A Foundation for the House of Medicine

Paul S. Auerbach MD

When you build a house, you begin with the foundation. The same holds true for the U.S. health care system. The President and Congress are scrambling to put up a reform structure that would have a better chance to succeed if the cinderblocks and joists were in place. No health care system in our country can develop adequately unless supported by validated information, policies and procedures based upon accurate data related to its most important features, and updated continuously. While there are agencies and institutions that can answer some of our questions, a comprehensive assessment is lacking. We should learn much more – the sooner, the better. Conflicted entities cannot be relied upon for objectivity, so if the government would like to increase its role in health care, creating a method for objectifying the rationale for change is the correct place to start.

The need to do something about health care is predicated upon the notions that we spend too much, perhaps to achieve inadequate outcomes and leave too many people without access to a reasonable desired amount of care. The rush component is fiscal and therefore political. Predecessors created entitlement programs that have grown for many reasons and are projected to break our bank. So, we have come to the brink where there is little tolerance for growth in health care, and the rhetoric of rationing. Difficult choices lie ahead.

What might we do to establish the foundation? I believe that it will be best achieved by incremental processes that can be managed to significant contributions. I want to learn much more about what health care I should be receiving and why I should want it. While we spin expensive and frustrating cycles on global reform, biting off much more than we can chew, I urge federal and state governments, science agencies, medical societies and organizations, and academic institutions to put forth all necessary effort to accomplish the following, in order to provide a foundation for successful health care reform:

Focus on outcomes.

As a doctor, I can do the best job for my patients if I’m able to form an impression and make decisions based upon facts. A man comes to me with the worst headache of his life and a stiff neck. Does he have a migraine, meningitis, bleeding aneurysm, brain tumor, abscess or something else? My physical examination puts me in the ballpark, but then I need assistance. What tests are available and what are their costs and risks? Is there a decision tree for best practices that I can follow? Is there a neurologist or neurosurgeon available with whom I can consult? If he needs an operation, do I know the skill and success rates of the operators to whom I can refer him? Would he be better off staying in my hospital or being transferred?

We cannot afford to keep practicing medicine by impression when there is a clear need to objectify our behaviors. Whether by creating a national clearinghouse for health care-related data or accomplishing this through individual efforts, we should seek to be evidence-based. There are means to establish, for instance, the immediate and long-term outcomes of a similar, if not identical, brain surgery on a doctor-by-doctor, hospital-by-hospital, and state-by-state basis. The same way that we enjoy consumer reports for automobiles and computers, we should be privy to analyses that guide us to the best doctors, hospitals and practices. For starters, each medical specialty can accomplish systematic reviews. These will guide us to complete the necessary prospective evaluations needed to refine our initial conclusions about clinical, financial and societal implications.

Rationalize drug therapy

Assign the Food and Drug Administration to compare every drug on the U.S. market with branded and generic versions available anywhere, worldwide. If there are not yet reasonable comparative analyses, then design and implement them as soon as possible. Ensure drug quality, then purchase at low cost. Next, compare alternative drug therapies and regimens. Strive to determine the precise incremental differences in outcomes. Create scoring systems if need be, and make them understandable and functionally interoperable.

Define the needs and desires of the American people for health care

I’m tired of listening to middle-aged pundits preach the value of an elder’s life, as if they have insight. Let’s put the issues to the American people and find out what they really want. And whatever “it” is, let’s find out if the respondents are willing to pay for it for others, even if they don’t want it for themselves. Carefully designed interview and polling methods should shed light on the desires, if not necessarily the needs, of persons who pay taxes, care about their families and deserve credit for their life histories and ability to make these sorts of decisions.

Create a mandate for advance directives

This recommendation is directed at a potentially controllable aspect of cost containment, and relies upon on the explicit desires of individuals. As part of each person’s state tax return, he or she should be required to complete an advance directive, which could be changed or amended at any time for any reason. A person should be allowed to decline to complete the directive, but only by officially indicating their declination.

Pay active attention to medical manpower issues

The U.S. population is growing. The ratios of doctors to consumers, and the distribution of primary care physicians and specialists, will perpetually be out of whack unless there is active manipulation of training incentives and financial support for doctors who are necessary to keep this nation healthy. We are not training enough doctors to handle our increasingly elderly and medically complex population. There should be active management to train and recruit doctors, nurses, therapists, technicians and other allied health professionals.

Use computers for decision support

Someone needs to take a strong hand to prevent proliferation of an electronic Tower of Babel. My impression of current electronic medical record offerings is that they are designed for billing purposes, not to facilitate real-time clinical decision support. The promise of cost containment because of computer technology will not be fulfilled unless their use guides practitioners to be more effective, eliminate unnecessary hospitalizations and procedures, and diminish errors. Furthermore, electronic medical records are not yet easy to use. Do we really have our best and brightest software engineers working on these tools?

