President Has Gone Over To The Dark Side

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President Obama has succumbed. The lure of the Dark Side – with its Blame Game – was too powerful. Though he acknowledges that “our healthcare system is broken,” he points the flying fickle finger of shame at people: this time the doctors.

Doctors as Villains
We have known for decades that over-, under- and mis-use of medical technology produces bad outcomes and wastes money. We have known for millennia that incentives affect human behavior, and providers are human.

Under fee-for-service, the more the doctor does, the more she/he gets paid. Some doctors do too much (over-use). Under capitation, the less the doctor does, the more she/he gets paid. Some doctors do too little (under-use). The system is inconsistent and contradictory.

None of this surprises me. What astonishes me is how the majority of doctors actually ignore what is in their personal financial best interest when deciding what is best for the patient.

As a pediatric cardiologist, I could order an echocardiogram on every single child I see with a heart murmur. The test carries no risk. I could rationalize the need. It would generate lots and lots of money. The problem is that word “generate:” it should really be replaced with “waste.”  While all those unnecessary echoes would be revenue to the hospital, they would be unneeded costs for the nation.

President Obama has fixated on this under- and over-use problem decrying it as a major cause of healthcare over-spending and by inference, blames the doctors.

Differences in practice patterns: money and quality
Representing the Administration on Charlie Rose (June 15, 2009), Peter Orszag of the Budget Office pointed the finger at the doctors saying that: a) different quantities of health care delivered in various parts of the country produced similar quality, and b) homogenizing these differences, i.e., curbing doctors’ overuse, could save billions without impairing quality of outcomes. I am sure he means well, but he doesn’t have a clue.

The measures of quality used for comparison were negatives: days in hospital; discharge diagnoses; complications; deaths; and hospital bills. Not one measure of outcomes-we-want, like restored function or longevity. “Quality” is not the absence of death.

Secondly, his offhand estimate that changing doctors’ practice patterns could be a major factor in reducing national unsupportable healthcare spending is ludicrous. The amount saved by standardizing practice patterns is less than a drop in the bucket compared to:  worthless (but costly) bureaucracy and regulations; perverse incentives; actions without evidence; and defensive medicine – to name but four out of ten reasons for healthcare spending.

Finally, many (most? all?) doctors use “too much” or “too little” health care when the “right amount” is unknown: not unknown to them but unknown to everyone. A national database of medical processes and positive outcomes would show what works; what does not; and what it costs. Such a database does not exist. Why not?

How the regs prevent learning “the right amount”
There are a host of regulations, HIPAA merely the latest and greatest, aimed at keeping medical information isolated and unshared. Examples have been given in previous blogposts. Efficient transfer and free exchange of medical information – which COULD teach us those magical “right amounts” – is trumped every time by what bureaucrats believe are vital security measures, more important than learning to do good for patients.

When the Administration talks about how medical records will improve efficiency and outcomes, they need to note that the major source of inefficiency and inability to share information is their own regulatory bureaucracy.

Prior recipients of the Villainy Award
The doctors are merely another in a string of culprits identified as responsible for our healthcare mess. Prior villains include the hospitals; big pharma; and the ever-popular insurance companies. Interestingly, two who have never been singled out have been trial lawyers and the administrative bureaucracy itself.

Does blaming ever solve anything?
Blaming the doctors is wrong for three reasons. 1) As above, the assignment of blame is unfair. 2) Blaming per se always does one thing and always fails at a second. It invariably produces defensive behaviors and invariably fails-to-fix. 3) Even the President (rightly) said that the problem is a broken SYSTEM. If he wants to make things better – fix the problem, not the blame.

Fix what is broken: the system. Don’t blame the parts.

System MD

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