In a post originally published on The Health Care Blog and reprinted on Bob Laszewski’s Health Care Policy and Marketplace Review, health care analyst Brian Klepper asks: “Is Meaningful Health Care (Or Any Other Kind Of) Reform Possible?”
His answer: “I’d be surprised. Delighted! But surprised.”
I decided to answer him.
Klepper believes that the lobbyists are just too strong. Always incisive, he pulls no punches: “In a policy-making environment that is so clearly and openly influenced by money,” it’s just not likely that “Congress will be able to achieve health care reforms that are in the public interest.”
I disagree. I believe economic pressures are pushing us toward a political turning point. (If you want to understand what is happening in history or in politics, follow the money.) The Bush administration has been thoroughly discredited. Americans are ready for change. Healthcare reform will not happen tomorrow; it will require a bare-knuckled political fight. But it will happen, and this is why: Although lobbyists are powerful, so are voters. And they realize that we are approaching a flashpoint.
You’ll find the rest of the post here.
To comment, come back here.
From my perspective CMS has already been making meaningful improvements…albeit still in their infancy… it’s clear to me CMS is leading the way.
Maggie
You are correct! WE are indeed AT LONG LAST at a tipping point on health care reform.
One major factor is that Big Business will pressure Congress for economic relief from unsustainable health care costs.(Except of course the Medical Sector Big Businesses)
Klepper is wrong about his perceived power of health care sector lobbyists.
These individuals, in the next few years, will be looking to other sectors for jobs in which to prostitute themselves.
IN SHORT,MAGGIE,WE WILL BE GETTING HEALTH CARE REFORM FOR THE WRONG REASONS.($)
But we will get it! You can count on that!
Dr. Rick Lippin
Southampton,PA
ralippin@aol.com
I usually agree with you Maggie, but I am not so sanguine. It depends on what side of the fence you are on:
1) AMA and AARP carted out lobbyists by the droves to fight the “good fight.” Perhaps “our” victory, but in the end, cash and influence weighed heavily in that battle (someone reached docs and seniors, and it wasnt the tooth fairy).
2) Voters understood this schism. How many times in the past have constituents raised their voices and threatened their elected officials to vote yeah or nay, or pay the price. It happens, and not always at an inflection point. This was not about health care reform, this was a band aid on a gaping wound–as well as a well framed entitlement “steal” (seniors get that–as do most folks). If the Dems win a new and improved SCHIP battle, I will say the same thing. Peanuts in the scheme of things, and we are still nowhere. I dont see that as progress.
3) Talk about what voters dont understand: Unleash the lobbyists in presenting health care 2009: “big bad govt” vs “money driven maniacs.” Each side will spend their 100’s of millions and we will see how quickly grid lock, lack of inertia, yada, yada, rules the day. The good vs evil argument wont be clear, only to the minority (and maybe Lou Dobbs).
Sadly, my faith is sagging (DME bidding anyone?). A few people wrote that if the Mcare bill did not pass, we would have had a cataclysm–and thus, a divine wind to bring about the change for which we clamor. I agree. Until something very bad happens and precipitates change, expect more of the same.
BTW, both Obama and McCain’s plans have more holes than swiss cheese–obvious, and they are not going to get us from point a to b. Without truth and salesmanship (of the political kind of course–Reagan, FDR, etc), lobbyists will sell the myths. May the biggest pocketbook win.
I hear your response now…
wrong about his perceived Rick, I’m hoping you’re right that the “power of health care sector lobbyists” is wilted. But $400 million in lobbying and campaign funding is nothing to scoff at. Our job is far from over.
Jack
I know this is a huge lobby and economic force. But-putting aside public sentiment for reform-it is not stronger than the economic clout of the rest of US Big Business who wants and needs health care reform to remain globally competative.
