When will we get to debate healthcare? by Neal Little, M.D.

When do we get to really debate health care? Did I miss some planned forum? All I seem to be hearing about is health insurance reform. And it’s labeled “sweeping” healthcare reform. Funding is certainly a big issue that needs to be taken up, but it certainly should not come under the label of health care reform, and it should not substitute for health care reform. The healthcare reform I mean consists of changes in the way, manner, or substance of health care delivery? It may be an inconvenient truth that those in political power do not like, but physicians, in their interaction with individual patients, control healthcare; not insurance companies, not hospitals. If they are not on board with a new system, isn’t it doomed to failure?

There are enormous issues facing physicians and patients alike when it comes to healthcare.There are so many substantive issues that need to be addressed before we can decide what healthcare will cost, and therefore how much of it we will get, and who and how we will pay for it. How do we define end-of-life care? We know that enormous resources are spent in the last six months of life, and yet progress in defining when someone is approaching it has at least not been on my radar screen. How do we decide if new technology, or new drugs, or old ones, for that matter, are effective? How do we measure “cost-effective’? What level of evidence are we prepared to accept to assure us of effectiveness? Who should do it? Do we trust the manufacturer, or a “panel” with paid representatives of the manufacturer, or its rival? The FDA? Are their panels independent enough? Are medical journals sufficiently independent of commercial influence to be a reasonable source for such information? We know that there is virtually unlimited demand for healthcare. After all, “if you’ve got your health…” If we are going to limit what is done, how is that best accomplished? Co-pays? Deductibles? A list of approved medications, operations, devices? Do we base access to resources merely on age, apparent age and wellness, anticipated life expectancy, an arbitrary amount of care already having been provided, patient “QALY”as they are commonly calculated? Where is the debate? Where are the congressional committees and polls? If what we are talking about is “change”, how can we approach that in the current legal environment? After all, part of the usual definition of “standard of care” involves what the “..physician would do under…similar circumstances” and is therefore a reference to historical practices. Where does change fit into that?

It seems like those debating how to contain healthcare seem to think that jiggering the payment mechanism will be the appropriate step. There's a loud outcry that physicians are paid to provide services, and therefore they simply do provide more services, and costs go up, of course. When physicians are paid to not provide services, and they then don't provide them, they're also looked upon as the bad guys. This is a no-win situation. And if we have some large entities such as an insurance company, or a federally based project to create arbitrary rules about what the physician can and cannot provide, then the physicians begin to "game" the system so as to try to get the appropriate care for the patient. Again, a no-win situation.

And who in this debate has suggested that Americans want choice in their health care plan? Who cares who provides the plan, as long as the services provided are those that you need, you can see the physicians and go to the hospitals that you want? How well does having a choice between health plans assure you of that? The way health plans conserve their money is to create special contracts with special groups of providers, and limit services, procedures and medications. Therefore, your access will be limited to those providers, those approved services and medications. How did having a choice in a plan increase those options? Even sophisticated health consumers have trouble deciding what kind of health plan will meet their needs.

And since this is an EM blog, if I ever hear another politician use a phrase that contains something like "and not have patients wind up in the expensive emergency departments “ I will realize that they have been ignorant of the facts for too long. With emergency departments consuming less than 3% of the national health-care budget, we are the biggest bargain in medicine. Is it somehow more efficient for 20, 40, or 100 practitioners in the service area to keep their offices open evenings and weekends so the patients won't go to the emergency department? That's what we in emergency Medicine do, we keep our office open all the time so that any problem that comes in can get evaluated. We provide outstanding care. We are the only consumer driven specialty. We develop and hone our skill set based on what is necessary to the patients that present to us, not on what we happen to have as an academic interest. Our skills and services are driven by consumer demand, and we’ve done an excellent job of developing those skills and services.

When and where do we get to talk and debate these issues?

