Fragmentation and Healthcare Reform
Art by donna K mcgee
What does the term “fragmented” health care system mean?
The word is used frequently to describe what is wrong with health care in the United States.
It is what makes the maze of US health care so amazing.
The opposite of fragmented is organized.
A recent excellent story by Alix Spiegel on NPR’s All Things Considered explored practice patterns in the state of Maine and illustrated the subtle ways that fragmentation engenders unnecessary care that actually is harmful to patients.
It starts with fragmentation of the reimbursement system.
Most doctors are not paid a salary. They are business people who sell their time and their services. And the things they do to patients are classified into thousands of procedures, each one of them with a separate billing code.
This is not a difficult concept to grasp. Some people are paid a salary and are paid the same regardless of their productivity. Hopefully not over the long run, but that is a separate issue.
Others have their day broken into units called hours. The more hours they work, the more they get paid.
Doctors and hospitals have their days broken down into procedure codes. There is a whole industry around procedure codes. It allows the creation of the the fee for service reimbursement system and according to many it distorts incentives in the delivery of care.
For instance, it turns out that if you increase the number of doctors in an area, chances are that the use of medical services will rise. If there’s one doctor in a town with 100 patients, then he’ll schedule your heart checkups for once every six months, but if another doctor comes to town — and now the first doctor has 50 patients — the doctor will just schedule your heart checkups for once every three months. There’s a very simple reason why, says Frank Read, an eye specialist who participated in the doctor groups.
“I don’t want to be sitting on my thumbs all the time — I want to be busy. And that may unconsciously loosen my criteria for doing a procedure.”
This is not to suggest that heart checkups are harmful. Rather it illustrates one pressure for doctors to do more procedures. Ms. Spiegel described the groundbreaking work of Dr. Jack Wennberg who has spawned a new way of analyzing what doctors do. Again Ms. Spiegel:
His insight: It was doctors, not patients, who drove medical consumption, and all kinds of things influenced the decisions a doctor makes when a patient enters his office. Sickness and patient preference play an important role, but a much smaller role than patients and the health care community had originally thought….
And this, in miniature, is one of the big problems with the way that the current system is set up. It’s a problem some call “more is not better.”
Doctors exist in a fee-for-service system that encourages — and really because of the threat of malpractice and having to battle insurance companies — in some ways actually forces them to do more. More surgery. More tests. More of everything.
And while most Americans just assume that more care is good, it turns out that more isn’t always better for patients…
But study after study has borne out the truth of this completely anti-intuitive conclusion. In fact, Fisher and other researchers estimate that almost one-third of the care given in our country today is that kind of care — care that isn’t really helping people.
The United States spends more than $2 trillion on health care every year. So the cost of that 30 percent unnecessary care annually? $660 billion.
So how does do we organize a system differently?
Dr. Atul Gawande offered a glimpse of an alternative approach in his article in The New Yorker, The Cost Conundrum. He described observing two different specialists at the Mayo Clinic collaborating on the most effective treatment of a patient.
The whole interaction was astonishing to me. Just having the cardiologist pop down to see the patient with the surgeon would be unimaginable at my hospital. The time required wouldn’t pay. The time required just to organize the system wouldn’t pay.
The core tenet of the Mayo Clinic is “The needs of the patient come first”—not the convenience of the doctors, not their revenues… I asked Cortese how the Mayo Clinic made this possible.
“It’s not easy,” he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focused first on what was best for patients, and then on how to make this financially possible…
The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs.
“When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing,” Cortese told me.
Next up – fragmentation on the patient delivery side. Can we organize care delivery before we organize patient delivery?
The American Medical Cartel – Evil! Has, as documented by Dr. Oz on CNN, let Americans, even Jews, Young Jews, die, unattended, of curable diseases, in slums, cancerous lesions suffered to a painful death, without even benefit of morphine, dressings changes! Inhumane! Even Hitler offered those who lost his “Selection” process, a swift death in gas chambers! Not so for the current day American! He languors in slums, on park-benches, in rooming houses, dying, and not even the Simon Weisenthal organization protests this American Holocaust! Are dead old German Jews worth more in publicity in a doubtful, exaggerated, poorly documented, holocaust over sixty years ago, than current day young, American Jews! Are the “Corporately paid, guided, “Selection Committees” in air -conditioned offices, bribed with secure pay, any more humane than the Officer, on the docks at Auschwitz, who at least condemned some to certain quick death, a humane thing under the circumstances, not a penniless death as curable disease eats away their very life? So Sad, how blind we are when others suffer, so comfortable in our own security blankets, as the dollar falls, the system falters and threatens us all to the same fate, as the capitalists, corporatists tighten the criteria to satisfy accountancies profitability equations, as the stats show who costs too much, who is a good risk, and the “Selectors” apply their dictates, Millionaires turn to Billionaires, and paupers field grows daily – the American way!