Health Care Re-Form

The debate in Congress right now is mostly about whether and how to get everybody covered by health insurance and how to pay for it, but as we've discussed here -- ad nauseum, I imagine -- if that's all we do it will be a disaster. We'll just end up bankrupting ourselves and we won't end up any healthier.

One of the essential changes in the way we do medicine that I probably haven't talked about enough (is that possible?) is redirection of resources from specialty to primary care. Health Affairs has made an enlightening discussion of this problem by some heavy hitters available to you, the unwashed.

As Sandy et al review the history, specialty care -- procedures such as imaging and surgery, and services by specialists who focus on a particular body part or disease process -- has acquired and retained much higher remuneration and prestige than primary care -- basic health promotion and care coordination by a doctor who deals with people as whole people and has ongoing relationships with patients. As a result disproportionately many physicians are drawn into non-primary care specialties, primary care providers are overwhelmed by their caseloads, and health care spending is misallocated away from health maintenance and disease prevention and toward expensive and often non-cost effective intervention.

The root of this problem is really cultural -- the historical ascendancy of an exclusively biomedical model of health, which devalued public health and the bio-psycho-social understanding of personal health and well being -- which became deeply entrenched due to the disproportionate political power of the specialist medical societies. It is a very difficult problem to unravel.

These authors propose, and I endorse, a radical restructuring of payment systems which ultimately produces a health care provider workforce which is 50% in primary care. That means there will be fewer specialists, fewer procedures performed, and more income equity between primary care providers and other kinds of doctors. But, it also means your doctor will have more time to spend with you and more resources to work with you to take care of yourself and your family.

It is in large part due to fear of such an outcome that the AMA and the hospital association are resistant to meaningful reform. Yes, they want everybody insured so they can be assured of getting paid, but they don't want any other changes that will force them to scale back their horse farms. The legislation that we get this year is not going to disappoint the American College of Radiology, but the issue is whether it will lay a foundation on which we can build something that will disappoint them in the end. The publicly sponsored plan and comparative effectiveness research are both essential levers we will need to build a health care institution that truly takes care of people. They have to be non-negotiable.