Sean Khozin, MD, MPH

As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. Atul Gawande

As Gawande puts it, we are now witnessing a “battle for the soul of American Medicine.” There is a lot of blame going around but there is a trend that is starting to emerge: we need a redesign how care is delivered. Gawande likes the idea of having integrated healthcare delivery systems, like the Mayo Clinic, where salaried physicians work in multidisciplinary teams and there is a fair amount of collective thinking. As the CEO of the Mayo Clinic told him, “When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing.”

If we conclude that the Mayo Clinic model is applicable to other parts of the country, replicating it requires reforming the system in such a way that it does not financially threaten physicians (less than 10% of healthcare dollars go to physicians) but changes the incentives from doing more to thinking more. Most physicians would find getting paid for their time this way more fulfilling but are currently burdened by a payment and malpractice environment that promotes doing more that’s needed and disregards the cognitive aspects of medicine (Although the issue of malpractice is downplayed by some, physicians of all specialties and creed practice defensively).

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.

In recent years, doctor-bashing has become a popular hobby. Physicians seem to blamed for everything. A friend and retired pathologist, Dr. Richard Reece, recently described this phenomenon on his blog as follows (excerpt):

For a number of years, physicians, as the most visible symbol of health care delivery, have been criticized, chastised, and blamed for everything — as the primary source of exploding health costs, practicing poor quality care, to being computer troglodytes for failing to accept money-losing electronic health records designed to document their every act.

You can tax doctors all you want, reduce their fees, regulate them, blame them for system dysfunction, but these actions taken collectively, are likely to reduce the number of existing doctors, discourage young people from entering the profession, and cause mobile doctors to adopt other options. One of the most common options is not seeing new Medicare and Medicaid patients because of low rates of payments and high burdens of paperwork.

The moral of this tale: without more doctors, health care reform measures promising greater access is meaningless, and more regulations, more information technology, more cuts in reimbursement, even more token rewards for installing EHRs and meeting quality indicators, are not likely to produce more doctors.

Marginalizing and blaming doctors is, at best, counterproductive to realizing meaningful healthcare reform. Let’s all come together and engage in constructive dialogue. The stakes are too high and affect everyone in the country.

There are no one step solutions for managing complex change such as healthcare reform at the national level. Many factors have to come together in perfect harmony.

Consumers shopping for health insurance today face more choice, complexity, and financial exposure than ever before. In an increasingly uncertain world, what they are really seeking is peace of mind in their choices. Insurers that address the emotional needs and biases embedded in the typical consumer’s behavior will be successful in creating and distributing effective products, earning the consumers’ trust, providing a more satisfying shopping experience, and, ultimately, helping consumers better manage their health. The McKinsey Quarterly

Insurance companies continue to be profitable not because they have extraordinary products but because of how they’ve positioned themselves. Unrivaled as an industry, they’ve enjoyed a comfortable share of a very large market but consumers today are more sophisticated and have evolving needs that must be met. Ignoring these needs can make the health insurance industry unstable and irrelevant as providers begin to come up with innovative ways of connecting directly with patients and the new administration increases efforts to expand its control over the flow of healthcare dollars.

For Margalit Gur-Arie, writing for the Health Care blog, the future of primary care is a barren landscape:

I fear that the independent family doctor is going to go the way the corner bookstore went, and be replaced by the cold, impersonal, shiny mega-clinic chain in the city. It won’t be long after that before Wal-Mart sets up the Wal-Health clinics in rural America. Any young kids out there planning on going to medical school and hoping for an illustrious career with Wal-Mart?

The Institute of Medicine defines continuity of care, the core attribute of primary care, to have 3 dimensions: continuity in information, continuity in management, and continuity in the patient-physician relationship.

Margalit Gur-Arie’s vision of the future of primary care will at best lack one essential element of continuity: the patient-physician relationship. But does this really matter? The person who commented on her story certainly thinks so:

I’m going to look for an internist who will agree to be my ombudsman if my health indicates a need for any kind of specialist (heart, circulatory, ortho, etc.). I understand being referred to a specialist, but I don’t want to be sent off on my own. I really want a medical pro to guide me among several options… and if possible, I want his second opinion about anything a specialist would do if it is anything other than trivial or an emergency.

I don’t know if I will succeed in finding the PCP of my dreams, but I know I can’t put it off forever. … In my case expertise is less important than a personal willingness on the part of a professional to advise me on matters I can’t learn on my own.