Dr.Rick Lippin
Southampton,PA
ralippin@aol.com
I only disagree with one profound point. You believe 1/3 to 1/2 of medical intervention is a waste. I believe 9/10 could not stand an “evidence based” evaluation. The vast majority of longevity gains have been due to public health measures. How many people get antibiotics for influenza? One could justify it as prophalactic depending on your economic assumptions – but thats just it. You will get different results on how much you say a life is worth.
While I agree that overcoming the power of healthcare industry lobbyists is certainly possible, there are numerous other challenges as well. Such as:
1. Providing insurance for the approximately 47 million people who don’t have it now will likely cost in the range of $100-$150 billion per year. At the same time, with the economy weak and the federal budget deficit for 2009 approaching $500 billion, finding the money (and the votes in Congress) to cover the uninsured will be difficult to put it mildly.
2 Middle class Americans will have to decide to what extent they are willing to pay higher taxes even if the tax burden on the wealthy is raised significantly. Proposals like Dr. Emanuel’s 10% value added tax dedicated to healthcare would represent a radical shift in how health insurance is financed. Will Americans be willing to trade an employer based system that they know for a tax based system that they don’t? I don’t know the answer. I do predict, however, that a 10% VAT will be extremely unpopular with the middle class and higher income elderly who will see it as a backdoor tax on wealth.
3 Interoperable electronic records have the potential to save money by eliminating duplicate testing and adverse drug interactions as well as by making data collection much easier to aid research into what works and what doesn’t. It’s a good idea which I strongly support. However, it will cost a lot of money up front to put in place. Doctors and hospitals complain that it’s unfair to expect them to pay for this investment when the benefits from cost saving accrue mainly to payers and patients. We will probably have to subsidize the investment while we wait for the benefits to come at some uncertain point in the future.
4 Preventive care is also a good idea because it extends lives. If we reduce the impediments to getting preventive care by eliminating co-pays, up front costs will increase, but the benefits won’t come until later, perhaps years later.
5 In the unlikely event that we can overcome trial lawyer opposition and implement a more sensible system for settling medical disputes, it will still probably take years before doctors start to reduce defensive medicine.
6 Comparative effectiveness research is also a fine idea, but it will require funding up front as well. Unless CMS is aggressive in refusing to pay for new drugs, devices and procedures that are no more effective than less expensive established treatments, savings could be a long time in coming.
7 Negotiating prices for drugs and devices could lower costs. However, if CMS is not prepared to keep FDA approved drugs off its formulary if a satisfactory price agreement can’t be reached, savings won’t materialize because CMS would have no leverage otherwise.
8 Capitation is a better model for aligning provider incentives to provide cost-effective care than the fee for service model is. However, until providers can estimate their costs with sufficient accuracy to allow them to determine what an appropriate capitation payment would be to give them a viable and sustainable business model, it won’t work.
9 Bundled pricing for expensive surgical procedures is another model that I like and support. However, unless CMS is prepared to push doctors and hospitals hard to work together to make bundled pricing happen, it will take a long time before its use is sufficiently widespread to produce meaningful savings.
I don’t mean to be negative, but reform will be hard even if the power of lobbyists can be overcome and bending the medical cost growth curve will be even harder. If it were easy, we would have done it decades ago.
Lisa, Rick, Brad,Jack, dan k, Barry,
Thank you all for your comments
Lisa–You are right, CMS has been taking some initiatives going in the right direction. They’ve even been doing some comparative effectiveness reserach, though this Congress won’t let them implement it when making coverage decisions..
Rick– You are right that non-health care industries will be on the other side of this battle. Employers cannot afford health care inflation.
BUT–and this is a big but–the majority would be willing to go along with so-called health care reform that gave the middle-class health insurance with high co-pays (like 20 percent each time you are hospitalized–PLUS a $5,000 deductibe (the 20% doesn’t count toward the deductible)
. This is Aetna’s current “managed access plan” for small businesses. The policies are filled with holes and shift unaffordable costs to the individual family (who could easily wind up with a $40,000 bill for a hospitalization) but low premiums for employers.
