As we wait to see what the Supreme Court will do with the Obama Administration's Affordable Care Act (ACA), many people and organizations are not simply waiting around wringing their hands. There seems to be ever-increasing activity depending not only on one's expected outcome of the Court's deliberations, but also as a window of opportunity for taking aggressive steps to gain market share, recruit physicians, enlarge practices, or shift cost burdens to others. Those engaged in these and other similar activities have one goal in mind—to protect their future incomes as much as possible.
The government also is not standing still. The feds are implementing certain aspects of the ACA, particularly Accountable Care Organizations, because at this time it is the law of the land.
During this period of expectation, there is a constant flow of opinion articles and scholarly publications in the lay press and medical literature addressing the issues. Many of these select "the key problem" in our current system that "must be fixed." In other words, there is often a big, bad wolf that is predominantly responsible for the "mess" we are in.
Here are some candidates for being the big bad wolf with a summary of comments from their accusers:
Obama: His plan, this theory goes, is unworkable, unconstitutional, costs too much, and violates states rights. Let market forces deal with this. We have a successful capitalist system that has served the hard-working business leaders well; they have the ability to straighten this out without some government-run system that rations care. There is no inherent right to medical care and, in any case, the relationship between patient and doctor is sacred and government should not get in the way.
Doctors: The doctors are greedy, say those espousing this view. The charges for physician services in this country are many times greater for the same services than in other developed countries, even when services are carefully matched for acuity and complexity. Many physicians are unwilling to provide services to any patients with only Medicare insurance because of low reimbursement. Some economists who have studied the reasons for the substantially higher costs of health care in the U.S. compared with other developed countries have concluded that "It's the price, stupid." Without controlling prices charged by doctors (and hospitals), there is no hope for controlling the overall costs of care.
Hospitals: According to this group of accusers, hospitals are inefficient, dangerous, and largely ineffective at controlling costly medical complications. Hospital administrators are rewarded handsomely for a positive financial performance, but are not penalized for poor quality of care, for failing to reduce preventable errors, hospital-acquired infections, inefficiency, mediocre patient services, and the like. Most hospitals have been unconscionably late to the installation of effective information technology systems. In the 30 years or more since airlines have digitized reservations and tickets, hospitals are still struggling to make the various systems user-friendly for doctors, nurses, and others in the provider system, and often make their jobs harder and more time-consuming. Hospital billing IT has been effective for decades, so the problem is not due to a lack of money or software; it is a lack of will. These are lost opportunities to reduce the costs of care.
Insurance Companies: And, say those blaming this group, health insurance companies cannot lose money. They set the premiums, they can maintain income by shifting costs to employers or to the public by raising premiums or by increasing co-pays from the patients. Few have invested in improving the quality of care. The only incentive for reducing the cost of care that gets their attention is when an action increases profit margins.
Patients: Patients in America want the freedom to seek and have any doctor they wish at any price and any medication or diagnostic test in existence whether of demonstrated value or not, say those making this complaint. However, they want insurance to cover these costs irrespective of demonstrated value. Cost-effectiveness plans are viewed as simply rationing care that they have a right to. This last group raises a conundrum, because non-medical issues, like hope, often dominate the discussion.
A study by Darius Lakdawalla and colleagues in the April issue of Health Affairs, "How Cancer Patients Value Hope and the Implications for Cost-Effectiveness Assessments of High-Cost Cancer Therapies" (2012;31:676–682) deals with this dilemma. Patients were offered a choice in a theoretical situation akin to taking $100 or getting $200 if they flipped a coin that came out heads. In the actual study patients with metastatic solid tumors were asked to choose either a therapy that promises a virtually guaranteed (I said this was theoretical) survival of 18 months ("safe bet") or a therapy that offers a similar average survival (could be much worse) but with a chance for a longer survival ("hopeful gambles").
In this study, 77% chose the hopeful gamble. In other words, they would flip the coin for the 50–50 chance to get $200 rather than the assured $100. For the patients, guess which of their choices almost always costs a lot more?
I could go on, but you get the idea. There is some truth in all the accusations, but they are often based on politics, left or right ideologies, half truths, and oversimplifications to create a "big, bad wolf"—the one big thing to fix that would turn the health care industry around.
The ACA passed by the U.S. Congress and signed by the president; what happens if it is declared unconstitutional? There is not even a hint of an alternative on the political front. We are likely to stay on the same track until health care becomes unaffordable for much larger sections of the public.
Failure to change a dysfunctional physician reimbursement system to one with incentives for quality care and fiscal efficiency will lead to more and more Medicare and Medicaid patients unable to find a physician to care for them, and higher and higher co-pays for the fully insured. Also the rush of physicians toward larger and larger for-profit multispecialty practices or hospital employment will limit the options for insurance providers to negotiate with in-network providers; this could lead to cabalistic regional monopolies leading to increased prices for medical care.
Hospitals have been preparing to qualify to be Accountable Care Organizations by hiring physicians and implementing quality measures. If Obama Care is struck down, are they likely to continue to make those changes? Will Medicare continue to implement bundled payments? Insurance companies tend to gain if the ACA, or most of it, is upheld. Individual states under the ACA would get federal money and considerable leeway in management of the healthcare funds. Would they continue on that track without federal support? That is unlikely.
Patients are always in the middle with little power and, too often, a sense of desperation. As the study in Health Affairs has shown, for patients with advanced cancer, hope for a better than average outcome despite the risk of a poorer than average outcome is a powerful factor in their choices because it influences their quality of life, however long that may be.
In short, there is no "big bad wolf" to blame for the situation. Times have changed and all parties listed above have adapted, or tried to adapt, to protect their own interests, not always with positive consequences. The 1965 Medicare Act had the unintended side effect of sparking an increasing focus on the business of medicine rather than the professional calling of medicine; that trend has accelerated in the past two decades.
That and the meteoric increase in technology have simultaneously caused the upward spiral of costs and also constructed barriers between caregivers and patients, between technology and hands-on care, between costs and affordability, between access and none.
It will take bold action to get us on a more sustainable track, but the childish political gridlock in Congress makes political solutions unlikely.
I have always hoped that physicians, as the primary and most important representatives and protectors of the patient, could play an important role in finding solutions, but, sad to say, the power and unbelievable financial resources of the political-industrial complex makes that hope seem vain.
Now Available in Book Form: Simone's Maxims—Updated and Expanded: Understanding Today's Academic Medical Centers
Dr. Joe Simone's popular "maxims" about the behavior of academic medical institutions, their leaders, and their faculty, first published as an editorial in Clinical Cancer Research in 1999, are now available in book form, greatly expanded and updated. The 160-page paperback book ($15, ISBN 978–0-9832958–9-1, available from Editorial Rx Press and Amazon, also includes updated versions of many of his related columns in Oncology Times.
He notes that the maxims were accumulated and developed from years of personal experience and many mistakes, as well as occasional revelations, both personal and from the experiences of colleagues.
Additional information is available at editorialrxpress.com; firstname.lastname@example.org