Thursday, April 3, 2008

"The most expensive thing of all is the loss of trust"...

As an administrative physician for a large group of physicians, I have come to the conclusion there are four main reasons healthcare costs are escalating in this country and they are fairly easy to understand-- I hope I am up to the task of explaining :)

1. The various players in the healthcare system (patients, government, physicians, hospitals, insurance companies) no longer trust each other. In a multiparty prisoner's dilemma games, the players are 'defecting'.

‘Defecting’ means various players in the system are increasing barriers to improve things (from their point of view), but in totality are making things far more worse than they would otherwise be.

In many ways, what we are witnessing in American healthcare is analogous to the financial credit crunch. Imagine a marriage with all kinds of written rules, regulations and procedures-- would it really ever work?

Yet husbands and wives in reality must behave according to rules, or things would fall apart between them for lack of trust. When it is necessary to behave outside the rulebook, trust and faith in one another is really the only thing that allows it. And they must allow it, or the marital rigidity would lead to divorce.

It is kind of a circular problem without answer, and yet it only works when couples trust one another.

2. Many well intentioned regulations, drafted a long time ago (many before you and I were born) designed to protect patient care, now dramatically increase barriers to competition. But these regulations are almost immodifiable today-- would any attempt to modify them, helath practitioners would recognize a reductin in barriers to entry for competition and begin raising fears of poor care (if you think on it, this is really no different than #1.

The biggest of these 'sacred cows' are the rules governing what a physician or healthcare practitioner should be, and what skills they should have before they can practice ANY form of medicine.

Yet the reality is we do not need physicians to read x-rays (I sometimes think art student would do just as well), we do not need physicians to perform most interventions like angioplasties or colonoscopies (think of the complex manual dexterity of many fine craftsmen), etc… these and many other skills do not require a full medical school training to perform.

And while the training to perform these skills might still be rigorous, still it does not need to be as lengthy, or broad, or expensive. Most of the other things medical students learn in medical school are completely unnecessary to practice these (and only these) skills. There are many other skills in medicine, where training for that one skill does not require the training of a entire modern medical education, with its tremendous investment and lengthy apprenticeship.

As medicine becomes more procedure oriented, this issue is becoming more significant.

And since all of these laws are passed at the state level, they are often ignored in national discussions.

I believe changing healthcare training from the very beginning into two camps-- one camp where people learn a narrow range of skills, and another where they continue to learn deep and broad knowledge, would be perhaps the greatest 'low hanging fruit' cost saver of them all.

And the 'deep and broad' camp should not perform many proceedures. The conflict of interest is just too great.

3. Most people do not understand the fractal nature of illness and healthcare spending (most people don't even understand fractals!). This leads many people to the wrong impressions regarding who is ill, what is 'bad medicine', and where our healthcare money is spent.

Further, as people don't understand fractals, they don't understand how to reconcile fractal issues such as scaleinvariance with issues like trust.

4. America continues to avoid a values discussion on when it is 'OK' for our healthcare system to ration care. It avoids the conversation: "can we, should we, will we, and who will do it?" Indeed the very notion of rationing or triage (so fundamental to medicine once upon a time), are completely anathema to most Americans today. But the reality is we must ration (we already do, we just don;t admit it). We must decide how we will do it. We must decide who to empower with rationing care, just as we have empowered judges to administer justice.

Further rationing SOMETIMES requires override the wishes of individual patients and families (like judges sometimes override plaintiffs and defendants), so that 'our collective finances' might be protected. And if we empower someone to ration care, we must empower them with the ability to be wrong, as judges are so privileged. Without the ability to be wrong, rationing can never work.

You may not have ever thought on how physicians in America once guarded our healthcare resources, but believe me, they did. They still do in countries like England and France, but in America, with its diminishing trust, SOME of the physicians who once guarded our resources have lost trust in their patients, and are now prescribing care without concern for the collective. And they are doing this quite independently from any financial benefit they may gain by providing additional healthcare. Physicians are human; they too fear publicizing errors and character assault.


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