Change from Within

President Obama gave a thoughtful speech to the American Medical Association on Monday and did what a President should do: he tried to inspire change among a group who collectively has resisted it.

Real change only happens if health care changes from within. Not surprisingly, the President was booed when he announced adjustments to federal reimbursement schemes for physicians. Could it be that physicians would rather have 50 million uninsured Americans than get to the real business of changing the way they practice? I don't think so. The physicians I work with every day believe in the President's principles for reform and understand their own role in cutting costs and improving quality.

However, there were several important omissions. One was obvious - there was lots of information about various arguments in support of the need to slow the growth rate of U.S. health-care costs but there were few specifics about how to actually achieve it, and the devil is in those details.

He also built the speech on the assumption that our health-care system is physician-centric. In fact, it is and must be patient-centric. Physicians have been voting with their feet for a number of years and leaving primary care for a number of reasons, including the excessive administrative burdens and the steadily increasing overhead costs that have reduced their income. The primary care physician role models for students have simply dwindled and these physicians are generally not particularly happy. Yet medical schools are being urged to increase enrollment to produce over 5,000 more MDs per year in order to increase access, especially primary care access. This increase is not 1) possible 2) feasible in a timely fashion or 3) necessary and it is unlikely that production of more physicians will have any impact on the shortage of physicians in poor neighborhoods or rural settings.

There is much discussion about the need for many more primary care and specialty care physicians but this is only if we try to preserve the status quo and do not re-configure and systematize how health care is delivered, by whom and in what settings. For example, part of the re-configuration would be to develop rapid national consensus on how to manage the most costly chronic diseases -- diabetes, hypertension, depression -- publish the standards and be paid only for care that follows the standard.

However, there is currently a shortage of health-care services, and many of those services are not best offered by a physician, but by a nurse practitioner, a nurse, a nurse-midwife, a nutritionist, a pharmacist, a physician's assistant, a psychologist, a health coach, etc. These providers organized in teams would be far more productive and see far more patients than a single physician. Today, physicians are paid piecemeal for the number of patients and procedures they do. We need to move to a system where they are paid for their unique expertise and additional skill sets beyond those of other members of the team. If all health professionals were allowed to independently practice at their full level of competence and legal scope in a future cost-effective, team-based health-care delivery system, there may not even be a shortage of health-care providers. An important part of providing care at a reasonable cost is assuring that consumers have access to a wide range of health-care services delivered by the right licensed provider at the right time, for the right reason, in the right setting and for the right cost.

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Colleen Conway-Welch

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Change from Within