By John Ballard
Color this post dry but important.
I would like to point to something new and sexy but health care reform, despite the histrionics, is basically a boring repetition of already known facts in the hope that reform efforts will eventually reach critical mass and those in authority will enact meaningful change.
John K. Iglehart is founding editor of Health Affairs, a bimonthly policy journal that he started in 1981. He has served as a national correspondent of The New England Journal of Medicine and was elected to membership in the Institute of Medicine (IOM) of the National Academy of Sciences in 1977. In addition to many other credits he holds a degree in journalism from the University of Wisconsin-Milwaukee and has been a journalist-in-residence at Harvard University.
Thomas R. Russell is the Executive Director of the American College of Surgeons (ACS). The College has more than 69,000 members and it is the largest organization of surgeons in the world.
Dr. Russell's residency training was interrupted by military service in Vietnam from 1968 to 1970, during which he was a Lieutenant Commander and US Navy Flight Surgeon. In addition to the College, he holds membership in and has been active in the affairs of the American Society of Colon and Rectal Surgeons and a variety of other professional associations. Dr. Russell has published extensively on scientific and educational topics related to colon and rectal surgery and general surgery.
As Dr. Russell leaves his position at ACS he is interviewed by John Inglehart in a wide-ranging interview that anyone interested in health care reform should at least scan. I didn't come across anything new or shocking, but Im reassured that professionals like these are keenly aware of the challenges at stake and have creative solutions for some of the problems. The transcript is divided into the following topics.
- Surgeons and quality improvement programs
- Surgeons and physician payment reform
- Best ways to slow health spending
- Consumer-driven health insurance
- The health care workforce: now and in the future
- Scope-of-practice issues
- Malpractice law and best-practice protocols
- Commercialism in medicine
- The political influence of organized medicine
- Congress and the cost curve
- Vision for the future
Rather than my parsing these points, the reader is urged to check out the transcript. The list here will help you focus on whatever subject or subjects interest you most.
I was attracted to a few ideas worth repeating.
Russell: We now have about five years of experience with one of our programs that measures risk in relation to a patient�s outcome�the National Surgical Quality Improvement Program (NSQIP)....it�s going to take awhile to develop accurate measures that are reliable, risk-adjusted, and based on valid clinical data and then take that information and formulate deductions that will be useful and understandable to non-clinicians.
Iglehart: I would assume that more than a few surgeons regard such activity as an intrusion into the independent practice of medicine. Is there a generational difference among surgeons in their willingness to cooperate or at least participate in these kinds of initiatives?
Russell: Absolutely. The younger surgeons have trained in an environment in which they to expect that the quality of care they deliver will be measured and evaluated, so they don�t really have any difficulty participating in these activities. It�s some of the older physicians who entered practice in a more autonomous era who struggle with these new forms of oversight.
This underscores one of the main obstacles I sensed early on in this debate. Aside from ulterior motives clearly behind the opposition to reform (drugs, medical devices, insurance, fee for service business model) stands old-fashioned stubbornness and pride on the part of established doctors and their staffs who simply Don't. Want. To. Change.
[Russell] I feel very strongly that patients need to take more responsibility for their own health. I used to tell my patients, �You are your own best doctor.� It�s simply absurd for patients who have been setting themselves up for medical problems by smoking, overeating, or overdrinking for 50 years to expect physicians to reverse the health consequences of such behavior. We�ve got to empower patients to become better stewards of their own bodies.
Next, physicians must take a closer look at their practices and be certain that the services they provide add value, not just more work, which has driven a lot of people in the past. Indeed, all stakeholders, including the insurance companies, pharmaceutical companies, device manufacturers, and so on, need to focus on determining which products and services actually have a positive effect on quality of life and not just on their bottom line.In surgery, there�s a lot that we could do differently to help bend the curve. For example, we�re probably doing more screening than is medically necessary, and reducing the number of tests we do on low-risk, healthy patients would save money. We also need to look in a very thoughtful, ethical way at rational � I�m not using the word rationing, I�m using the word �rational��ways to improve end-of-life care.
[...]
In addition, the medical and surgical professions need to develop protocols for the best ways to approach diseases. We need policies about when scans, such as a CTs and MRIs, are indicated, and to make sure they are not unnecessarily repeated by another physician. And we must develop standardized ways of treating diseases so that every health care professional involved in coordinating a patient�s care is addressing the condition in the most cost-effective way that follows the scientific evidence.
