Dust off ideas on health care

Posted Feb. 22, 2010, at 6:17 p.m.

This is the second of two articles about desperate efforts to control health care costs.

Among the other mothers of invention I know (necessity, alcohol, getting caught by your mother sneaking to an R-rated movie, etc.) is desperation. Desperate times drive us to seek answers in ideas we never would consider when times are good, and these are desperate times in health care reform.

Sometimes desperate answers are lousy (see Part I in my Feb. 9 column), but among the piles of ideas in the smoldering ruins of the national health care debate are many worth pulling out of the debris, dusting off and pursuing. Here are a few of those many, with my twists:

• Accountable care organizations — the idea that a consortium of doctors, hospitals and other health care providers would be collectively accountable for high-quality patient care managed within a specific budget. That organization would actually have to manage the cost and quality of patients’ care. In the current system, most providers of health care are invested primarily in the control of their own costs, not all of our costs. Joint accountability between physicians (the primary source of spending decisions in health care) and hospitals (the primary providers of most other health services), nursing homes, etc., is probably the only way the providers of health care are going to get wholeheartedly invested in control of all health care costs over the long haul.

• Accountability for all. Just as no provider of care should be without responsibility to hold down costs, neither should any competent patient. All of us should have health care insurance, but none of us should get it without some share of the costs of our care, or without some responsibility to help keep ourselves as healthy as possible. The more we spend care-lessly, the more we weigh, the more we smoke, the less well we care for ourselves, etc., the more we should pay.

• A medical home for every patient. If you have health insurance of any kind, you must have a primary care provider (internist, nurse practitioner, physician assistant, family doc, pediatrician, etc.) paid for, and held accountable for, the coordination of your care. Decisions about expensive care — surgery, going to the ER, MRI scans, etc — need to go through that provider. Primary care has been proved to hold down costs and reduce the risk of premature, preventable death from chronic disease for patients who have it. There is no rational delivery of health care without it.

• A national medical malpractice reform, based perhaps on pre-lawsuit screening panels and standardized settlements.

• A national system for reviewing medical tests and treatments for benefit and cost effectiveness. We waste billions of dollars on treatments and tests of marginal benefit. Use of many of these is driven by drug and device manufacturer marketing to patients, unmitigated greed and ignorance of real effectiveness on the part of physicians and patients. We need a national center for effectiveness in health care that rates treatments and tests, is protected from lawsuits and meddling by industry and Congress, and lights the way through the health care wasteland. Then, the share of what a patient pays out of pocket for care should be tied to effectiveness; the less effective the treatment, the more you will pay out of pocket. You can still have it if you want it, your doc in the accountable care organization can order it is he desires, but it’s coming out of both your pockets. In lieu of that, our profligate waste — which adds up to more than the cost of insuring every uninsured American — will continue.

These kinds of options — which could hold costs down in some potentially rational way — are alternatives to the current collection of desperate measures that insurers, patients, employers and health care providers are pursuing to their individual advantage and our collective ruin. It’s time for our leaders to fire a shotgun over the heads of this medical barroom brawl to get everyone’s attention, sit the parties around the tables and channel the desperation toward constructive ideas. There are plenty.

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. He is also the interim CEO at Blue Hill Memorial Hospital.

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