Stanley Feld M.D.,FACP,MACE

 Patients are first. Patients are the reason for the existence of the healthcare system. Physicians are second. They are trained to understand the pathophysiology of illness and to treat patients for their disease. Everyone else is a secondary stakeholder (provider).

 All the stakeholders create waste in the healthcare system. If an accurate analysis were performed, most of the waste and the resulting profits would be attributed to the secondary stakeholders. Patient and physicians drive this waste and profits into the hands of the secondary stakeholders. Neither patients nor physicians are aware of driving the waste and profit into these stakeholders’ coffers.

The patient-physician relationship should be a one on one transaction. Patients and physicians are frustrated and many have accepted the disappearance of this human-to-human interaction. 

 Healthcare insurance companies and hospital systems think they own the patients and the physicians. This will turnout to be a fatal misperception.

 To many observers of the healthcare system, there are no simple solutions to fixing the dysfunction. One reader wrote:

“ There are so many contending interests, physicians, patients, hospitals, surgeons, labs, health insurance companies, public funding, et al., there will never be an ideal plan simply because of the tensions that exist between the above actors.”

“This is compounded by the population diversity which impacts ability to pay, willingness to practice preventative health or comply with medical recommendations.  Add into the mix the highly influential emotions that cause patients and their family to make inappropriate or unwise decisions.”

 The dysfunction in the healthcare system is so complex that most people look to blame someone for the dysfunction. The easiest targets are physicians.

  I believe there is a simple way to solve the problems. It is by creating a consumer driven system that provides enough financial incentive to consumers to inspire them to prevent the development of chronic disease, teach them to treat their chronic disease with effective systems of care and provide information on finding physicians who will provide care. The solution has to be driven by individuals responsible for their care.

 A case in point is Kris Carr author of Crazy Sexy Cancer

 “Before finding Dr. Demetri at Dana-Farber, she spoke to four other oncologists. One kept her waiting for three hours, gave her 10 years to live and then abruptly left to see another patient. Another off-handedly suggested a triple organ transplant. But something about the wrongness of it all galvanized a previously untapped drive in Carr.

  “I realized,” she says, “that if I was going to make it through this, I needed to become the C.E.O. of my own healing start-up.” Carr called her imaginary company “Save My Ass Technologies Inc.” She began meeting with doctors as if they were applying for a choice job with her.

 Consumers can drive all the waste out of the system. People do not want to believe this because the profit created by the waste is counter to their vested interest. Many health policy experts think consumers are too stupid to find good medical care. It is not that they are too stupid. Consumers feel powerless in the present system.

 Right now the solutions are finger-pointing solutions based on hunches and little evidence.

A physician wrote an editorial in the Bangor Daily News.

 I think my profession collectively has failed miserably to lead on most hot issues of health care reform. It has not, for example, led efforts to get all Americans health insurance, to reduce medical errors, or to reduce waste in health care in order to help make it affordable for us all.

 The statement is meaningless to me. It is grandstanding. The problem is if you tell a lie enough times it becomes the truth. The big question is which testing and which procedures are appropriate to improve well-being.

"Which road will physicians choose when it comes to reducing the number of wasteful procedures they perform and for which they get paid? We do countless colonoscopies, heart catheterizations, MRI scans, joint scopings, office visits and much more that waste billions of dollars and cannot be eliminated without physician leadership of a “whack out the waste campaign.”

 A reader of my blog replied to the statement made in the article in the Bangor Daily News.

I'd like to know who are the docs that are doing all this overutilizing that we keep getting accused of by others, and even by members of our own bunch.  I haven't practiced that way, and I don't know docs who do.  Where are all those miscreants?  I'm wondering if that may be another example of a false statement being repeated so often that it eventually acquires a ring of truth."

In another departure from conventional thinking by the traditional media the same reader continues:

"And, while I'm thinking about it, what can we do with the percentage that healthcare expenditures form of the GDP when the GDP is going into the tank, and healthcare is not?  Doesn't that make the percent for healthcare seem a whole lot larger than it otherwise would be?  Maybe we should be railing away at the people who have allowed our GDP to get to the miserable level it now forms.  Instead of it all being Bush's fault, maybe it is the fault of the unions whose greed drove all those jobs overseas, not to mention the excessive government regulations and taxation of corporations that make disincentives to GDP growth in our country?  Maybe our view of things is narrower than it ought to be.  D"

We should not be satisfied with conventional thinking. Finger pointing doesn’t solve the problem of dysfunction in the healthcare system. What does is recognizing patterns and changing approaches to the healthcare system that serve to align incentives of all the stakeholders without totally disrupting the structure that exists.

The most important stakeholders in the healthcare system are patients. They should control the healthcare system. Consumers should make all the other stakeholders compete for their business. There is too much waste, too many middlemen, too many markups and too much abuse by all the stakeholders.

 The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone. 

