By Steven Pearlstein
Wednesday, June 17, 2009
Last week's column on doctors and health reform generated lots of mail -- most of it, as you might expect, from doctors indignant that anyone would suggest that they might bear significant responsibility for a health system's failing.
At the top of the docs' list of culprits are plaintiffs' lawyers, whose zeal has supposedly saddled them with sky-high malpractice premiums and forced them to practice costly defensive medicine.
Next come the greedy and incompetent insurance companies that try to dictate how they should practice medicine and try to pad profits by scrimping on coverage.
Docs also blame for-profit hospitals for putting the interest of their investors ahead of those of doctors and patients.
They cite the pressure from patients who reflexively demand the latest and most expensive treatments.
And, of course, they blame the government for forcing them to accept Medicare reimbursement rates that don't cover their costs.
The basic view from behind the stethoscope is that health care would be a whole lot better if only the docs were given free rein to treat their patients, organize their practices, run the hospitals and set their own fees.
Okay, so maybe the docs don't put it quite that starkly, but that's what it comes down to. And I guess if you start with the view that they know the most about medicine and are motivated simply by the desire to do what's best for their patients, then it all makes perfect sense.
Unfortunately, we know now that much of that worldview is wrong.
Yes, malpractice litigation is a problem in some regions -- and, in particular, in some specialties -- but independent studies have found that it is nowhere near as big a culprit as doctors believe in driving up overall health-care costs. I, too, wish that President Obama had mustered the political courage to back reasonable limits on malpractice damage awards. But one of the reasons malpractice suits are still necessary is because doctors have transformed local professional review boards, which are supposed to protect patients, into nothing more than mutual-protection societies.
It's also true that insurance companies have often created inflexible bureaucratic processes to try to manage the cost and quality of care. But given that there is overwhelming evidence that doctors tend to order up tests, perform surgeries and prescribe treatments whose costs far outweigh the benefits, you can hardly blame the insurers.
Most often, studies show that physicians are simply unaware of the latest medical evidence or choose to discount it because it runs contrary to their training, local custom or economic self-interest.
Ezra Klein, my new colleague at The Post, has also identified what he calls the "House" factor, named after the popular TV show. It's the belief, widely held by doctors and their patients, that a really clever and creative practitioner can outsmart the standard protocols and achieve heroic outcomes. This makes for great TV drama but, as Klein notes, we could all have better health at a lower cost if docs were less inclined toward the medical equivalent of the diving catch and simply were more disciplined about kneeling down for routine ground balls.
That's what the best health centers and managed-care organizations have done. And it's what health reformers have in mind when they talk about moving from a fee-for-service model, in which doctors are paid on the basis of the quantity of things they do, to a pay-for-performance model, in which they are paid for the quality of health care they provide.
To its credit, the American Medical Association, under outgoing president Nancy Nielsen, has embraced payment reform and the push toward evidence-based medicine. And insurance companies report that docs have begun to respond positively when they are contacted by another health professional and shown scientific studies finding that there is a better way to treat a particular disease. By and large, however, practicing physicians still think that nothing should interfere with the sacred right of doctors and patients to make all medical decisions, even when they are wrong.
Docs also seem to have a blind spot when it comes to money.
While many docs think that the profit motive at insurance companies and hospitals has corrupted the health-care system, they bristle at the idea that the same incentives might be at play in their own practice.
Docs seem to take it as a given that physicians in the United States should earn twice as much as doctors in the rest of the world -- and five times more than their patients, on average. Mention these facts and you are guaranteed to get a lecture about the crushing debt burden that young docs face upon completion of their medical training. Offer to trade free medical education for a 20 percent reduction in physician fees, and you won't find many takers.
I have nothing against doctors -- some of my best friends are MDs. The overwhelming majority of doctors are competent, hard-working professionals trapped in a flawed system that gives everyone the wrong incentives. That system is no longer viable -- economically, politically, morally.
The choice for doctors now is quite clear: They can agree to give up a modest amount of autonomy and income, embrace more collaboration in the way they practice medicine and take their rightful place at the center of a reform effort that will allow them to focus more on patient care.
Or they can continue to blame everyone else and remain -- stubbornly -- a part of the problem.