Friday, September 19, 2008

Health Care Reform: Time for American Medical Leadership to Start Thinking Ouside the Box. Part Two

Now we'll look at another Perspective article in the New England Journal of Medicine, titled Collective Accountability for Medical Care – Toward Bundled Medicare Payments. It was written by senior members of The Medicare Payment Advisory Commission (Medpac).

Let's be clear upfront that Medicare's underpayment of primary care services has had a devastating effect on the supply of primary care physicians and their services over the past 43 years. The family doctor is disappearing. Only a third of all U.S. physicians are primary care doctors - the reverse ratio of all other countries that spend much less on health care than we do but have far superior results.

The article is a well-written scholarly discussion of a proposal to bundle hospital and physician services for each admission. The authors correctly state that Medicare spending is excessive and unstable and is far from delivering value for the dollar. However, the authors do not address Medpac’s role in causing this situation. They claim that the incentives in a fee-for-service system are the root cause of this problem. Their solution is a bundled payment system, where Medicare would pay a consortium of hospital and physicians a fixed amount for 30 days of care for each hospitalization. The goal of this proposal would be to better coordinate hospital and later outpatient care.

As I see it, this proposal has two major flaws:

1)It in no way addresses inappropriate care. Should the patient have been admitted to the hospital in first place and were the services in the hospital appropriate considering the patient's overall condition? Inappropriate care accounts for about a third of all administered care in the U.S.

2)There is no mention of the critical importance of the primary care physician and the significant adjustments to their reimbursement so that they can spend a minimum of thirty minutes with their patients at each visit and be able to follow their patients once they are admitted to the hospital. However, in Medpac’s submission to Congress in which it discussed bundling of care, an increase to primary care providers was suggested. This increase would be accomplished by an adjustment to the complex formula now being used to insure budget neutrality. When attempted in the past within the present system, this approach has proven inadequate.

Although in the Congressional report it was mentioned that many specialists do provide some primary care services, there was no mention of how dramatic the undersupply of primary care physicians is, nor of their vital role in chronic disease management. There was also no mention that it will take years of significant payment increases to rectify this shortage.

In my opinion, the answer to this problem at this time is to have internal medicine sub-specialists who are consulting on the patient’s major medical problem assume primary care responsibility for that patient if the patient has no primary care doctor. They would be reimbursed at the new higher primary care rates, but not the much higher subspecialty procedural rates for those primary care services.

I believe it is time for Medpac and Congress to admit the obvious-the present system is irrevocably broken and should be replaced with a Federal Reserve type Health Care Bank. The Bank, with expert advice, would adjust physician payments to adequately fund primary care as its first priority, then fund subspecialty and procedural care. This difficult task should take place without political interference. That would be thinking outside the box.

Health Care Reform: Time for American Medical Leadership to Start Thinking Ouside the Box. Part One

A recent Perspective article in the New England Journal of Medicine raises concern that because the federal Food and Drug Administration (FDA) has approved certain drugs, citizens could not sue drug companies in state courts because of the preemption clause in the U.S. constitution which states that federal laws trump state laws. The article, Why Doctors Should Worry About Preemption, was written by three physicians on the Journal staff . Given their positions, they are among the top leaders in the medical community and exert considerable influence.

FDA approval is based on a four phase process with all information supplied by the drug company at a cost to the company of over eight hundred million dollars. There is much debate as to how to improve this process. Aside from this debate, the authors of this article support the concept that after FDA approval, state tort litigation augments drug safety and enhances consumer confidence in the safety of medications and devices.

I disagree and here's why:

1) Legal action does not address the fundamental problem of our drug/device approval process. Presently clinical research to define the efficacy and safety of these commodities are funded, designed and controlled by these companies. The cost of bringing a new drug/device to market is enormous with failure risking the viability of the company. As has been repeatedly shown in the recent past this research is tainted by inappropriate design, withholding of results, and conflicts of interest.

2) Patients have confidence in drugs and devices when prescribed by their physicians even though the safety and efficacy may be proven otherwise somewhere down the road. It takes many years before tort cases reach any helpful conclusion and, by that time, many patients may have been harmed.

3) Allowing drug/devise direct marketing to the public has distorted the public's view of the safety and efficacy of these products, while considerably increasing their cost.

A possible solution to this litany of problems is to have all drug and device clinical research funded by the companies, but through the National Institutes of Health (NIH). This would ensure rigorous design, honest and timely reporting of results. We might then have more high quality information disseminated to the medical community. People with conflicts of interest at the NIH would be excluded from this activity.

Funding by the companies would also be mandated to include follow-up of all products to spot any problems that occur once the drug is available to the mass market. If problems do occur or efficacy is not proven, the FDA could immediately withdraw the product from the market.

Using this system, knowledge from rigorous scientific processes would drive the system, rather than a drawn-out legal process that also has the potential for emotional misadventure, as occurred with the silicon breast implant litigation. I also propose the discontinuance of direct advertising to the public that creates excess demand for newer more expensive products that may have no benefit over older off-patent material.

It is my hope that the leadership of the prestigious New England Journal of Medicine will expand the scope of their view to consider fundamental change to the oversight of this industry rather than a slow, extremely expensive and some times grossly inappropriate legal system. We must use knowledge and science to better treat our patients, not the courtroom.