Rx: We need people doctors
I was tickled to hear that the insurance industry is starting to think about lifting bans on the pre-existing conditions that keep a slew of Americans from getting health coverage. This has always been on the deep end of a pretty wacky system.
But there is a pre-existing condition that hasn't garnered nearly as much attention in the health care debate. It's the condition we all share: being a human being. As opposed to, say, being an organism subdivided into parts and scattered over the medical landscape from neurology to podiatry.
Health care reform has focused, rightly enough, on the 50 million uninsured Americans. Reformers are homing in on price tags that are off the (medical) charts. We are told of financial fixes and electronic records that will save the day, or at least the budget.
But speaking as the CEO of a wholly owned body, I don't think we're talking enough about the care in health care.Consider one of the least secret medical records in the country: the erosion of primary care doctors. A half-century ago, we had equal number of generalists and specialists. Today there are two specialists for every generalist.
In clear view and with all undeliberate speed, we developed a system that rewards procedures over primary care. As analyst Robert Blendon puts it bluntly, "It's absolutely clear that payment systems have been negotiated that reward specialty time and use of equipment." The incentives tip toward the kind of medicine that is performed with hands, tools and technology over medicine that is practiced with eyes, ears, and mind.
The average generalist now earns 55 percent less than the average specialist. Many students apply to medical school to connect with and take care of sick people. They graduate to become what one doctor slyly calls "proceduralists." They enter with a strong desire to look after families and exit with a ticket to X-ray femurs.
It was this business model that produced both runaway costs and discontent. Now we are told that a business model can fix it.
As Drs. Jerome Groopman and Pamela Hartzband wrote in a thoughtful New England Journal of Medicine piece on the changing culture of their profession, medicine is about more than metrics. It is both a "market relationship" where you provide goods for services, and a "communal relationship," built on a family model, where doctors help when help is needed, regardless of money.
"Assigning a monetary value to every aspect of a physician's time and effort," they write, "may actually reduce productivity, impair the quality of performance and thereby even increase costs." All while undermining the communal relationship. The business models don't touch the basic problem of an out-of-kilter system favoring CT scans over human connections.
"The hard conversation involves what we value as a society and what translates into the kind of care we all want," Groopman says. The "kind of care we all want" includes a known doctor who can diagnose, manage, coordinate and comfort.
This is especially important in an aging society. "I can't see an 88-year-old man for 15 minutes and find out what's wrong," says Groopman. There is nothing new in the discontent of doctors and patients, the shredding of personal relationships, or the shrinking pool of primary care doctors.
President Obama touched on the problem when he said, "Let's reimburse on the basis of improved quality, as opposed to simply how many procedures you're doing."
Speaking for my pre-existing condition of being human, it's the family doctors, the primary caregivers, who put the care in health care. Yet we talk of finance and efficiency, and the designated superhero is the electronic record keeper.
Are we to pin our hopes on that? Take two aspirin and call your computer in the morning.
© 2009, Washington Post Writers Group