Ask doctors about health cost cuts

Posted Jan. 12, 2009, at 6:54 p.m.

Last week I was pleading with Maine state legislators not to cut Maine Medicaid dollars to rural hospitals and some smart aleck legislator asked what I would cut instead. I hated it, but that’s a darn good question for all physicians. The answer: If physicians don’t want one set of cuts in health care spending they should help Maine and other states find different cuts that matter less. No single profession is better equipped to help legislators and others cut money from health care.

Despite some losses in prestige and influence, physicians continue to be the intellectual center of the American health care universe. No other stakeholder can match physicians for influence because, at the end of the day, it still is primarily physicians who order most of the procedures and pills, cut the patients open, and are asked by patients, “What would you do, Doc?” Physicians who have studied these issues have the most sophisticated knowledge of what care actually makes the most important differences in patient outcomes.

This is not to denigrate the wisdom, importance or value of other health care professionals. (In fact, they also need to get into the business of telling our legislators and other stakeholders how to cut health care costs.) Nor is it to suggest that self-interest is not part of what motivates physicians, just as it motivates us all.

The reality is, however, that health care still is a physician-driven world. That makes it especially important for physicians to step up to the plate and use that influence to rein in health care costs, instead of primarily jumping into the fray to resist such efforts. The failure of physicians and their medical associations effectively to take on that leadership role has left others — insurers, legislatures and government agencies, and business — to do the cost-cutting job for us and to us, often without the guiding hand of organized medicine.

That means in these tough financial times health care often will be cut in areas that can do real damage, by legislators and others lacking medical expertise or a partnership in cost paring with physicians. The state’s recently proposed cuts in payment for services of physicians employed by Maine hospitals are a perfect example. Despite the fact that having primary care reduces the risk of premature death and overall health care costs, Maine Medicaid’s proposed cuts will hit primary care (family docs, pediatricians, physician assistants, internists, nurse practitioners, etc.) hard.

If, when opposing those cuts, Maine physicians also came forward to help legislators figure out where the Medicaid budget could be cut with less impact on the basic health care of poor, primarily rural Mainers, there would be less chances of legislative budget surgery on the wrong body part of Maine’s health care system. With physician guidance, as health care cost increases are progressively ratcheted down and state budgets for care of the poor are slashed, more of the impact might fall first on health care services of lesser value and last on things that patients really need, such as primary care close to home.

There is a catch, however; if you want docs to sit around a table and tell the rest of the world how to save money by reducing medical care of marginal value, the conversation will go nowhere without some degree of medical malpractice reform. If the result of physicians appropriately holding back care of marginal value (e.g., a head CAT scan for a patient with headaches that don’t meet what studies suggest should be the criteria for the CAT scan) could be a malpractice suit when something goes wrong (such as a missed brain tumor) as a result, forget the involvement of medical associations and most physicians. That quid pro quo on malpractice reform may be the price for getting physicians fully engaged and leading the cost control discussion.

The right role for physicians is to lead the initiative to cut costs in American health care, not reflexively oppose it. Regardless, the health care cost control train has left the station and the only decision for physicians is whether they will be the engineers driving the train, or tied with patients to the tracks in front of it. The time to decide is right now.

Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems and is on the staff of several hospital emergency rooms in the region.

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