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More Things Wrong with American Health Care


Last week Jeff Brown, MD, enumerated some of the issues wrong with American health care, but there are still more problems: including fraud, customer service and malpractice.

Last week I responded to a naive query about what was wrong with American health care, in a top 10 format familiar to us all. It actually ran to 13 and touched upon high cost, poor value, inadequate transparency, little accountability and insufficient communication involving all sectors; doctors being unable to keep up with new published best practices; doctor-to-doctor breakdowns, likewise doctor to patient, patient to doctor; and so on.

I included the expensive, and ultimately unsustainable, interposition of businesses and insurances companies between patient and doctor, leading to the wrong incentives to all involved; the fee-for-service cost driver; and, finally, the abrogation of responsibility for improvement by both patients and doctors, individually and severally. You'd think these alone would be enough to saddle any population with more expensive and unproductive dysfunction than we could handle.

Yet, as they say on late night infomercials, "But wait! There's more!"

1. Finances

Let's start with the ax that I have been grinding for almost 15 years in these pages: the financial and organizational illiteracy of most doctors due to their absence from our training. That's because 100 years ago, when the current medical training model was reorganized, at the urging of the Flexner Report, there was no need for such training and awareness. But we all know how mightily things have changed and become geometrically more complex.

Don't panic — doctors don't need MBAs. Doctors only need appropriate context, current economic and organizational context built into their training. Medical educators please take note.

2. Malpractice

The next thing wrong with American health care is one of medicine's favorite whipping-boys, malpractice threat, with its consequent high insurance and defensive medicine costs.

So far, the rich and powerful tort lawyers have blocked most meaningful changes to such common-sense reforms as no-fault award panels. These changes certainly would reduce medical tort lawyers’ high incomes and might, they say, decrease the downtrodden's access to legal justice.

Most objective studies place the overall costs of our current malpractice situation in "just" the single-digit percents, however. Reform is definitely needed, but malpractice is not the critical driver of cost as some would have it.

3 and 4. Fraud and waste

Next on our list is the ever-popular (in Washington, at least) "fraud and waste" group. Fraud certainly exists, especially in Medicare and Medicaid, because of lax controls and enforcement and needs to be firmly minimized.

"Waste" is endemic, but opinions of what waste is, actually, is the result not just of political points of view, but of the many inadequately addressed issues chronicled last week and today. Let's just stipulate that there is a lot of waste in all areas of health care as it is practiced in America.

5. Customer service

Another area of counterproductive systemic weakness is the fact that in this most service-oriented of all human activities organizational customer service is patchy at best. For instance, there are unjustified, and unannounced, waits at every step of any medical path.

"Customer Service" is not a window, or an attitude, that you will see very often in our sector of the economy. And when you do see good and caring service (and to be fair, there is an abundance) it almost always comes from the personal efforts of one of the many dedicated individuals who have given their careers to helping others.

But you won't see good service very often from the organizational side. American medicine, presumably because of a historical scarcity of health care resources, has always existed for the convenience of the doctor, not the patient. And, sad to say, it still largely does so today.

And there’s still more

Well that's only five more and I am out of room again. So I'll keep the ball rolling next week and as long as it takes to summarize at least the big issues we confront daily in health care.

But don't get too depressed with it all; at the end of the series, in the interest of fair play and equity, I will enumerate much of what is "right" in American health care — and there is a lot to be proud of to be sure. If there weren't so many good things in American medicine, the bar set so high, many of these problems that I am running down probably wouldn't be expected to exist.

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