Getting the Doctors to be the Doctors

Physician readers of this blog probably saw the two-page “viewpoint” piece by Dr. Ezekiel Emanuel in the January 4, 2012 edition of JAMA, under the title, “Where Are the Health Care Cost Savings?” The upshot: “First, physicians must be the leaders and must stop looking to drug companies, insurers, or someone else to initiate and achieve cost savings.” (When I read “someone else,” I think, “government.”) I think there is a lot to this—it’s not just an example of asking physicians to answer to society rather than care for patients, a charge with which Dr. Emanuel is undoubtedly familiar. Consider his reasoning:
• Slowing the growth of health costs means “going where the money is” by identifying approaches that can cut costs by at least $26 billion a year, or 1% of current expenditures.
• That implies improving care of people with chronic conditions like coronary artery disease, diabetes, congestive heart failure, and others. About 10% of the population currently requires about 64% of the costs, and most of the 10% are people with a few chronic conditions like coronary artery disease, diabetes, and the like. These patients would be better served, at lower cost, by concerted efforts to reduce avoidable complications, improve patient monitoring, increase medication compliance, use specialists more efficiently (read: selectively), and use technology and currently-less-reimbursed activities (home visits, lifestyle and transportation services) to achieve these.
• Many popular suggestions for reducing cost would have a low “bang for the buck:”
o Malpractice reform might save $11 billion, or 0.5%, per year;
o Reducing insurance company profits means cutting into an amount that, in 2010, totaled $11.7 billion for the 5 largest insurers;
o Drug reimportation might save $2.6 billion;
o Replacing all brand name drugs with generics would save Medicare Part D less than $1 billion;
o Rationing end-of-life care is similarly misguided—in 2010, only 255 patients nationwide had care costing over $1 million each, and while those with bills over $250,000 add up to 6.5% of health costs, they cannot be identified in advance, so planning good but cheaper care for them prospectively is impossible. Besides that, people would “raise the charge of ‘death panels’”—something else he’s heard before. (Insert the emoticon of your choice here.)
Physician leadership principally means, for Dr. Emanuel, that they must work together to redesign care delivery for chronic illness—a challenge, but “only effective physician leadership can ensure successful redesign.” It also means, however, that physicians should not just accept that they will have to be paid differently (bundled payments rather than fee-for-service), they should take the lead in proposing how that deal would look.
I know, I know—Dr. Emanuel is famously a proponent of the “IPAB,” and the notion that doctors will magically see their way to enlightened new ways to pay them is pretty facile. But I cite this piece to suggest that the core point—the doctors have to be the doctors—is the critical one. It is for the doctors to tell the rest of us—not for us to tell them—how they can best care for us, collectively as well as individually, and to identify and implement best practices for that. It seems to me that, whether the challenge is avoiding unnecessary complications or critically asking whether that expensive, marginally effective new cancer drug is really good for a patient, that we should encourage the medical profession to be out in front here. The challenges are immense, and not new, but can’t strong societal leadership by doctors, in the name of caring for their patients better, be part of a vigorous revived Hippocratism?