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Archive for October, 2009

PostHeaderIcon Healthcare Focus: Quality or Quantity

What is the message?    What do you want?

The World Health Organization definition of health has not changed since 1949.  We were asked this the first day of medical school.  No one answered correctly:

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

Political strategists play with focus groups to achieve Machiavellian goals.¬† Issues can be framed positively or negatively.¬† In a recent series of¬† soundbites with Republican and Democratic response tracks, Republican strategist, Frank Luntz,¬† found the political segment that was most effective for both Republican and Democratic viewers was the one that featured a female physician.¬† She was real, conveying substance and legitimacy.¬†¬† See Luntz explanation of focus and metaphors.¬† For an even more revealing look at looking at mind-control watch¬† The persuaders — one of the most eerie documentaries FrontLine ever produced.

This week the President met with “selected physicians” to shore up his support.

This entire public debate would have had been far more successful with tighter focus and goals — health insurance reform and regulation.¬† We may be on the verge of another government giveaway.

John Podesta,¬† President Clinton’s Chief of Staff, was interviewed on the Charlie Rose show last month.¬† His words were quite prescient.

“We’re very close to finally doing what for 60 years presidents and congresses have been trying to do which is to produce quality, affordable health coverage for every American.”

And therein lies the killer paradox.¬†¬† Affordability implies universal access.¬†¬† Universal access implies quantity.¬†¬† Quality and quantity are mutually exclusive.¬† You don’t go to Costco or Target or Wal-Mart for quality service.¬† If you’re lucky, you may find quality merchandise.¬† But not service.

Health maintenance organizations (HMOs) were heavily promoted by the Nixon administration in 1973 to contain costs — Managed Care.¬† We physicians had another name for it — “mangled care.”¬†¬† The largest of all HMO’s today, Kaiser Permanente, demands minimalist, algorithm-based, cost-driven medicine.¬† Lonnie Bristow, a former President of the AMA, recently called this “a work in progress” at a town hall meeting here in Northern California.¬† Indeed, a work in progress.

Want to know the simple formula for HMO Medicine?   And by extension the cost-savings approach to medicine?  It is a very simple formula.

Lives x Capitation = Revenue

That’s it.¬†¬† It’s all a numbers game.¬† Notice what drops out?¬†¬† Quality!¬†¬† Not even factored into the equation.¬†¬† Using a simple mathematical model you can see that cost-driven medicine (managed-care)¬† is incompatible with quality of care.¬† And that is what we all experienced, those of us who have practiced in HMOs in the past.¬† All of us.

The administration and congress is using the same old arguments proffered over 30 years ago.   We will be saved by the cost-cutting gods.  The Green Visor man.  The guy that eventually wraps up every car deal.   Read Dr. Bernadine Healy.   Then from Kip Sullivan of Labor Notes:

Biemiller went on to say that HMOs ‘can provide better quality medical care at lower cost than the fragmented fee-for-service system’ and that the savings HMOs could achieve were ‘enormous.’¬† His only significant reservation about Nixon‚Äôs HMO bill was that it would have subsidized for-profit HMOs.¬† But because there is no evidence that managed care is less toxic in the hands of nonprofit than for-profit HMOs, this reservation was of little significance.

Harvard and Stanford trained Dr. Margaret Hansen aired this short segment on KQED radio — the lost art of medicine.¬†¬† Ancient voices from Andalusian Spain, Maimonides, echo similar sentiments every bit as fresh today as when written in the 12th century.

Medical practice is not knitting and weaving and the labor of the hands, but it must be inspired with the sole filled with understanding and equipped with the gift of keen observation; these together with accurate scientific knowledge are the indispensable requisites for proficient medical practice

The ancient wisdom of the Greeks was lost to Western civilization for 1000 years after the fall of the Roman Empire that had succumbed to endless corruption, incompetence and sybaritic excesses.¬† Greek culture and knowledge passed to Byzantium and Islam.¬†¬† I appear as either a dinosaur/curmudgeon like Paul Muni in the Last Angry Man or a messenger from the future.¬† We were taught the “laying on of the hands” was essential to diagnosis and healing.¬†¬† Great medicine is the accomplished art, intuition and inductive logic of the physician with the wise use of modern technology. Attributes of the 15th Century Surgeon should still be emulated: the eye of an eagle, the heart of a lion and the hands of a woman, the gentleness of a lamb and the patience of a saint.

Service, expertise and time.   That is the challenge.   Will you receive necessary and deserved time, expertise and personal service or simply a 10 minute expedient and tangential encounter? Is this the face of medicine?

Robotized Doctors

Robotized Doctors

The new medicine awaits — like the Phoenix rising — the paradigm shift.