Many “bi-partisan” plans for reform would happily accept this as part of the menu of plans that Americans would be offered. You could, of course, pick a more expensive plan–if you could afford paying premiums of $7,000 or $8,000 a year. But for middle-class families (earning $45,000 to $65,000 joint–which is the group clusteredd around median income of roughly $57,000 joint income) and even upper-middle class Americans (earning $65,000 to $95,000 joint income), this high-deductible, high co-pay plan full of holes would be about what they could afford.
Meanwhile the bi-partisan reformers could say “look–everyone has insurance. We’ve succeeded!)
And nothing would be done to move toward evidence-based medicine, to reduce hospital errors, etc.
Many years ago many employers really cared whether or not their employees had good coverage because they knew that if employees were sick, this lowered productivity. (They also felt some real concern and loyalty toward employees would would stay with them for 20, 30 or 40 years.)
But today, employees change jobs so frequently, that if a diabetic doesn’t get the care he needs–or if I don’t go for a mammogram because it’s a hassle–and there’s a $50 co-pay–chances are by the time the diabetic needs an amputation or I develop breast cancer, we’ll be working for someone else.
So, we have to be very wary about support from employers and big business, and look carefully at the details of the plans–particularly when there is a “menu” of plans “to fit every pocketbook.”
That said, Ezekiel Emanuel’s argues, as you (Rick) do, that the non-health care industry will fight for reform, and that we’ll get it, even if “for the wrong reasons” )
IF (and it’s a big IF) we tried to pass legislation implementing Emanuel’s plan, I think he’s right. We could get support from non-health-care big business because his plan does away with employer-sponsored care altogether.
Employers would no longer have to pay for health care. It would be financed through a 10% VAT tax. Meanwhile, in order to keep their best employees, employers would give many of them raises equal to what the employers are now spending on health benefits–and be very, very relieved to be out of the health benefit business.
Meanwhile, the VAT tax would produce revenues that would allow the government to give everyone the same very rich comprehensive package of benefits (better than the benefits that 80% of employers offer now) FREE OF CHARGE, No Premiums, No Co-Pays, No Deductibles.
(In countires that do this, everyone goes for preventive care, and overall health is better while spending on healthcare is contained.)
I’ve written about his plan here http://www.healthbeatblog.org/2008/05/a-fresh-look-at.html
and here
http://www.healthbeatblog.org/2008/05/a-fresh-look–1.html
It’s brilliant. The VAT tax is not regressive. (EVERYONE-BEFORE COMMENTING ON THIS, please go back and look at the posts. )
But, as Ezra Klein has written, Emanuel’s plan is probably too smart, too rational and too fair to ever pass Congress. Also, voters would have to really pay attention to understand why the VAT tax plus free health care is better for everyone–rich, middle-class and poor.
Brad–
I hear you.
And let me say that I am not hopeful that we will get the kind of national health care reform that we need in the next few years.
In fact, I would rather see us Not try to pass national reform unless we can do something that offers health care–and not just health insurance–to everyone. (See my reply above to Rick.)
But I am hopeful that we could reform Medicare in a way that begins the work of reforming national health care. (See my recent post on Medicare Reform as a Demonstration Project)
That said, I agree that expanding SCHIP and taking away the entire bonus that we’re now paying Medicare Advantage insurers is “peanuts” in the larger scheme of things.
Nevertheless, even if these are baby steps, they are first steps. It’s been a long time since we’ve seen Congress stand up to for-profit health care lobbyists and win!.
Yes, the support on the Medicare Bill passed las month was certainly bought–and delivered –by the AARP. But at least the AARP was on the right side this time. (The organization knows that the winds are shifting in Washington.)
Moreover, I can’t help but think that the experience of voting for what’s right–and winning–won’t give some very discouraged Congressmen and women hope.
I too, am skeptical about Obama’s plan. We don’t know all of the details, but I fear that it will offer a “menu” of insurance plans that will lead to tiered healthcare, and good care only for the wealthiest 20 percent. Also, I don’t see how they plan to finance it. (They admit that they were counting on following Medicare in slashing doctors’ fees–except Medicare isn’t slashing doctors’ fees across the board.)