Stanley Feld M.D.,FACP,MACE

The Role of Physicians in Controlling Medical Care Costs and Reducing Waste by the RAND Corporation and David Geffen, University of California Los Angeles School of Medicine, Santa Monica was just published in the Journal of the America Medical Association (JAMA).  I do not think the JAMA should have published this article.

1.Why would the JAMA publish such an article?

2. Why are physicians blamed for all the waste in the system?

3. Why is it the physicians’ responsibility to eliminate waste when they are not the cause of the greatest percentage of the waste?

“The amount of money spent on medical care is increasing faster than the gross domestic product (GDP), and the federal deficit is increasing.”

The initial statement assumes that the government deficit is increasing because physicians control government spending for healthcare.

This is only partly correct. The question I have is maybe patients should drive medical costs and not the government.  

The government bureaucracy and the healthcare insurance industry has created this cost monster.

 “Budget experts believe that the deficit cannot be reduced unless medical spending can be controlled. What role will physicians play in controlling health care cost growth? Are physicians even willing to play a role?

The article outlines the steps physicians must take to reduce waste and therefore the budget deficit. The assumption is physicians are the main source of the healthcare system’s waste.

The RAND Corporation does not consider the waste of the government bureaucracy, the healthcare insurance industry’s excessive fees, the hospital systems’ excessive billings, nor the pharmaceutical companies excessive charges for medication. Not considered is the excessive waste that results from the forced practice of defensive medicine because of the lack of tort reform.

If all these issues were addressed, waste and costs would be markedly decreased. There would be no need to try to commoditize physicians’ medical decisions.

I cannot visualize success in trying to commoditize the physician’s decision-making processes.

The healthcare system should be consumer driven with the consumers owning their healthcare dollars and making their own healthcare decisions. The government must help teach consumers to make appropriate medical care decisions with their own money. The government could provide the money. It would eliminate all the bureaucratic waste and secondary stakeholder abuse because it would create a true marketplace driven by consumers and not an artificial marketplace driven by government inefficiency. Consumers must make their own medical care decisions and be responsible for their actions. 

The authors of the article suggest that physicians have three options for participation in controlling healthcare costs. The problem is it assumes the burden for controlling costs are the responsibility of physicians.

     1.     "Physicians can do nothing."

      2.    "Health care can be rationed."

     3.   " Physicians take the lead in identifying and eliminating waste in US health care system."

    4. (We have tried to lead.)

    5. (President Obama has ignored us.)

“Physicians could define waste by assigning all services to 1 of 4 types of care—inappropriate, equivocal, appropriate, or necessary”.

This is subjective busy work that is destined to fail. It will also stifle creativity, thinking, problem solving and innovation.

Physicians try to practice evidence-based medicine. There are defects in determining best practices. In many cases the conclusions drawn from clinical results are inaccurate. It is arbitrary based on the bias of the experts picked to be the judges.

1.Inappropriate care, the potential health benefit to the patient is less than the potential harm caused by the procedure, device, or drug

2. With equivocal care, potential harm and benefit are about equal.

3. With appropriate care, potential benefit to the patient exceeds potential harm.

Necessary care is appropriate, represents the only viable option, and produces a large health benefit.

Who decides appropriate and necessary care?

An excellent example is the difficulty deciding appropriate and necessary care in the use of post-menopausal hormonal replacement therapy. The study design of the Women’s Health Initiative (WHI) was defective, the execution of the study was ineffective and the statistical analysis was inaccurate. The conclusions of the WHI are suspect. Yet the WHI has been heralded as evidence based medicine for best practices. It has changed the course of women’s health forever.

A tool to measure clinical waste across all clinical services does not exist. This is because the definition of “clinical waste” is ever changing. Today’s best practices can be tomorrow’s clinical waste.

Physicians are constantly trying to define best practices. It must be the job of physicians. Physicians are constantly trying to teach other physicians best practices. Physicians are constantly trying to learn to keep current.

The best practices have to be put into context with changing scientific concepts. Potential bias must be evaluated.

The clinical decisions should not be the interpretations of policy wonks or bureaucrats.

None of this is black and white. Policy wonks, economists and bureaucrats have little understanding of the complexity involved in clinical decisions.

Their interest is to somehow try to quantitatively measure physicians’ clinical decisions against an artificially created set of standards defined as waste.

“Physicians prefer the medical definition. But it is not known how much clinical waste is in the system.”

Another excellent clinical example of the controversy is the treatment of choice for Graves Disease (hyperthyroidism). There are cogent arguments for the treatment of choice for Graves Disease with either radioactive iodine or medications such as PTU or Tapazole. There is no unequivocal scientific evidence for an advantage of either treatment.

Attempts have been made to prove an advantage of one treatment over the other. When there is a lack of unequivocal evidence for best practices, patients must be given a choice of therapy.

A defect in the attempts to determine best practice in clinical research is the elimination of patients’ freedom to judge and choose or participate in the best treatment choice for that individual. 

It is physicians’ responsibility to defend and maintain that freedom for their patients. The reasons for waste in the healthcare system should not be determined arbitrarily by bureaucrats.   

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.