Physicians sometimes see reforms that lawmakers do not.
Few patients and providers seem happy with the state of health care. The ideal delivery system is uncertain, and overhaul of the current structure will be a topic of debate for years.
But in the meantime, it is important that we continue to strive for change with other common predicaments that waste dollars, lives, and time. Physicians are often better equipped than politicians at pinpointing day-to-day problems in the effective delivery of health care. The following five reforms, though not without controversy, would immediately save money and improve care.
Require unbiased expert witnesses. If physicians didn't know whether they were hired by the prosecution or defense, they would be free to provide unprejudiced testimony. Patients harmed by malpractice would benefit, and so would unfairly accused physicians. Keeping the expert witness neutral would decrease legal expenses and potentially decrease superfluous lawsuits while allowing the jury to hear the truth.
Implement copayments for futile care. Physicians who practice in hospitals understand the incredible funding that goes into futile care. Families sometimes refuse to discontinue ventilators in end-stage cancer, terminal multi-organ failure, etc. As a result, hospitals and Medicare share the burden of these extraordinary expenses. I've had family members admit their desire to keep a suffering relative alive just to continue receiving monthly veteran's benefits. Others, understandably, react emotionally instead of rationally, but need to share in the financial reality. If all physicians involved in a patient's care are certain the care is futile, and an independent physician agrees, some of the financial responsibility must be shifted. If families were required to pay even 10 percent of these costs, they would view such situations differently.
Reduce critical care for terminal patients. It has always amazed me that surgeons can refuse to operate in the setting of terminal disease, but an internist cannot refuse to perform CPR and critical care for the exact same patient. When it is clear that a patient has less than a few days to live, it is ridiculous to pay for critical care while 47 million other Americans can't afford basic care. Terminal patients do need aggressive care, but it should be delivered in the form of palliation. Yes, doctors are imperfect at long-term prognosis predictions. But we are darn good at it when a patient is in his final days and hours of life.
Make it easy to get unsafe drivers off the road. When I was a resident in Oregon, the hospital kept Department of Motor Vehicles forms on each ward. When somebody was admitted with a condition that made future driving unsafe, a physician faxed that form to the DMV. The patient was then required to follow up with a DMV-approved medical exam in order to be ruled a safe driver again.
When I moved to Colorado, I learned that many states don't have such a system. I see patients with uncontrolled seizures, brain tumors, alcoholism, dementia, and other conditions that should keep them off the road. We tell them not to drive and write that into their discharge instructions, but we all know that noncompliance with those recommendations remains significant.
Primary care doctors are sometimes reluctant to tell longtime patients not to drive. In light of this, hospitalists and specialists should have more power and responsibility to keep the roads safe. The savings in medical care, as well as in lives, would be a major benefit to society.
Gil Porat, MD, is a hospitalist in Colorado Springs, Colorado. Send your feedback to firstname.lastname@example.org
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