Archive for May, 2009

The Benchmark of a Civilized Society

“The benchmark of a civilized society is the quality of its justice.”
–Jack McCoy

Jack McCoy, for those who may not own a television, is the fictional District Attorney on the TV series Law and Order. Jack may be fictional, but his words are poignant, and while the quote above was not originally offered as an indictment of the way we deliver healthcare, it may well have been. I’d suggest that it is equally poignant to say that the benchmark of a civilized society is the quality of the healthcare provided to its citizens. Perhaps more to the point, the provision of quality healthcare, accessible to everyone, is the benchmark of a just society.

Recently, I received a discouraging email from a member Family Physician whose quality as a Family Doc may only be surpassed by his quality as a person. The note was discouraging not only for what he said, but for all of the implications that it held. This physician made a decision to practice in one of the lowest income, most underserved communities in our state. He has been a role model for younger physicians who want to make a difference. He’s been the access point to care for people who might not find that care without him. Last week, he closed his practice to new Medicaid patients. The economic condition of his practice also caused him to lay-off his Physician Assistant; he simply could no longer afford her. For a moment, as I read his email, I couldn’t help but think that if this Family Physician is no longer able to care for the community to which he is so clearly committed, then we may be beyond the point of no-return with regard to healthcare in this country. There was a time not so long ago when members called me lamenting the decision to hire a PA because they could not afford to hire another physician. Look how far we’ve come! Still, this situation highlights what I believe is the single most unspoken truth with regard to our healthcare “system.” The current financial model, which rewards procedures and proceduralists at the expense of wellness and those who would keep us well, will never provide us a path away from the fractured care that is not only bankrupting us, but is also leaving far too many without the care that a civilized society should – must – provide. Simply enough, even as healthcare reform is suddenly visible on the horizon, true change cannot – will not – ever occur until we, as a culture, begin to value primary care to a greater extent. Why don’t we? Some blame the big-bad insurance companies. There is probably truth to some of that. Others blame “Big Pharma,” and again, you’ll probably find some truth in those complaints. Some people argue that the only answer is a single-payer system (Medicare for All), while others fear that adding more government to any problem is simply a way to guarantee that we reach the lowest common denominator in the universe of possible solutions. I don’t know which of those answers is best, but I do believe that they are all ultimately red-herrings. I am also quite certain that the next few paragraphs will make some people uncomfortable, perhaps even angry. So be it.

We live in a society that values personal freedom above all else. We live in a time where too many people “learn” in sound-bites. We live in a culture where for far too many of us “specialized” is synonymous with “quality.” Yet in healthcare in the United States, study after study shows that we over-utilize services to exorbitant expense with little additional benefit to patients. Study after study shows that throughout the rest of the world, those societies who base their system on a strong primary care infrastructure get better results with lower costs. “We the People” get it. Lawmakers are starting to get it. The problem is that our system continues to focus the “reward” in the direction of fractured, costly care. Why? Because “We the People” can intuitively understand that we can no longer afford to spend disproportionate resources on the last six months of life with no benefit to the patient, as the Dartmouth Atlas of Healthcare has once again noted in its most recent release…until it is our loved one, or the thought of ourselves, at the end of life. “We the People” can quickly see the insanity of paying a Dermatologist three or even four times what a Family Physician or other primary care physician earns for providing the same care that a Family Physician can provide in many cases…until it’s our spouse with a suspicious mole and not the nameless, faceless “other guy.” Again, Why? Because we’ve heard the sound-bites that specialization is better and our personal freedoms demand that we are able to seek out any care at any cost regardless of data that would indicate that there is no difference in outcome. I’d suggest that any argument against that mindset, if not a losing argument, is certainly not an argument that can be won in anything close to the near term. Perhaps more importantly, even if we know the argument to be based in fact, attempting to change public beliefs fostered over decades and lifetimes keeps us from addressing the 600-pound elephant in the middle of the room, an “elephant” that may provide a more immediate result, if we have the courage to look at it.

Earlier, I noted that our system provides the bulk of the rewards to procedures and those who perform them. Until that reward system changes, I believe that we will never find our way out of the quagmire of healthcare financing in this country. It’s easy to say that we need to “value primary care,” but until we equate those words to the need to redistribute the payment provided to physicians they will remain just words. This is dangerous ground to be certain. Physicians have long been conditioned to maintain the “house” of medicine. It is certainly not popular for a physician to suggest that his or her colleague should make less. I suppose then, that it’s a good thing that I forgot to go to medical school because it is my opinion that a system that subjects primary care physicians, those who not only stand on the front-line of healthcare, but also those who coordinate an increasingly complex system for confused patients, to a condition and business model of practice that is not sustainable, while at the same time providing excessive wealth to proceduralists and other sub-specialists, is doomed to fail. Even if you take exception to that belief, I would challenge anyone to argue that there is a more obvious reason why it is so difficult to attract the best medical students to a primary care practice.

With all of that said, I am a realist. I am not suggesting that those physicians whose practice is based on procedures are not providing critical and necessary care. Nor have I lost sight of the fact that those physicians who bring highly specialized skills, acquired through long years of difficult training, deserve to be well compensated. Simply put, it would be unrealistic to suggest that the primary care physician and the neurosurgeon should be compensated at the same level. I am suggesting that the ratio of compensation needs to be brought to a more sustainable level if we truly want to rebuild our primary care infrastructure and provide the access that everyone deserves. We can continue to fight the common enemies. We can continue to advocate for a payment system that is not run by organizations whose primary motivation is their own wealth. However, while we fight those battles, we might want to consider that another solution may be as simple as bringing physician compensation into a more justifiable ratio.

The benchmark of a civilized society is the quality of its justice, and its healthcare.

That’s my opinion.  I’d welcome yours.

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