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Why the “Doc Fix” debate matters to all of us

There is once again lots of discussion in the healthcare community over what we lovingly call the “Doc Fix.” The doc fix is that annual struggle in Congress to un-do the automatically triggered reduction in physician payment based on the entirely UN-sustainable “Sustainable Growth Rate” (SGR) formula. I am not the person to explain that formula, but feel free to read all about it on your own. My message today is less about formulae and policy, and more about what it means to you and me.
So, for those who are NOT regularly tuned in to healthcare issues beyond the fact that you or someone you know is occasionally a patient, google “doc fix” and read the most recent news — or just read the article at the link at the bottom of this page. Once you have read a bit on the topic, it will be easy to dismiss this as “rich” doctors complaining. That’s reasonable, but consider this: We KNOW (lots and lots of data support) that where there is a strong primary care infrastructure, where primary care docs are an integral part of the healthcare team (where patients have a “patient centered medical home”) healthcare costs go down and health outcomes improve (the system spends less to keep you healthier). Now consider that your son or daughter (or YOU) are considering going in to medicine, and really wants to be a family physician and deliver the kind of high quality primary care that our country so desperately needs. They (or you) can do that and all it will take is about $200k in debt – or the equivalent in personal wealth, willingness to work harder and less family-friendly hours than most of your physician colleagues, start the “earning” portion of their (or your) career in your 30s making barely enough to cover that debt…and never approach the salaries earned by your anesthesiologist, dermatologist, or almost any other “ologist” colleagues (in many cases earning 50% or more LESS) and have the additional pleasure of being told by the government that their (or your) pay will be arbitrarily reduced by 30% — and even if the self-important (er…I mean “well-intentioned”) politicians to whom we entrust our government DON’T do that, your paycheck is going to be held hostage for 10 days or so while those same “well-intentioned” Congressional representatives bicker over politics.
A person capable of being accepted in to medical school is clearly smart enough to be a doctor, or for that matter any other thing they may choose to be. So ask yourself, would you choose the path of a primary care physician? WHY would you want your son or daughter to choose that path?
If we want the kind of healthcare we deserve then this annual exercise of the “doc fix” must end once and for all with a new formula that replaces the SGR, and our system that rewards procedures at the expense of coordinated care MUST change. If not; if we don’t force our representatives to make difficult choices based on what is right rather than on how to keep all “voting blocs” happy, I fear that there will be no one left to provide the primary care that we deserve.
As always — and perhaps even more than always — these are my opinions and not necessarily the opinions of my employer (although I’d be willing to bet that most of my members agree).

The article I mentioned on the “doc-fix:”

Info on the PCMH:

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The Choice: Customer or Beneficiary

It’s been a long time since I blogged here. I had become concerned that I would be seen as speaking for the organization from which I draw a salary. I do that in other forums, willingly and with pride. So, while I would assume (hope) that many of the wonderful people for whom I advocate would agree with me here (or at least find what I say to be provacative enough to cause them to think), this blog does NOT express, nor is it endorsed by the NJAFP, the AAFP, or any of their members.

This morning I read an editorial by Paul Krugman of the NYT. While I agree with some of Mr. Krugman’s points, and disagree entirely with others, what jumped out at me today was that everyone who has something to say about our broken, fragmented healthcare “system” is able to clearly (and usually articulately) identify what they believe to be the source of the problem. Few however, offer solutions other than very typical, and usually partisan (a la Krugman) ideas that are often rejected by large portions of the electorate (and I’ve become convinced that this is all we are to most politicians…a measurable commodity on their march to power). Given that I am also long on problem and short on solution, maybe I am no different. That said, there is an 800 lb elephant in the middle of the room, and we need to begin as a society to talk about it.

The foundational problem is that our culture has become to quick to depend on “someone else” to take care of us. Greed and laziness are leading too many to NOT understand the consequences of “what they want.” The other day as a part of the budget debate, the president said (paraphrasing) “most Americans hate gov’t spending but like what it buys.” I disagree. I think that most Americans like what it buys THEM as long as they feel that some OTHER schmuck is doing the buying. This is the issue with healthcare. Most WANT their care to be the “commercial transaction” that Mr. Krugman eschews, as long as what that means is that such a transaction comes with all the protections and control that we gain as a paying customer…we just want someone else to pay the bill. Until we wrap our arms around that issue and make some tough decisions. The question that we need to ask ourselves with regard to our healthcare is “do we prefer to be customers, with all the rights, protectections AND RESPONSIBILITES that go along with being the person who pays the bill, or would we rather be “beneficiaries” — which by definition requires that we give up some control to those who pay the bill? I am well aware that in the commercial system as it currently exisits we are in many cases paying an “insurance company” who doesn’t treat us like a customer either. I am not debating the merits of a commercial system vs. a government funded system. I am however, suggesting that the root of our problem is, to borrow a phrase, “uniquely American.” We tell ourselves that we are the most fiercely independant culture on the planet. That is certainly a quality that has served us well throughout our rather young history. However, I fear that for many the interpretation of independance has conveniently eliminated the responsibility that is its prerequisite. Mr. Krugman is right. We can’t be “consumers” in a “commercial transaction” with the healthcare system if our neighbor is footing the bill. The flip side is that if we ARE consumers, there will be some who can “afford” more than others. Neither option is perfect.

Consumers or beneficiaries? I think we need to choose.

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EHR’s and Cost Savings – Not A Sure Bet

While there is increasingly less doubt that a system-wide revaluing and rebuilding of our primary care infrastructure will both reduce health care costs and improve health outcomes, there is less certainty with regard to the contributions of the high-tech elements of health reform. A recently released study by researchers out of Harvard Medical School scheduled for publication in the American Journal of Medicine suggests that despite Congressional support of more than $19 Billion, claims of increased efficiencies attributable to hospital computerization (EMR) “rest on scant data.” The study was based on a review of over 4,000 hospitals over a 5-year study period. The hospitals examined were at various stages of EMR implementation and capability, and ultimately even the “100 most wired hospitals” (as defined by an independent ranking of hospital computerization) are seeing neither cost savings nor significant increased administrative efficiencies. Additionally, the study found no appreciable difference between these “leaders” and the full study sample. In addition, researchers from Massachusetts General Hospital have also just released a study with a similar design and a conclusion that there was “little difference in the cost and quality of care” between those hospitals who had adopted EMR and those that had not.

While each of these studies can be challenged to some degree given the personal agendas of the authors, they leave me more convinced than ever of my previously held opinion that the jury is simply still out on EMR. There are clear advantages that should be obtained from the adoption of health information technology (HIT), but the entire enterprise is compromised by poor design. EMR’s are designed with the goals of the individual user, physicians and hospitals, as the focus. I think of this focus on management of individual patient records, coding technology, billing and the like as design based on micro level goals. Instead, the objective should be to meet the goals of the health system at the macro level. This is the functional equivalent of asking each airline to invest in separate, non-interoperable systems to control air traffic, and then expecting airline safety to improve. In fact, it is my opinion that the only way to control, and potentially reduce health care costs and improve outcomes at the system level through application of HIT is through the creation of a standardized, universal, completely interoperable system, or at the very least, the development of technology that allows the currently disparate systems to communicate as an interoperable information system.

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