The emperor remains unclothed

I guess I shouldn’t be surprised when two of the architects of the health care reform act write an op-ed that continues in the deception that the law would deliver access, choice, and lower costs.  But that is what Ezekiel Emanuel and Jeffrey Liebman offer in their New York Times article, “Cut Medicare, Help Patients.”

The authors start by saying some things that make a lot of sense.  They point out that it would be smart to “eliminate spending on medical test, treatments and procedures that don’t work -- or that cost significantly more than other treatments while delivering no better health outcomes . . . [and that} can be made without shortchanging patients.”

But they quickly give up that fight:  “The sad truth is, Washington is never going to do a good job of making smart cuts to Medicare.  Elected officials hate being blamed for directly restricting access to medical treatments -- even when those treatments are proven to be worthless.”

So then they revert to their underlying bias, er, theology:  “The responsibility for ending unnecessary medical spending needs to be placed in the hands of doctors and hospitals.  This can happen only if we change our fee-for-service payment system.”

How much damage is being done and how much time is being lost by our society by a religious belief in a payment scheme that has not been proven and that has many inherent difficulties?  As I have noted, not the least of the difficulties with capitation is in deciding the transfer payments among the different medical specialists.

And then to add salt to the wound, they say:

“These seeds of a solution lie in the accountable care organizations, medical homes and bundled payment reforms that were authorized by last year’s Affordable Care Act.”

As I have discussed, the ACO framework prescribed by Congress is inherently flawed because Congress could not and will not limit patient choice.  An ACO cannot manage patient care if there is a PPO structure in place, allowing patients to shift care not a non-ACO provider at will.  Meanwhile, the ACO framework also has risks of market concentration that are drawing the attention of federal antitrust regulators.

This whole discussion is incredibly painful to watch, especially when Emanuel (or was it his brother?) admitted privately during the Congressional debate on the ACA that the costs of providing universal insurance access were well above those that were being publicly projected, and that, ultimately, the US would be forced to pass a value added tax to cover the health benefits that were the result of the law.  What’s the chance of that during this political environment?

On this blog, I have talked about things that can work and that are within the power of Medicare to implement.  The most powerful would be to change the relative fees paid to primary care and other cognitive specialists, compared to proceduralists.  Giving a primary care doctor the ability to spend more than 18 minutes with a patient could change the nature of those doctors from having a triage function to allowing proper management of care.

Medicare can also engage in real clinical transparency, insisting on the publication of real-time information about infections and other important aspects of quality and safety as one of its Conditions for Participation.

But, we must also find fault with the nation’s doctors and hospital administrators who fail to lead process improvement in their institutions, even in the face of documented quality and safety enhancements and cost savings in exemplary hospitals.  Medical schools, too, have systematically failed to teach young doctors about the science of improving care delivery.

I have often asked the question, “What does it take?”, suggesting that a failure to proceed with such changes and to engage in full-hearted transparency is unethical behavior -- in the most fundamental sense -- on the part of the medical community.  As long as the medical profession fails to demonstrate its own ability to improve results and lower costs and engage in patient-driven care, you can count on officials in Washington and in other jurisdictions to offer prescriptions that simply will not work.  The resulting resentment and anger on the part of the profession then feeds a negative vicious cycle.

Time’s a-wasting, folks.  Let me make this very personal, and perhaps uncomfortable to some of my readers.  As e-Patient Dave likes to say, “Patient is not a third person word.”  We will all be patients some day.  What kind of system do you want in place when you are in the lying in the bed rather standing next to it, or when a loved-one is there?  Chances are that it is not the system that you are helping to run right now.  You can rationalize your inaction and compartmentalize your thinking all you want, but a failure by you -- if you are a medical or administrative professional -- to demand and lead improvement is, in fact, a deadly decision.