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Steven Pearlstein

What 'Dr. Bush' Ought to Prescribe

By Steven Pearlstein
Wednesday, February 2, 2005; Page E01

During his State of the Union message tonight, Dr. Bush will say he's got a plan for treating America's health care disease, with its excessive costs, mediocre results and 45 million uninsured. But his prescription is driven more by market ideology than logic and experience. And, at best, it will yield small results.

Health savings accounts, for example, are a good way to get some consumers to shop for value. But they will have almost no effect on the 5 percent of Americans who account for 70 percent of the spending each year, whose treatment will be covered by "catastrophic" insurance. After all, people don't shop for hospitals when they're having heart attacks.

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The Missing Schools of Highest Ed (The Washington Post, Jan 28, 2005)
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Similarly, while malpractice reform may deal with one reason docs and hospitals practice "defensive" medicine, it won't change the fact that they also make more money practicing medicine that way.

Association health plans hold out the promise of lowering the cost of small-group health insurance by circumventing state laws mandating certain kinds of coverage. But doesn't that bring up the larger question of whether those state mandates should be lifted for everyone else?

And then there is Dr. Bush's welcome push for computerized medical records. Everyone agrees this is the single most important step toward reducing costs and improving quality. But if it's so crucial, why has the administration decided to invest so little money, take a decade to implement it and promise never to use regulation to require doctors and hospitals and nursing homes to use it?

This is a real missed opportunity. More than a decade after the Clinton health care debacle, there is finally a consensus on how to reform the American health system, with lots of new data on what works and scores of pilot programs already showing solid results. That was the message I took away from the World Health Care Congress meeting in Washington this week, and from talks with executives from some of the country's biggest employers, hospitals and health plans.

But when I pressed a little harder and asked why, with more than a billion dollars being wasted every day and half of all treatment failing to conform to "best practices," progress was so slow, the answer that came back was invariably the same: The stubborn refusal of doctors to change the way they practice medicine.

Oh, yes, there are plenty of fingers to be pointed at others as well. Consumers who put too much emphasis on convenience and the freedom to choose their own providers, even if they don't have the slightest idea how good or bad they are. Health plans that realized long ago they could make more money in the short term gaming the insurance system than improving the behavior of doctors and patients. Hospitals that would rather have no measure of quality of value than have one that may favor their competitors.

But all of these could be overcome if many more doctors would consult the latest medical evidence rather than treating patients the way they always have.

They could be overcome if doctors would organize themselves into larger, multi-specialty practices rather than flying solo or sharing offices with a few other docs of the same specialty.

It would certainly help if doctors would invest in information technology that could not only save them time and money, but also tell them when their patients failed to fill prescriptions or when their costs or health outcomes were out of line with other docs.

And we can only imagine what would happen if doctors would agree to be paid according to whether they delivered good outcomes at a reasonable cost, rather than according to how many procedures they performed.

Over the next decade, America will reengineer the health sector, just as it did just about every other industry, relying on information technology, best practices and pay for performance. Doctors can either take the lead in that effort or be dragged kicking and screaming into the new era. The choice is theirs. The time is now. And that is the message Dr. Bush needs to deliver to the nation tonight.

Steven Pearlstein will host a Web discussion at 11 a.m. today at washingtonpost.com. He can be reached at pearlsteins@washpost.com.

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