Comments

[Myles Riner, MD]

These are really good points, and reasonable questions. At times, when EPs have had a bit of success with legislative initiatives or in the pursuit of problem payers, I have said many of these same things, even written them. At other times, like right now, when reality sets in a bit, I realize that political debates, even if we can participate in them, and even if we are heard, will not have much impact on the decisions that are made on health care reform in D.C.. It's not that we don't have legitimate issues, or a valuable perspective on health care. It is simply that we do not spend enough money where it counts, on campaign contributions. Those that do spend heavily can expect to be heard, and those that spend outrageously, will likely get their way. Unfortunately, it's not just about having the opportunity to debate these important issues, its about whether the debate even matters. I would love to believe it does, but the evidence suggests otherwise.

[Sue Ieraci]

Hi, Neal
Like you, I am constantly frustrated by the constant political mantra to "get patients out of the ER" (don't they know that House of God is no longer PC??), while the general public keep voting with their feet and using our services more and more. If you were in any other specialty, would't you call that success? If you were a really popular Cardiologist or Paediatrician, and people had to wait months to get an appointment, wouldn't that be seen as a sign of success??

Over here in Oz, I thought that this was mainly to do with the funding split between federal government (which funds general practice ) and states (which fund public hospitals). There is an incentive to "cost-shift" from one to the other for cases that are theortetically GP-type patients (another bug-bear). However, I'm now thinking that maybe it's deeper than that...maybe what makes our success is the very things that make health care increasingly expensive - it's a combination of community (including medical) risk aversion, and ever-increasing expectations. Through these two influences, we've created a whole raft of "health care" activities - a combination of treatments and rule-outs, that don't actually make people feel better - they make us and the community feel better! Case examples - active treatment of the very disabled very elderly, and the multitude of tests for dizziness or rule-outs for abdominal pain or serious infection.

What this comes down to is a true understanding of what our specialty actually consists of. To me, my specialism is the cognitive (or intellectual) skill of risk-assessment, problem-solving and decision-making. Of course, this includes skill at information-gathering (good old history and examination), but mainly the ability to work out what really needs doing in a hurry, and then what needs doing to help the patient feel better and get them on their way. We can do some resuscitation and wound management procedures, but these aren't unique to our specialty, they are easily taught skills. What we are really skilled in is working out what to do and when, and more importantly, what can or should NOT be done, or can be left until later.

So, those people who say "only true emergencies should go to the ER" don't actually understand the full range of services we provide. In the case-mix of most standard ED's (US/Canada/NZ/Oz/UK), only about 10% of cases actually need urgent time-dependent resuscitation. Perhaps 30% are what I now term "low complexity" - ie the diagnosis and required treatment are obvious fron the time of arrival - and the remaining 60% need some skill at risk assessment and complex problem-solving.

Take the young patient I was involved with yesterday - an eight yr old with para-testicular swelling, sent by his GP to our U/Sound department. The Ultrasonologist (a medical specialist) came over with the films that showed a mixed-density mass adjacent to a normal tests (in a well child). What now? Can I take the patient off his hands?

Is this child needing urgent treatment? Well, no. Is this a complex case that needs some problem-solving and consultation? Yes. Is everyone worried that it might be something nasty? Yes, that's it. So what do I do? I call the Urologist (I know how to do that), hand the phone to the U/Sound doc to describie the mass, then arrange admission as requested by the Urologist (I know how to do that too), and I contact the Urology team to take over the patient (another skill of mine). Did this child need to come anywhere near ED? Well, no, but everyone felt "safer" because they did, and because we know how to do stuff.

This is only a minor example, but shows that we know what to do about just about everything, and that's why people come to us.

How do we get our own community, let alone the wider community and government, to understand that Emergency Medicine is about a lot more than resuscitation? Then, how do we get through to everyone that it is risk-aversion and ever-increasing expectations that are making health care more and more expensive?

[Am Ang Zhang]

I enjoy reading your post. Found your site via Grand Rounds.

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[WolfEthel]

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