The academic world of health care likes the Obama health “reform” act. They are now figuring out how it will affect healthcare since it is a slapdash combination of pork barrel projects and untested assumptions. For example, it uses all the old command and control theory to deal with utilization and cost.
For years, the debate over health care has rested on the assumption that the uninsured should be brought into the health-care system the rest of us use. But what if something like the opposite is true? What if the best way to help the uninsured is to make the health-care delivery system they already use — the St. Elsewhere model — better, more efficient, and more affordable — in short, more like the VA? And what if, eventually, the rest of us could join that system?
Longman says the first step is covering the uninsured, particularly low income people. We’re on that path now with the passage of health reform. But we don’t have to put all the newly covered people into the current strained fee for service system and Medicaid. He proposes creating the “Vista Health Care Network” (VistA is the name of the VA’s electronic medical record system). Invite the “St. Elsewheres” and individual doctors to join an integrated delivery system to serve the newly insured. Like the VA, it would have a team approach, use health IT and comparative effectiveness protocols. Doctors would be salaried, and rewarded for quality not quantity. In other words, it would be what has now become known as an “accountable care organization.”
This is the standard fantasy of the political left. If we could just get rid of those evil profits and monetary incentives, everyone would adopt the virtues of the Utopia. Marx said “to each according to his need and from each according to his ability.” That may work well in religious communities where everyone is concerned with salvation. It doesn’t work in the real world, as anyone who studied the Soviet Union or Cuba should attest.
Longman predicts many struggling hospitals would see it as a lifeline. “Reimbursement rates would be set much higher than in Medicaid, and when combined with the efficiency in the VA model of care, they’d be high enough to guarantee the solvency of participating providers.”
Does anyone really believe that ?
The hospitals that take Vista’s offer would have to radically change the way they do business. They’d have to join the twenty-first century and integrate health IT into the practice of medicine. They’d have to embrace the VA’s safety culture. They’d also have to shed acute care beds and specialists and invest in more outpatient clinics in which, for example, diabetics could learn how to manage their disease, or people with high blood pressure could join smoking-cessation and exercise programs.
Where would the sick people go, if not to the hospital ? The graveyard ?
As with the VA, there would also be much more emphasis on integrated mental health-care and substance-abuse programs. Also as with the VA, doctors who work for these hospitals would be salaried and earn bonuses for effective performance (keeping their patients well). No longer would doctors have financial incentive to engage in overtreatment.
Yes they would have an incentive to under treatment. Sort of like the Netherlands ER doctors who give emphysema patients a lethal injection of morphine rather than admit them to the hospital. A doctor who admits an emphysema patient with respiratory failure is fired. Period. NO appeal. Everyone knows the rules. Except the families.
There is another opinion, well summarized in another medical blog. His posts are heavily embellished with humor that not all will appreciate. His ideas, however, are right on the money.
Until quite recently, DrRich counted himself among the stalwarts of scientific strict constructionism. He was truly dismayed that the NIH and some of our most well-regarded academic centers (under the guise of wanting to conduct objective “studies” of alternative medicine) have lent an aura of respectability and legitimacy to numerous bizarre ideas and fraudulent claims masquerading as legitimate medical practices. To DrRich, such developments were yet another clear and unmistakable sign of the End Times.
Furthermore, DrRich (a well-known paranoid when it comes to covert rationing) saw a more sinister advantage to the official and well-publicized support that government-funded institutions were giving to the alternative medicine movement. Namely, fostering a widespread impression among the unwashed rabble that alternative medicine is at least somewhat worthwhile (and plenty respectable) advances the cause of covert rationing. That is, the more you can entice people to seek their diagnoses and their cures from the alternative medicine universe, the less money they will soak up from the real healthcare system. With luck, real diagnoses can be delayed and real therapy put off until it’s far too late to achieve a useful outcome by more traditional (and far more expensive) medical means.
I think there is some truth to this. Chiropractors, for example, have made good use of the myth that their services are far cheaper than conventional medicine and therefore a money saver. The legislators who vote for these “money saving” changes in the law have never spent much time looking at the house size of chiropractors compared to MDs. In the Workers Compensation world, I have seen a case in which a disabled worker received 900 chiropractic treatments in one year.
Rather than a term of opprobrium, “alternative medicine” may actually be our most direct road to salvation. Indeed, DrRich thinks that far from damning alternative medicine, we should be blessing it, nurturing it, worrying over it, in the precise manner that a mountaineer trapped in a deadly blizzard would worry over the last embers of his dying campfire.
What turned the tide for DrRich was a recent report, issued by the U.S. Centers for Disease Control and Prevention, estimating that in 2007, Americans spent a whopping $34 billion on alternative medicine. That’s $34 billion, for healthcare (in a manner of speaking), out of their own pockets.
The implications of this report should be highly encouraging to those of us who lament the impending creation of a monolithic government-controlled healthcare system, and who have been struggling to imagine ways of circumventing the legions of stone-witted, soul-eating bureaucrats now being prepared (Sauron-like) to descend upon us all, doctor and patient alike.
This is why DrRich has urged primary care physicians to break the bonds of servitude while they still can, strike out on their own, and set up practices in which they are paid directly by their patients. Such arrangements are the only practical means by which individual doctors and patients can immediately restore the broken doctor-patient relationship, and place themselves within a protective enclosure impervious to the slavering soul-eaters.
This is the lesson to be drawn. We’ll see how many physicians take the hint. The seriousness of the trend is suggested by the efforts of the government, especially in Massachusetts, to make private practice of medicine illegal.
DrRich has speculated on various black market approaches to healthcare which could be attempted by American doctors (and investors) should restrictive, government-controlled healthcare become a reality. But now, thanks to the success of alternative medicine, there is a direct and straightforward path for American primary care physicians to re-establish a form of now-long-gone “traditional” American medicine, replete with a robust doctor-patient relationship, right out in the open – the kind of practice where patients pay their doctors themselves.
Simply declare this kind of practice to be a new variety of alternative medicine. Likely, PCPs will need to come up with a new name for it (such as “Therapeutic Allopathy,” or “Reciprocal Duty Therapeutics”), and perhaps invent some new terminology to describe what they’re doing. But what’s clear is what they will be doing is so fundamentally different from what PCPs will be doing under government-controlled healthcare as to be unrecognizable, and nobody will be able to argue it’s not alternative medicine. In fact, it will seem nearly as wierd as Reiki.
There is a novel suggestion.
Tags: health care, medicine
thanks for the help!