Wednesday, June 10, 2009

Physicians: Paradise Awaits in 'Achieving Health Care Reform' from the New England Journal of Medicine - not.

Physicians, are you feeling demoralized? Are you angy over the decay of your professionalism? Do you think public and private insurance plans have commoditized your expertise?

If you're not a physician, do you need some simple nostrums that you can quote on behalf of wholesale health reform?

Well, look no further than the latest issue of the New England Journal of Medicine, which has the temerity to hector its physician readers on why and how they must support the health reform proposals that are coming before Congress in this legislative session.

Much like Dante gazing upon the concentric spheres of Heaven described in the Divine Comedy, the ivory tower academicians Elliott Fisher, Donald Berwick and Karen Davis behold four levels of progressive delight that await a compliant physician community. The first consists of a tripartite world aimed at increased safety, better health and lower costs. The second is made up of 'clinical microsystems' that are made wonderful thanks to quality improvement activities. The third is made up of large accountable high performing health care systems that mimic integrated delivery systems, complete with electronic health records and care management programs. The fourth is the wonderful alignment of all payment, regulatory, legal and educational systems that includes universal insurance. Ahh, say the authors, if only physicians would embrace these 'win-win' virtuous visions, rancorous debate over a public insurance plan would fade away and budgetary watchdogs would be muzzled. What's more, a reassortment of the money would lead to doctor's having greater take-home pay and a decrease in health care costs - even if it means reducing future Medicare payment rates. The celestial path? Simply agree to a 1.5% savings in exchange for universal health insurance and reform that promotes accountable health orgizations, gain-shares, bundled payments, pay for performance and the subsidization of electronic health records.

The Disease Management Care Blog thinks physicians have already bought into the need for safety, increased health and lower cost. They also know all about quality improvement. However, many practice in independent physician-owned settings and are unlikely to willingly link up with the local hospital systems in accountable organizations for the reasons that have already been described in Eliott Fisher's Health Affairs article on the topic: physicians are successfully competing with hospitals to offer cheaper and better services, their culture is one of cultural autonomy, hospital-physician gainshare arrangements could be viewed as monopolistic and the local politics would be thorny. The DMCB also doubts its colleagues a) would support any Medicare fee schedule reduction, b) would find universal insurance to be a panacea, c) believe gain shares, bundled payments or other reforms mentioned above are as proven as many policy makers would have you believe and d) agree with the Congressional Budget Office that the costs of such an approach would not be matched by the savings.

So, what would engender physician buy-in? The DMCB would be happy to write a Perspective for the New England Journal and awaits the invitation. It won't hold it's breath.

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