The problem is that a practicing physician is confronted with the one-on-one reality of trying to help the specific patient in front of him or her.So, physicians are constantly faced with the dilemma of whether to try to meet society�s demands and be responsible stewards of resources or to meet the individual patient�s specific demands. But I think that as we bring the public along and as physicians educate themselves, we�ll all gain a better understanding of the fact that the money available for health care is finite, and we have to learn how to allocate it more appropriately. This way of thinking is becoming more common among younger physicians and surgeons, and is being approached didactically in residency. [ed. In case you missed it earlier.]
Repetition is at the heart of learning.Have we heard this before????
Hello...???
Someone say end-of-life care is expensive?
Russell: [Medical malpractice] is a huge problem for many surgeons, depending on their practice location and specialty. The specialties of OB/GYN and neurosurgery face particular challenges. High premiums of more than $100,000 a year for malpractice insurance are not uncommon for these specialists or for any physicians practicing in certain states, such as Florida. Furthermore, the risk of being sued leads physicians to practice defensive medicine, which adds costs to the health care system. Organized medicine and many Republican legislators have long argued in favor of capping awards for noneconomic damages, but I don�t believe the nation will ever reach a consensus on that proposal, although a few states have implemented the limits. I think instead more efforts should be made to educate, in this case surgeons, about how to avoid or better manage risk by staying within their scope of practice. Communication with the patient and his or her family throughout the surgical experience is also key to helping these individuals understand why there was a negative outcome. When a mistake is made, apologize, if you practice in a state that has passed legislation providing legal protections for saying, �I�m sorry.�
Very important, too, is for the profession to develop evidence-based best practice protocols and for physicians to follow them closely. In my era, we objected to this form of standardization and called it �cookbook medicine.� But, as calls for accountability have increased, lawmakers should consider setting policies that protect physicians who adhere to professionally developed protocols. In these cases, if a patient sues because of a bad outcome, the physician can respond with a legitimate defense: �Look, I followed the protocol that we all agreed was best practice. I�m sorry for the bad outcome, but a bad outcome does not equal malpractice.�
This simple principle cannot be overemphasized.
Early in the debate I came across a guest post at Maggie Mahar's place from a retired physician which is worth studying in full. But this part stuck with me well enough for me to have it bookmarked.
Protection Against the Threat of Malpractice Suits
Many health care providers will be willing to implement these changes in their practices if the government provided them with cover by setting standards and explaining the standards to both providers and the public. This is partly because most providers really do want to provide the best possible care (and almost all believe they do,) and partly because establishing practice standards could protect against inappropriate lawsuits.
The most dramatic example of this can be seen in the history of anesthesiology. In the mid-70�s, anesthesiologists faced the highest malpractice insurance premiums of any specialty � often as high as $100,000 a year (and those are 1975 dollars, remember.) The Society of Anesthesiology, realizing that this was threatening the viability of many practices, created a national panel which developed a set of specific standards for anesthesia practice.
They then created a task force of lawyers and academic experts that offered its support to any practitioner who could document that they had followed the standards but was still being sued. Verdicts against anesthesiologists plunged, and -- since plaintiffs attorneys cannot afford to lose regularly �the number of lawsuits declined sharply Insurance premiums fell by 90%.
More importantly, complications of anesthesia and deaths from anesthesia also declined. The standards not only had the desired result of ending the malpractice crisis in anesthesia, but also made anesthetic management safer and more effective. This created an impressive win for the patients as well as the doctors.
This effect of practice standards on the malpractice climate could be helped along mightily if states passed legislation to codify the fact that documented proof of following best standards promulgated by federal agencies would serve as a clear and binding defense against charges of malpractice. This is not to say that patients do not deserve to be compensated when real malpractice occurs, but that the public also deserve protection from inappropriate and sometimes dangerous procedures, tests, and treatments ordered as �defensive� medicine to try to avoid lawsuits.
But in the end, let me stress, while the government needs to play an important role in creating and documenting standards of care, organizing the effort to improve care and providing �cover� for doctors, hospitals, and insurers, it is doctors who write the orders. They and they alone have the power to reform the quality and cost of our health care system from within.
It's called "best practices." When professionals are in agreement about what constitutes best practices, non-professionals, including lawyers, have a damn hard time arguing they are wrong. They might argue that best practices were not being followed, in which case perhaps someone should be in trouble. But the individual who knows and follows best practices, from housekeeper to case manager, is standing on very firm legal ground and accusations of malpractice are the last thing they worry about.
Check out my other post from MD Whistleblower.
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