Long-term, reform can save money, but the upfront costs of healthcare reform will be high
Nevertheless, if Obama is elected and appoints very strong, intelligent reform minded people to head up Medicare, the FDA and other agencies that are involved in healthcare, that will make a huge difference.
I remember when DAvid Kessler took over the FDA at the beginning of the Clinton administration. It was a sea-change. He took on Big Tobacco (something everyone said “couldn’t be done.”)
He didn’t win the battle to let the FDA regulate tobacco as a drug, but his war on tobacco led to that wonderful, televised moment when the CEOs of the largest tobacco companies had to stand up in front of a Congressional committee and try to explain why they didn’t believe that tobacco is hazardous to our health.
That was the turning point for the tobacco industry.
The head of the Centers for Medicare and Medicaid also could make an enormous difference. Private insurers follow Medicare’s lead on everything from what they cover to how they pay doctors and hospitals.
And, as Lisa says commenting on the post about Hospital Inspections, if CMS begins doing serious hospital inspections–and listens to the best state regulators–hospitals will be forced to take patient safety seriously.
I recently attended a conference on Medicare reform where someone from the Medicare Payment Advisory Comission said that, off the record, private insurers are begging Medicare to tackle some of the toughest reforms–so that they can follow.
If Medicare begins to insist on evidence-based medicine, so will insurers.
And I’m told that the Senate Finance committee is seriously interested in legislation that would set up a Comparative Effectiveness Institute.
As to whether Big Money
always determines the outcome in Washington . . .
I’m old enough to remember what happened in Washington before 1980—before the beginning of 20 years of conservative administrations, punctuated by 8 years of briefly liberal, ultimately centrist rule.
I think would-be reformers who came of age (turned 18)in the late 1970s, the 1980s and the 1990s are easily discouraged because they cannot remember a time when reformers beat corporate interests.
The don’t realize what happened in the 1960s—in part because they have been brain-washed by Reagan’s revisionist history of the 1960s as an era of hippies, drugs and welfare queens.
In fact, Washington accomplished a great deal during that time: civil rights reform, women’s rights, the anti-war movement and the war on poverty (which actually did great reduce the share of Americans living below the poverty level—though in the past eight years, the percent living in poverty has gone back to pre-sixties levels, with children suffering the most).
If more people understood the anti-war movement of the 1960s and the tragic history of our war in Vietnam, we never would have gone to Iraq. Virtually everyone I know who was in college sometime between, say, 1965 and 1974, realized, during the run-up to the war in Iraq, that this was going to be a terrible re-play of Vietnam– except that rather than being a guerilla war fought in a jungle, it would be a guerilla war fought door to door. Many older friends also saw the parallel.
But I’m digressing. My real point is this: Big Money did not support the civil rights movements, the anti-war movement (corporations made a fortune on Vietnam manufacturing napalm, etc., just as they are making a fortune on Iraq), womens’ rights or the War on Poverty. Yet Congress passed major legislation to make all of these things happen.
Granted, we had leaders like Martin Luther King, Lyndon Johnson (who showed courage on domestic policy), Robert Kennedy and William Sloane Coffin. But, today I am hoping that leaders who realize the opportunity for a real pendulum swing will step forward. The fact that the economy is in such bad shape creates an environment where people are ready for change—especially when it comes to healthcare.
More and more people are going to realize that they cannot afford Medicare’s co-pays and deductibles. More and more people are going to discover that they cannot find doctors who take Medicare patients.
If you’re old enough to remember the “Grey Panthers” you know how effective seniors can be when they target Congressmen and decide to turn them out of office. I expect (hope for) quite a bit of turnover in Congress over the next four years, with activists replacing centrists.
