What’s next for health care reform?

By ROBERT D. GILLETTE

It wasn’t supposed to turn out this way, was it? Just a few weeks ago it seemed that the United States Congress was close to enacting meaningful health-care reform that would bring our medical system up to the standards of other industrial nations. These countries typically spend 20 to 30 percent less per citizen for health care than we do while providing universal medical coverage and longer life spans than our citizens enjoy. The reformers said that we could match the results obtained in other countries by creating a national system that employs their best practices, fine-tuned with a generous dose of our famous American ingenuity.

Now the drive for constructive change seems stalled, a victim of prolonged bickering, intense lobbying and bitter partisanship in Washington and around the nation. Congress is beset by doubts, conflicting agendas and outright falsehoods. Some pundits, more intent on embarrassing President Obama than on protecting the nation’s physical and fiscal health, are gleefully proclaiming that health-care reform legislation is dead

Americans must face the hard fact that our medical system has many wasteful features that must be corrected if the cost monster is to be tamed. The current debate has highlighted some of them, but others are being overlooked. For many years our payment system has rewarded subspecialists much more liberally than general physicians (family doctors, general internists and pediatricians). Medical students know about this situation and have been “following the money” into the high-tech subspecialties, leading inevitably to overuse of costly procedures and a tendency for patients to bounce from specialist to specialist without adequate guidance and coordination of their care. Increasing focus on this technology has led to withering of the primary care services that can reduce waste while keeping small problems from become very big problems. Experience around the world confirms that strong primary care is a vital part of an optimal medical system.

Higher expenditures

In part, the current strife reflects the fact that health care expenditures will go up, rather than down, in the first few years after a new system is created. There are two big reasons for this. First, there will be a big initial cost surge as medical coverage is provided to the more than 45 million Americans who lack health insurance now. Some of this cost will be recovered as these folks receive mainstream primary care that focuses on preventing crises instead of trying to solve them.

The second reason is that it will take several years for doctors and institutions to learn and adopt the cost-effective practice styles that will be required in a new clinical environment. No raindrop thinks that it is part of a catastrophic flood, and few practitioners can see that they will be part of the problem until they learn to be more prudent in performing and ordering procedures. Medical educators bear major responsibility for today’s practice styles, but they typically don’t like to deal with cost issues and they seem unready to lead the way to the fresh clinical thinking that is so urgently needed.

Innovative but costly medical procedures and treatments are often adopted on the basis of wishful thinking and limited evidence, only to be discredited years later when better research shows them to be without value (universal prostate cancer screening may be headed in that direction). We need better research, more critically evaluated, to determine which of the new procedures are worth adopting, and for which patients. Futile treatment is worse than no treatment, because it wastes dollars that could be better spent on people who can really be helped.

Some cost-increasing factors will persist with or without system reform. Our population is aging, and older people need more medical services than younger ones. Destructive lifestyles including smoking, overeating, abuse of drugs and alcohol, unprotected multiple-partner sex and lack of exercise all take their toll. Our erratic, wasteful lawsuit system provides only a crude approximation of justice, while most of the dollars paid into the system go to lawyers rather than claimants.

Health care reform may not succeed this year, but long-term failure would be catastrophic economically and shameful from the humanitarian standpoint. If a bill is not passed, the wisest course might be to create a presidential commission to study all aspects of the situation and to report its findings and recommendations after the 2010 midterm election.

X Robert D. Gillette M.D, is a retired family physician and medical educator who resides in Poland, Ohio.