As doctors we’re always telling people to cut the fat—cut it out of your diet and off your middle. Now we need to trim it if from the health care system, and it seems that we’re as adept at it as the Congress is at carving the pork out of their legislation. The problem, in both cases, is negative incentives. 

In the latter case, if you’re an elected official who believes his job hinges on bringing home the bacon to his or her respective state, you make pigs. It can’t and won’t change until the system changes, until the American people demand it in a clear and uniform voice. 

In the health care arena, I believe the vast majority of the problem is overuse due to system corruption, not abuse secondary to greed. A system riddled with fear of litigation and increasing overhead and regulations encourages overuse. Practice patterns change slowly and insidiously until the new “standard of care” seems natural, both to the physicians providing it and the patients clamoring for it. But now it’s becoming more and more unaffordable and there is no easy fix. The government uses blunt force—it calculates which outpatient procedures are most ubiquitous and cost the most in the aggregate, and slashes reimbursement, punishing the good (the low utilizers), the bad (the over-users) and the ugly (the abusers) equally. 

I struggle with the physician end of the solution more than any other, perhaps because I am one, and because ultimately we make the decisions that initiate the process. I’ve mentioned in past blogs how integrated, salaried systems like the Cleveland and Mayo Clinics and Bassett Healthcare have been lauded as providing high quality care at less cost. But porting this to the whole of health care and requiring that all doctors become salaried smacks too much of socialism; on paper it works, but not in the real world. It runs counter to human nature, it disincentivises and can lead to abuse on the other end, underutilization, one of the problems we’ve seen with managed care. 

I think we need a novel approach. As I mentioned in my 15 solutions, some form of centralized medical records to reduce duplicate testing is overdue. But that isn’t enough. A more sophisticated system of decreasing reimbursements (even declining to levels of meeting only office overhead) based on test/procedure volume normalized to patient load and severity might be one approach to consider. 

The bottom line is that none of this will work in a vacuum. If tort reform is neglected and patient expectations continue to run high, I’m afraid we’re all in for more of the same—a high calorie pork-laden health care system. 

Pass the butter.


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