Thursday, February 25, 2010

The President's Health Care Summit

My friend Julie Eckstein, the former State Health Officer of Missouri, now works with the Center for Health Transformation led by former Speaker of the House Newt Gingrich. She has asked me to participate as a "expert" (which I always thought was a guy from out of town with a Power Point presentaiton) in a live blog on the proceedings of the President's Health Care Summit. As part of this, I was asked to write an introductory commentary. I encourage you to join the discussion at

When I was asked to think about today’s Health Care Summit, I kept thinking of Santa. When you’re a kid, you make a wish list and tell Santa everything you want. What Mr. Kringle actually brings is whatever, in close consultation with your parents, he actually wants to stuff into the sleigh. (For the record, you might also get whatever your relatives have an inclination to purchase, especially if said gifts are particularly annoying to your parents. This is why my nieces and nephews have metal drums, carpet-adhering Play-Doh, and bow and arrow sets.)
The Health Care Summit should be my opportunity to tell Santa my wish list. But unlike the list of my twelve-year old son, an endless roll of specific items originating from the television and the internet, my list is that of a practicing emergency physician looking to see if we can at least share a baseline understanding of our systemic health care problem. So here are four things I would like to hear:

Health beats health care. Health is defined by the World Health Organization as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” It is a factor of not only medical care, but of genetics, culture, economics, education, and environment. By way of contrast, health care refers to system of delivery of medical treatments (doctors and hospitals), while health coverage refers one view of how such services are mediated between patients, physicians, and external payers (public and private insurance plans). This distinction is critical to understanding the true impact of the current debate, which has started to address the problem of health care coverage. We have not yet begun to address issues of health except in the most peripheral fashion. Decreasing smoking rates, preventing obesity, and mandatory seat belt laws can do more for the health of the nation than expansions of Medicaid or individual mandates to purchase private policies. And while I firmly believe that every citizen of this country deserves access to the health care system, there is a relative paucity of evidence to suggest that changes in health care alone will have a major impact on overall health.

Health care cannot, by its nature, work by free market rules. I've always had a problem with looking at health care as a marketplace subject to the same market forces as buying a home appliance. Health care is accessed differently than other markets...for example, your doctor or insurance plan often tells you where to go for care, as opposed to choosing any appliance dealer of your choice...and if your need is emergent rather than elective, your choices are often circumscribed by geography, urgency, or the need for specialty services. The specialized nature of health care means that individual often cannot make an informed consumer choice of costs, products, and services. I don't know that I can support the idea of heath care operating as a free market system, not because there's anything wrong with the free market, but because health care cannot, by its very essence, operate in that way except in a very limited realm of choices and services. An employer choosing which health plan to offer employees can operate according to free market principles; the employee's use of that policy cannot.

Health care is a doctor-driven process. Trying to figure out who’s in charge of the health care system is a great game, almost as fun as Parcheesi. But from a day-to-day, operational view, physicians still actually run the show. It’s the physician who provides an entry point into the health care system through the office or clinic. It’s the physician who provides the assessment, orders tests, requests consultations, and order drugs and other treatments for acute or chronic medical conditions. It’s the physician who has to balance clinical realities, resource management, consumer demands, and societal expectations while keeping the patient’s welfare first in mind. It’s the physician’s actions (or lack thereof) which drive the medicolegal system. Health care costs are driven by the process of establishing the diagnosis and providing care, all of which are under the expert control of the physician. And while physicians are unquestionably subject to, and necessarily react to, all the outside influences upon their practice, the fact remains that nothing gets done, care is not provided, costs are not incurred, and paperwork is not completed without the doctor starting the chain of events. So it seems to me that if we really want to reform health care, we need to concentrate on the role of the physician. For example, we already know that it’s difficult for Medicaid patients to get into physician’s offices due to reimbursement and medicolegal concerns. While it’s true that expanding Medicaid gets more patients “coverage,” what makes anyone think that simply expanding Medicaid means more patients will actually get to see a physician?

Access x Quality = Cost. I’ve always thought that out of every relationship, good or bad, you find something of value. And so I must thank the worst boss I ever had for introducing me to this equation, one which effectively summarizes the entire problem of any health care system.

• Access is the number of people who have entry into the health care system.
• Quality represents the number of services provided.
• Cost is, well, cost.

It’s a zero-sum game. If you increase health care access while holding service level stable, costs go up. If you increase the services provided to a constant population, costs rise. The only way to hold costs down is to limit access or limit services. Both of these are unpopular, which is why costs will continue to rise. Either decide to place limits to control costs (personally, I’d rather see greater access to a limited scope of services) or just accept that health care reform is going to cost more…a lot more. I’m less worried about the details or direction of change than I am about simple honesty.

Why are these thoughts on my wish list? Because acknowledgement of these basic facts is the first step towards real improvement. Failing to recognize these tenets as true is easy, and allows plenty of room for argument, planning, and policy without requiring any hard decisions. But hard decisions are what we need if we truly want to arrest what all parties acknowledge is a precipitous decline in the health of the nation.

This being said, I will be pleasantly surprised if any of these things are mentioned at the Summit today. I might even be tempted to take a nibble off my Stetson. My expectation, however, is that instead of an open and challenging dialogue about the root issues of health and health care, we will simply hear more political posturing from both the left and the right. None of which, unfortunately, will take us any closer to repairing a system that is irrevocably broken.

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