A doctor's prescription for healing American health care

October 17, 2008

As a patient, small business owner, and physician, I also have an opinion on what needs to be done to right our health-care system. Following are my recommendations for creating a healthier United States.

Key Points

With the presidential election only a couple of weeks away, Senators John McCain and Barack Obama are doing their best to convince you that their respective plans will rescue our health-care system from imminent ruin. And there's no shortage of pundits and partisans debating which plan-if either-will come to the rescue. As a patient, small business owner, and physician, I also have an opinion on what needs to be done to right our health-care system. Following are my recommendations for creating a healthier United States.

STEP 1 BUILD MEDICAL HOMES

The patient-centered medical home model, proposed by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association, adds information technology, evidence-based medicine, and decision-support tools to the personalized care coordination doctors have offered for generations.

STEP 2 ESTABLISH EQUAL RIGHTS FOR DOCTORS

When it comes to equality, doctors get the short end of the stick in our health-care system. Payers now set non-negotiable fee schedules, meaning doctors can't set prices compatible with practice survival. The paperwork and preauthorization hurdles erected by payers have multiplied in just the past few years. Pharmaceutical companies keep pushing costly new drugs, believing that a few months of coupons will justify excessive prices (and preauthorization hassles) later.

Patients often suffer from "entitlementiasis," having adopted a consumer view that the customer is always right. Their satisfaction is measured by whether they got what they wanted-antibiotics for colds, orders for exotic lab tests-regardless of whether their requests were medically indicated. Politicians jump on the bandwagon for EHR and other health-information technology, imposing another costly unfunded mandate on doctors.

In short, as part of restructuring the health-care system, physicians need to be put back on a level playing field with the rest of the health-care players, so they can provide input prior to implementation of supposed cost-saving measures that often only transfer costs to doctors.

STEP 3 IMPROVE ACCESS TO DOCTORS

Access to insurance coverage is worthless without access to doctors. Primary care physicians' income must be high enough to allow them to pay off staggering educational loans and, more important, attract new residents and medical students to primary care specialties. Patients, no matter where they live, should have access to a medical home overseen by a doctor. Incentives must be built into the system to reward doctors who choose to practice in underserved areas. Hospital emergency departments cannot be the medical home of last resort for the growing numbers of uninsured and underinsured Americans.

But primary care physicians can't do everything. Patients' access to specialists is equally important. Unfortunately, liability issues are choking off this access.

STEP 4 STOP THE BLAME GAME

I've seen many good ob/gyns, neurosurgeons, and orthopedists cross state lines to practice so they don't have to forfeit a huge chunk of their earnings toward liability insurance. It is essential for patients, lawyers, and juries to realize that doctors are human and they work with human fallibility on human-engineered systems. We will never have a zero-error rate, but we can certainly work toward it cooperatively through system redesign, rather than antagonistically through the courts.