Only Docs Can Do It

Merrill Goozner

First published 5/19 on Gooz News

Do what, you ask? Cut costs. So say Victor Fuchs and Arnold Milstein in a sprightly overview of the roadblocks to cutting health care costs in the latest issue of the New England Journal of Medicine.

The short essay begins with the observation that the most cost-effective and often highest quality health care systems in the U.S. (usually organized as non-profit, integrated groups like Kaiser Permanente or Intermountain Health) deliver care at 20 percent less than the national average. Spread their model to the rest of the system and it could lop a whopping $640 billion off the national health care tab.

So what stands in the way? One by one, they traverse the tangled web of special interests that divide up the $2.5 trillion health care tab.

  • Insurance companies? Standardization of practices that would create real price competition would reduce profits, so they resist.
  • Large employers? Only 20 percent require employees to pay the difference between low-cost and high-cost plans, fearing they will alienate employees.
  • The public? They are bamboozled by the media into thinking that health care is a “benefit,” not a cost paid by forfeited wages. And they think  there’s a cure for whatever ails them, not realizing that the $100-per-month prescription doesn’t really prevent them from having a heart attack, it just reduces their risk from 3 in a 1000 to 2 in a 1000.
  • Politicians? Just look at the campaign finance reports. Insurers, hospitals, physicians, drug companies, device companies, imaging equipment companies, nursing homes, and dialysis clinics are huge sources of campaign cash for politicians from both political parties. Cutting costs cuts everyone’s cash flow, including theirs.
  • And physicians? They resist change because standardization of care — the key to cost-effective medicine — threatens their professional autonomy. The specialists who dominate the field, and earn the highest incomes, would lose ground in any system that relies heavily on evidence for treatment choices.

Yet, like Obiwan Kenobe, they’re our only hope, the authors assert. After pointing out that the latest version of the Hippocratic Oath, the Physician Charter, calls on docs to work toward “the wise and cost-effective management of limited clinical resources,” they conclude:

There is not much that physicians can do directly to change the behavior of insurance companies, employers, or other stakeholders, but physicians are the most influential element in health care. The public’s trust in them makes physicians the only plausible catalyst of policies to accelerate diffusion of cost-effective care. Are U.S. physicians sufficiently visionary, public-minded, and well led to respond to this national fiscal and ethical imperative? It’s a $640 billion question.

The short answer, of course, is no. If they were public spirited, would they lobbying as hard as they are to restore physician pay — the so-called “doc fix” — which will cost the government another $300 billion for Medicare over the next decade?

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