearly unlimited demand for our services, continue to struggle against the industrial model and its values of productivity, measurement, transparency and efficiency. Industrial medicine is here to stay and we need to find a path towards harmonious coexistence with it.

While Dr. Davidoff points out how difficult coexistence of these cultures will be, he suggests that our only hope for success is by implementing an approach called “knowledgeable flexibility”. This approach requires that both “sides” recognize and fully accept the cultural precepts and worldview of the other while acknowledging their inherent irreconcilability. “Knowledgeable flexibility” challenges both physicians and bureaucrats/administrators alike to be educated in and appreciate the alternative worldview and to be, themselves, sufficiently flexible to move back and forth between cultural paradigms as necessary. We as medical leaders must recognize that neither culture has exclusivity on that which is “right” for the future of health care and both worldviews contain valid precepts that must be accommodated. This accommodation will require many more physicians to be conversant in industrial and management principles and all physicians to understand and acknowledge the validity and necessary role of the commercial culture in health care delivery. Similarly, health care administrators must embrace the imperative to try to understand (and appreciate) the tenets of the culture of medicine and be willing to work constructively with physicians to incorporate their professional values into the commercial paradigm. Ongoing and intense communication between individuals on both sides will be required and we need to accept the inevitable fact that an uncomfortable tension will always exist. We physicians cannot be like the artisans of the flatware company, refusing to adapt to change and finally disappearing. Neither can we abandon the core values of the professionalsim that have served physicians and their patients so well over the centuries (and continue to have real economic value today). Crafting the future in health care delivery will require a positive, constructive attitude from both physicians and administrators, a lot of hard work, and ongoing frank, open and empathic communication. We physicians must be part of the future and can be, without abandoning the professional values of our past.

References

1.  Rastegar DA: Health care becomes an industry. Ann Family Med. 2004;2(1):70-82.

2.  Davidoff F: Medicine and commerce 1: Is managed care a “monstrous hybrid”?   Ann Internal Med. 1998;128(6):496-499.