Wednesday, July 24, 2013

Does Ezekiel Emanuel Think We Are Weenies?

Tilburt et al published a study in JAMA this week suggesting that physicians feel that other players (lawyers, insurance companies, hospitals, etc)  are more responsible than doctors for reducing healthcare costs.  Furthermore, they are hesitant to promote reforms that eliminate the current fee for service payment system. 

Although I would bet the no one would be surprised by these findings, a scathing editorial by Ezekiel Emanuel and Andrew Steinmetz caught my eye.  Before I get to the particulars, I would like to make a few (hopefully mostly uncontested) observations.

1)Physicians are some of the most educated, hard working individuals in American society. Very few professions require a four year doctorate, plus a minimum of a 3 year apprenticeship.  After finishing our training, we have long hours, take phone calls over night, and work many weekends. 

2)People, by in large, don't go to medical school to make a fortune.  There are many other professions that are more economically worthwhile with less debt incurred. Based on the GPA requirements, these applicants could likely choose almost any profession.  Medicine is a passion and calling.  Those who do not feel so drop clinical practice fairly quickly.

3)The daily job of physicians is to investigate, consider, and choose between incredibly complex and different avenues, and then take action.  We are trained to see the subtleties in both the written word as well as during patient presentations.  This is a thinking man's sport.

So when a large majority of educated, capable, and thoughtful people proclaim an opinion, one would think it would be wise to pause, consider, and evaluate before wholeheartedly dismissing the group as a bunch of weenies.  Unfortunately, Emanuel and Steinmetz think differently.  They proclaim:

The findings of Tilburt et al. confirm this ingrained human behavior by showing that physicians are hesitant, if not unequivocally opposed, to taking bold steps to re-engineer incentives in the system -- steps that may well have the most meaningful effects on controlling costs...

I couldn't agree more. Yes, thoughtful physicians who have been led astray before, are not jumping into the arms of governmental change.  Let us ponder a few questions.

1)Have any of the finished medicare demonstration projects ever had positive results?
2)Has pay for performance in the past, on balance, shown a financial or quality of care improvement?
3)Is there any proof that ACOs or PCMHs will improve the quality or cost of care?
4)How is the government doing so far at balancing the budget in general?

As physicians we learn to use scientific evidence to support our theories.  We have been burned time and again in medicine by using logic above data.  After careful consideration, moving forward "boldly" but foolishly may do more harm then good.  Ezekiel's fantasies about healthcare are unsubstantiated.  Show us the data, and we will follow willingly.

The editorial continues:

This is a denial of responsibility...Of course, physicians do not want to be blamed for the country's major problem. But can they really be both the captain of the healthcare ship and cede responsibility for cost control to almost everyone else?   Ultimately, what this survey tells us is that physicians acknowledge that health care costs are an issue, but they are not yet willing to accept primary responsibility and take definitive action to lead change.  The rejection of transformative, bold solutions to address the seriousness of the cost problem is indicative of much bigger problems ahead of we don’t start seeing more leadership from the physician community.

It's simple.  If you want us to be captain of the ship and take on all the responsibility, then you have to actually listen to our opinions.  Rehospitalization policies, pay for performance, and meaningful use are all untested ideas that have made both our and our patients lives miserable.  EHRs have never been shown to improve quality or cost of care.  Study after study is starting to show that rehospitalization rates are extremely difficult to modify.

Most importantly, our lives as primary care physicians have deteriorated greatly in the last two years.  The amazing amount of paperwork, the denials, and the computers are sucking our attention away from real life, difficult, patient problems.  Ask any patient, they will tell you that the office environment has deteriorated.

Finally, Emanuel and Steinmetz warn:

Unless physicians want to be marginalized -- unless they are willing to become just another deckhand -- they must accept and affirm that they are responsible for controlling healthcare costs.

I guess he doesn't realize that we feel as if we have already been marginalized.  But "deckhands" we are not.  If we decide decide to jump ship, whose going to steer the boat?

Maybe Ezekial Emanuel will.


DW said...

great rebuttal to a sad state of opinion on our profession.

Anonymous said...

I agree that physicians should take some role in cost containment. This can be done, for example, by providing QALY data for treatments to help with valuation, and also to improve our care of the terminally ill. We cannot, however, take too prominent a role in dividin the pie, however, because we in fact want a piece of the pie.

The bigest problem with cost control is in fact the price setting by the feeral governement. In my own field, Rheumatology, a new bioloic was aproved several days ago. Its name is Simponi-Aria. Despite being the 6th TNF drug to the market, and despite being one of 10 bioloic drugs on the market, it is in fact going to be the most expensive. One might ask, how could such a competitive market aupport such a hih cost product? The answer lies in Medicare's 2003 modernization act, iving these companies total authority over the pricing of their product. Bioloic therapies for GI and Rheumatology conditions make up 3% of the total Medicare budget, so no small potatoes.

The federal goverment writes laws based on the interests of their closest lobyists. So when healthcare prices are to high as a result of government, what is the solution......more government.

I risk marginalzing myself by sounding like Milton Friedman in this grand age of communalism, but really some healthy competition would clean things up.

Right now we are fighting with hospitals and drug companies for a slice of the pie. Hospitals are addin new wings left and right, dru companies are raking in billions. There is plenty of pie to go around if competition distributed it according to value.