Prior to the 1960s, fee-for-service did not work. Since 1974, managed care appeared to make a difference until the late 1990s. In fact, neither system works. The reason is that there is no inherent control on spending. Medicine is not a free market.
Recent attempts at introducing market economics have been limited. We have a large number of buyers and sellers; however, they do not have freedom of movement within the market, nor do they have transparency. Free movement is hampered by the HMOs, PPOs and third-party administrators that steer patients into particular plans. Transparency is only now being built by placing information about hospitals and physicians onto Web sites. Patients do not understand these sites and do not act accordingly as they would when buying a car. They still ask their friends who is a good doctor, even if the Web site shows the physician has poor indicators.
In short, we need controls on cost and quality.
• Sen. Hillary Rodham Clinton (D-N.Y.) addresses cost when she mandates coverage. That addresses cost, since it will help reduce price shifting. Other controls on cost come from the efficient use of healthcare dollars.
• Better computerized systems will help with this, but it will take billions of dollars to invest in this infrastructure. Wisconsin with its www.whie.org, Florida and other states are starting this investment, but it will take years; and there are no national standards for interoperability.
• Our history with certificates of need in the 1960s did not work, since it was politicized. Canada uses a system of negotiating fee schedulespriceswith hospitals and physicians. We should consider this approach.
• Oregons public system defines what procedures are acceptable and only pays for these. Could this be done on a national scale?
• Transparency puts control back into the hands of citizens using healthcare spending accounts. These systems need to be developed better to help consumers decide how to spend their healthcare dollars. However, there is concern that patients will avoid routine health maintenancemammograms, prostate specific antigen levels, etc.as they try to hold onto those dollars. There needs to be routine care and catastrophic coverage built in to prevent citizens from becoming bankrupt when spending exceeds the limit of their account or insurance coverage.
Quality is a difficult topic. The industry is also addressing this through computerized systems. This reduces duplicate ordering, increases the efficiency of clinical workflows, since information is available at the point of service where health decisions are being made, it makes billing more efficient, it provides clinical decision support so that the physician does not order needless studies. Again, this takes billions of dollars of infrastructure. Computers have been shown to reduce lengths of stay in hospitals and to use resources better, such as ordering Vancomycin antibiotics appropriately, managing congestive heart failure better and reducing re-hospitalizations. Our experience with third-party insurance companies and Medicare trying to micromanage medicine has not worked. It has created a wasteful bureaucracy that is more expensive than the waste it is trying to preventand it prevents patients from getting care in a timely manner.
We have a lot of work to do to fix the system. I have touched on the salient features. Mandating healthcare coverage alone will not work. It is a good start.
Kevin P. Rosteing, M.D.Internist
Student Milwaukee School of EngineeringMedical
College of Wisconsin
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