Create health coaches

Uncoordinated care is the most expensive kind, because it leads to delay in diagnosis, redundancies, excess testing and procedures and failure to put episodes into context. Every person, particularly elders, should have access to a qualified health coach, whose responsibility is to allow the patient to be aware of history and options.

Support medical science to the maximum degree possible

Consider this list: cancer, dementia, diabetes, stroke, arthritis, immunodeficiency, infectious diseases. All of these are unsolved mysteries unless we allow scientists to create new knowledge. Discovery advances all aspects of medicine. Arbitrarily restricting research budgets is a foolish approach to cost containment.

And while we’re at it…

Stop demonizing doctors

With the exception of a small percentage, physicians are not driven by the desire to make enormous sums of money. Physicians struggle with themselves constantly about providing expensive life-prolonging care to neonates, elders and terminally ill persons, the cost of drugs, and our current global financial dilemma. Our debates are also about decency, compassion, wanting to do our duty, and accepting enormous responsibilities each day of our careers. Physicians who succumb to perverse incentives to magnify their incomes should be controlled, but they do not define U.S. health care, any more than greedy lawyers define the legal profession, child molesters define the clergy or corrupt politicians define government.

Understand what rationing really means

We are nowhere near the need to ration healthcare in this country. What we are near is an unwillingness to devote the amount of financial resources necessary to support the projected rate of growth in health care spending. To understand which programs need to be curtailed, or never initiated, we have to get our priorities straight. Let’s deal with two situations that will never change. First, we are governed by elected officials who have varying degrees of health care knowledge and interest. They have never shown a willingness to allow doctors to take the lead on reforming the system, arguing that if the health care profession wanted change, it would have created it. The problem with that logic is that no industry in this country makes the laws, and changes in the system cannot come any other way. What our government should do is put the best and brightest doctors in charge of setting the standards and working within the system to make incremental changes that address the foundation issues I discussed above. The second situation is that you cannot teach people health care economics when they don’t feel well. It is human nature to seek relief from suffering and improvement in one’s personal situation. The enlightened individual at the end of his or her days may go quietly (and inexpensively) into the night, but that is not the basis upon which we should expect to build our health care system.

Analyze health care systems of other countries

How many opinions are there about whether or not U.S. citizens would be better off with the Canadian system, British system, Swedish system or some other system? Let’s decide what’s important to us – mortality, morbidity, life span, wait time for hip replacement, drug rehabilitation – and do the comparative analyses. If there is a system that performs better than ours on issues that really matter to us, then we ought to be able to understand why and determine whether and how we can make the situation better here.

Quit considering a visit to the emergency department to be a failure

The maturation of emergency medicine as a specialty, and the way our EDs have responded to the failure of the health care system is a success story. Unless a patient has immediate access to the right specialist, the ED is the fastest, most accurate, and often only reliable direct route to the doctor who knows how to treat the problem. Think about it. You need a CT scan, neurologist and perhaps interventional radiologist when you have a stroke. Will you find that in your general practitioner’s office? Never. You need hydration, antibiotics, metabolic testing and a chest x-ray when you have pneumonia. Call your family doctor? Not likely. Rather than trying to drive patients out of the ER to an understaffed and overbooked community clinic that will immediately bounce anyone who is truly ill, why not refine and expand the ER concept to provide cost effective urgent care to people? Which leads me to…

Don’t count on healthy lifestyles to solve our problems

I am not a pessimist by nature, but it is difficult to believe that non-mandated suggestions to correct our diets, lower our weight, stop drinking and using drugs, and show caution on the freeways will thrive in our culture of consumption, fast food and cars, diminishing exercise, and disregard for the environment. If our laws allow the use of tobacco, firearms and fast foods, then we will continue to have lung cancer, gunshot wounds and fat people. We actually have a “sick care system,” not a health care system, and to suggest that it could be otherwise any time soon is to put way too much faith in human nature. What is reality? I think we should plan to live longer while being less able to care for ourselves, continue to blow ourselves up during wars with weapons, birth too many babies, and celebrate the right to be sugar and grease eaters, not wear helmets and lay out without using sunscreen. We won’t live forever, and our health care system should be designed for how we actually live, not the way we have been instructed to live. If and when we wise up, we can make the adjustments.

So, if we wish to build a house of medicine upon a foundation of data, communication, collaboration, value and accountability, then let’s be real about where we are, what we want, and how quickly we can alter health habits. Let our best medical minds work together to control our destiny by gathering and facing the facts, with every measure at our disposal.