Reforming Medical Care: A Task For A Generation

With the Supreme Court's historic decisions upholding Obama Care (aka  theAffordable Care Act)  the stars are aligned to light the path to affordable medical care for all – even in the U. S. of A.  Broadly affordable and available health insurance is one key part of  what is needed: the wholesale makeover of our medical world.

The once (and future) warring tribes of the medical, business and political regions of this nation have lately begun, to commence, to get ready to bring about this historic transformation.  Some are eager.  Insurance companies are salivating over all the new business from up to 30 million new customers.  Hospitals and clinics happily anticipate more paying customers making appointments rather than showing up in extremis in emergency rooms unable to pay.  Others are not.  Small business groups are spooked over the confusion of new requirements and regulations.  States are of two minds about Medicade expansion, now that the Supreme Court has made it optional.  Doctors dread the conversion from manual to automated medical records and an ultimate end to fee for service pricing.   

Good luck to them all! And rubarbs for the reactionaries who have made this day so hard to reach. But insurance is hardly the whole enchilada. Nor will we be at the end of that rocky path when everyone is covered. Medical care will still cost too much and as long as it does insurance will too. ObamaCare does not automatically change the way medical care is priced and delivered by doctors and nurses, clinics and hospitals, though it does mandate studies and pilot programs galore and encourage outcomes based pricing.

Meanwhile, the ever rising cost of medical care reflects a mismatch of supply and demand. Our chaotic and fragmented supply of increasingly exotic, perennially palliative medical services has collided with the insatiable demands of a medically addicted population of ex-hunter gatherers turned couch potatoes living so much longer thanks to past medical advances that they sicken and die from a whole new set of causes.  The best that can be said of them is that generally they are not infectious.

Those iconic words, "supply" and "demand" may suggest to the orthodox that the magic of the market place is all we have to invoke and all will be well. But, Adam Smith not withstanding, markets just don’t happen. They are created, nurtured, shaped, dominated and, yes, exploited by those most keenly interested in doing so. Eventually governments are led to intervene on behalf of one put upon constituency or another and to civilize marketplace conduct.

Medical markets evolve no differently. Doctors are now more rigorously licensed, drugs better tested, research more impartially conducted, hospitals and nursing homes more effective and pleasant, some frauds prosecuted, and standards of care tightened, if only because politicians have responded over time to public demand for reform and the medical professions, for all their faults, do prefer a service ethic over the law of the jungle.

But, even while we enjoy the improvements they have wrought, the zeal for reform wanes, we grow complacent and the iron law of unintended consequences ensures that the cycle will repeat.

Having been here before, we well know what we must do. All of us, in our respective social roles, must assume our share of the responsibility for the rising costs and diminishing results of the medical marketplace and take the opportunity provided by Obama Care to change our behavior in ways large and small.

–Doctors and Hospitals need to embrace information technology and best outcomes medical procedures. If timely patient and treatment information is accurately and readily shared electronically, and then if the practitioners deign to follow what is best in diagnosis and practice, several hundred thousand of us would not die prematurely and expensively each year from ignorance, silly mistakes and outmoded treatments.

Those step-children of the medical world in the federal Department of Veteran’s Affairs have won wide acclaim by success with both of these reforms, even though VA doctors work for the government in government run hospitals and clinics. If I were an MD enjoying the lucrative freedom of private practice in my chosen specialty I would think hard about that.

A conventional bit of folklore I remember from my youth was that in ancient China people only paid their medicine men when well, never when sick. In the late 19th and early 20th centuries, when the causes for many common ailments were finally deciphered and actual valid cures discovered, medicine men became doctors and charged for every treatment. This model needs to give way to team practicing, outcomes pricing and the practice of prevention. If the independent practitioner can’t continue without a fee for each service rendered so be it.

–Drug Companies need to ensure that a new treatment continues safe and effective once in general use, not just during clinical trials, and to aggressively pursue reports of adverse actions and ineffectual results. Then they need to do the obvious with the information.

Big Pharma ought not game the patent system with "me too" drugs in order to keep generic versions at bay and then tout these latest "wonders" on the tube. I for one promise never, ever to ask my doctor if that new pill I saw on television is "right for me." What a dumb question! What a dumb decision to allow such a dumb question to polute the airways.

If the drug companies can’t profitably conduct research to cure the common afflictions of the poor then the government must. It is especially important to save the children so women (and the planet) won’t be compelled to bear so many.

–Insurers should embrace, enthusiastically, the reforms of ObamaCare: no annual or lifetime caps, no denial of coverage due to pre-existing conditions, free preventative care, no cancellations when people are desperately sick, etc. Whipsawed by the jungle-like structure of their market, they have been driven to sell as much insurance as possible to those who need it least and then deny or delay authorization of treatment and payment of claims to those in greatest need in ways bureaucratic and exasperating beyond belief.  They have had to do this, they say, in order to compete in the corner-cutting scenario long endemic in their business.  Not any more.

For this bottom feeding business model, while technically not criminal, is grossly immoral, and must be a source of shame for many caught up in careers based on it – especially if they feel they can’t leave because then they would lose their medical insurance.

To survive the mounting fury of the public -- which cannot be channeled into anger at the big socialist government boogyman forever -- insurers had best beg the feds to reorganize and regulate their offerings even further in the years to come:

--A uniform menu of policies available to all regardless of age or dependency;

--No denial of coverage for preexisting conditions or life circumstances (including age, occupation and gender);

--Co-payments based on ability to pay;

--Coverage of all (and only) effective treatments for recognized ailments and preventions;

--Discounts only for healthy conduct (exercise, diet, safe driving);

--Penalties only for unhealthy conduct (smoking, substance abuse);

--Denial only for the unnecessary, cruel and problamatical treatments (non-reconstructive cosmetic surgery, genital mutilation and scientifically unproven medications and procedures);

--No lifetime or annual or treatment caps.

In most particulars this structure is the Obama Care goal, and is how the new Insurance Exchanges should structure the plans they accept.  It is also the way the federal government, including the military, has long provided for its own workers, retirees and their families – including the Congress (and this writer) -- living proof that a federally managed insurance system can work effectively with the private insurers – once it can corral their competitive juices within a guiding framework.

–We, the Insured especially must change to afford our longer, healthier lives. We should all know why the doctor tells us to take two pink pills twice a day, as well as do what we are told, and lead lives that make and keep us at a healthy trim through diet, exercise and sensible conduct.

--Parents who need it must be helped to ensure and nurture their children.

–-Schools and parents should refrain from feeding them junk.

--Adults, especially young adults, must not elect to ride free until old and sick.

--The very old ( I am 82) must learn to die as inexpensively as possible, rather than consume the bulk of all medical care adding unsatisfactory days to the last months of ever longer lives.

--Society in general, and care givers in particular, should accept the critical need to ease the terminal out of this world as painlessly and tranquilly as possible. Morphine addiction at the end of life is not immoral and should not be illegal.  Neither, under careful public procedures, giving the last word to the dieing person, should euthanasia.

–We, the People, finally, need to comprehend that this medical Rome will not be built in a day. It may take a generation and still be imperfect. But we need to persevere so our children will have something better to improve in their turn.