We might even see some activist Republicans—people like Lowell Weicker and Nelson Rockefeller– coming to Congress. In the past, there werehonest Republicans who stood up for egalitarianism, particularly when it comes to necessities like health care. Many were drummed out of the party under Reagan and the two Bush administrations, but perhaps they’ll come back.
Jack– I agree the battle for full-fledged national health reform is going to be a long, bare-knuckled battle.
Dan k– You’re probably right. Arguably, more than 1/3 of our health care dollars are wasted. We don’t have hard evidence for so much of what we do . . . And we do spend so much on hotel-like amenities in our hospitals . .
Barry– I agree with #1. This is why I don’t see real health care reform coming soon. It will take money. People won’t be willing to pay the higher taxes needed until things get really desperate (more people losing employer-based benefits).
On #2–a VAT is not a tax on wealth. It’s a tax on spending. So wealthy seniors who have saved and want to pass the money on to their children won’t be hit. Wealthy seniors who spent $300,000 a year will be hit. But as you get older, most relatively affluent people accumulate most of the things they want. Unless you’re an addicted shopper, I really can’t see how you can spend that much money, year in, year out.
But I doubt we’ll have a VAT anytime soon. I just don’t think most Americans (or their Congressmen)would take the time to really understand how a VAT dedicated to health care would work, and how middle-class people would come out head.
3–I agree. Health IT will be expensive, and we’ll have to subsidize it (as other countries have.)
4–I agree. 5–I don’t know. 6-Much depends on who becomes head of CMS and whether Senate Finance is willing to stand up to the lobbyists and support comparative effectiveness reserach.
7–I agree
8–Capitation will only apply to very very large multispecialty groups that can (and do) estimate costs and doctors in smaller practices who agree to accepting “bundled payments) with all of the doctors and the hospital involved in a particular episode of care paid a lump sum which they have to divvy up.
At this point, this is the only way that Medicare’s advisors are talking about paying for outcomes. They know that it is impossible to pay small practices for outcomes. (A few patients skew outcomes). So doctors who remain in small practices and don’t accept bundling will not be eligible for the bonuses–and won’t risk the penalties if their bundled group performs poorly.
But the bottom line is this: 20 years from now there will be many fewer solo-practioners and small group practices, even in the East. Older doctors will retire early and younger doctors will be going to work for hospitals and very large groups.
9– I think CMS will push hard for bundling–it’s the only way doctors can be paid for outcomes.
Maggie,
I know the VAT is a tax on spending. My comment that some among the middle class and higher income elderly will see it as a tax on wealth applies to those who find themselves in one or more of the following circumstances: (1) they sell their existing home and move to a retirement haven like Florida and buy a new (at least to them) house. Depending on how the VAT is structured, it may apply to both the home sold and the one purchased, (2) those who help pay college tuition for their grandchildren or help their own children with the down payment on a home will find that their money doesn’t go as far because of the VAT, and (3) people who like to travel on expensive cruises and the like will find their vacations 10% more expensive with the VAT in place than they otherwise would have been.
These elderly will say that they paid income taxes all their lives and saved and invested for their old age. Now that they want to enjoy some of the fruits of their labor by spending significantly more than their current income by liquidating investments, they have to pay a 10% tax on those big ticket items. That’s why they will view it as a back door tax on wealth.
Some of you folks are highy schooled and respected economists and political process scholars
I AM NOT-I admit that I am “an intuitive”
All my life, since childhood, I have had an uncanny capacity to forecast events and trends which I do not fully understand?(so he says immodestly:))
I believe the tipping point on US health care reform has arrived. I may be wrong?
I learned a lot from all of you.
Be Well,
Dr. Rick Lippin
Southampton,Pa
ralippin@aol.com
Dr. Rick, I agree with you 100%, the winds have shifted, the ship turned, hell froze over and pigs are flying.
The lobbyists will fight to prevent changes that do not fill the stakeholders’ pockets.
If Congress, CMS, or other professional organizations do not take meaningful steps (laws, programs, revaluing physician reimbursements) to rein in healthcare costs, the lobbyists will have no problem convincing fiscal conservatives in Congress to oppose reform.
Barry–
Here’s the standard definition of a VAT: “Value Added Tax or VAT is a nationwide tax of 17.5% (or occasionally 5%) levied on almost all goods sold by retailers.”
So it wouldn’t apply to purchase of a home or college tuition. It would apply to vacation expenses.
Wealthy seniors might well
object to paying a VAT when they bought a $100,000 car. But the fact is that the vast majority of seniors are not wealthy. And they do vote.
So the very affluent seniors really won’t have much of a voice.
Moreover, we do need to tax wealth. Too much wealth has been accumulated in the hands of too few families and this has really begun to skew the political process while leader to greater and greater inequality in wages, health care, education, etc.
This is why Ivy League schools are thinking about doing away with “legacy admissions” (favoring children of alumni.)
Rick & Lisa– I hope you’re right. My political
instincts tell me that we’re ready for real reforms. But, even assuming Obama is elected, I’m not at all sure that he is ready for major changes. In many ways, he seems a centrist, particularly on domestic issues.
And healthcare is not his main area of interest.
So on healthcare, I think we may have to look elsewhere for leadership.
But as I keep saying, I think Medicare reform is more likely, and that could really set the stage for national healthcare reform.
Joan– I tend to agree. I’m
really not counting on fiscal conservatives to support the reform we need–or at least not the fiscal conservatives who are in Congress today.
Lobbyists…Some people believe there are few fat rich men with cigare in their mouth, pulling the strings. But common, there is 16% of GDP involved! There are thousands and thousands of people, preferring this situation and not willing any change! Even in Canada, but our “lobby” is weak…
Lorne
Life Insurance Canada–
You’re half right.
Many of the people working in the health care industry want things to stay the same because they’re making a nice profit on the current system.
But a great mean health professionals–including doctors, nurses, physical
therapists, hospital executives and others are horrified by the poor quality,waste, high rate of errors, and general chaos of our borken, fragmented system.
Polls show that more than half of all physicians now say that our system needs a real overhaul–with government involvement.
This wasn’t true 10 years ago, but things have gotten so bad that anyone who cares about patients is very upset.
“Polls show that more than half of all physicians now say that our system needs a real overhaul–with government involvement.”
Well this sure does not say much for the foresight and social mission orientation of most American physicians for the last 50 years, IMO. They seemed to have sat back like Nero and fiddled while Rome burned, and now that the system is approaching a ruined status, they wake up???
Why now and what do they really want behind this renewed sense of social urgency?????
NG–
Why now? Because things have gotten much worse. Our hospitals are more chaotic. More patients cannot afford the care they need. In order to keep up with their overhead, many primary care docs (and others)are forced to see a patient every 15 minutes. (Their fees have come close to keeping up with inflation in real estate, utilities, etc. over the past 10 or 15 years.)
And the majority really are concerned about patients.
Let me quote from the Preface to my book where I describe interviewing doctors:
“I was surprised by just how many returned my calls. The great majority did not know me. I expected responses from perhaps 20 percent. Instead four out of five called back. Most talked for 30 minutes–or longer.To a man and to a woman, they were most passionate about what many saw as the declining quality of health care. With few exceptions, I was struck by their genuine concern, not only for themselves, but for the plight of their patients, the state of their profession, and their own inability to cope with the problems.
“We want someone to know what’s going on,” explained one prominent Manhattan physician as he described how much care had deteriorated at many of New York City’s hospitals. “But please don’t use my name.,” he added. “You have to promise me that. In this business, the politics are so rough–it would be the end of my career.”
I agree that doctors should have woken up sooner–but some did. Some have been fighting for health care reform since the 1960s.
But in the 1980s, as the country became more conservative, so did its doctors. I was teaching at an Ivy League university in the early 1980s, and I remember a student weighing the choice between law school (Harvard) and med school (Yale) in dollars:
“On the one hand, law school would only take 3 years, and when I came out I could earn . . On the other hand, med school will take longer, but if I become a surgeon I can expect to pull down . . .”
I remember thinking “Jeffrey, I hope I never find myself on an operating table looking up at you.” He really didn’t seem to have any particular passion for either law or medcine.
I’m afraid that during those years a certain percentage of students went to med school mainly in hopes of making a very high salary.
In the 1960s, there were not nearly as many sub-specialties and specialits, and salaries were not nearly as high. So people were more likely to sign on for med school because they were keenly intersted in the science and/or wanted to help patients. Medicine was a prestigious profession, but people looked up to doctors in large part because they helped people–not because they made so much money.
Today (and for at least the last 18 years or so) people going to med school know that there are many much, much easier ways to earn a good salary. Even top paid specialists could in most cases, do better if they just got an MBA or went to law school, and then went into the financial world. (Anyone bright enough and diligent enough to get through med school would be, in most cases, able to do very very well in the financial world.)
So the people who have chosen to become doctors in recent years are, I think, generally very patient-centered.
This is not to knock everyone who went into medicine in the 1980s–many were genuinely altruistic. But generally, it was a pretty conservative, very materialistic era.
“So the people who have chosen to become doctors in recent years are, I think, generally very patient-centered.”
———
Backing away from financial motives as part of the discussion, I want to reflect on what has happened over the last 30 years to show how tough reform will be if you really do believe the main problems are supply side controlled! BTW, I strongly agree that the main problem with our healthcare system is supply side factors. In fact I believe most providers and almost all patients have such incomplete knowledge of true effeciveness and side effects of treatments that they are basically following actions that are non-evidenced based but they believe are the gospel. Good intentioned providers are following what they believe is good care, yet here we are saying that 1/3 to 1/2 of most treatment costs are waste!! If this situation did not come about by purposeful intent, then changing the model of how providers treat will not involve them directly, but will involve where and how they have been getting their directions of what to do. That is getting right down to the very basics of the science behind the system. Is anyone seriously looking at that??
All I hear is costs, costs, costs, and access, access, access, but not much about value and efffectiveness.
Just how realistically are we going to get the system to be based on value and true effeciveness and how will we get providers to truly follow such guidance if we ever do find it???????
“Just how realistically are we going to get the system to be based on value and true effeciveness and how will we get providers to truly follow such guidance if we ever do find it???????”
The only way to accomplish this is to uncouple compensation from services provided. Surely we can find a way to reward hard work without linking it so directly to to what we doctors do to people. After all, thinking is hard work, too. Especially for me.
NG:
You write: “Good intentioned providers are following what they believe is good care, yet here we are saying that 1/3 to 1/2 of most treatment costs are waste!! If this situation did not come about by purposeful intent, then changing the model of how providers treat will not involve them directly, but will involve where and how they have been getting their directions of what to do. That is getting right down to the very basics of the science behind the system. Is anyone seriously looking at that??”
Yes, many people are looking very seriously at the science behind the system–and realize that the biggest problem is the lack of evidence-based medicine.
You are right: having “access” to a system based on anything else really doesn’t do people much good.
But both the cognoseceni of medicine and many in the mainstream media recognize the problem.
For a short list of stories nespaper citing the Dartmouth Research (which explains how much of our medicine is not based on medical evidence) in The Wall Street Journal, The New York Times, the Philadelphia Inquirer, the Miami Herald and the St. Louis Post Dispatch, see The State of the Nation’s Health,” Dartmouth Medicine, Spring 2007. http://dartmed.dartmouth.edu/spring07/html/atlas.php
Many providers are aware that we need evidence-based medicine, and would, I believe follow guidelines if they could find good reserach, organized, in one place (Which is what NICE does in the U.K.)
Most doctors really do want what is best for their patients. They don’t like working in the dark.
This is not to say that any of this will be easy.
Reform will require a bare-knuckled political battle between conservatives and progressives who have very diffrent values and priorities.
But I think we’re ready for that battle.