Physician, heal thy system

President Obama's ambitious healthcare reforms begin with doctors themselves -- if they take the medicine.

Published March 18, 2009 10:19AM (EDT)

Between the American Investment and Recovery Act ("the stimulus bill") and his proposed budget, Barack Obama is betting the house on healthcare. The president is investing close to $800 billion in reforms geared toward providing Americans better access to higher quality care at a lower cost.

Who would disagree that reform is overdue? Annually, healthcare costs are rising 2.5 percent. That increase squeezes people out of affordable health insurance, even in good times. Currently, total healthcare spending accounts for 16 percent of GDP. If healthcare spending continues to rise at current rates, it will account for 20 percent of GDP by 2015 and 40 percent by 2040. By then it will seem that the sole business of the United States is health and medicine.

"The path to fiscal responsibility must run directly through healthcare," says Peter Orszag, who heads the White House Office of Management and Budget, and who, in the absence of a confirmed secretary of health and human services, has been president's point person for healthcare reform.

Many of the reforms involve finding the most cost-effective therapies and safest practices, with the intent that care can be standardized. If enacted, the reforms would bring real change, transforming healthcare from a fragmented cottage industry into an integrated system where patient care is consistent, safe and based on the best medical evidence. But amid all the talk about reform, what hasn't received a great deal of attention is that this new era of responsibility begins with us, the doctors themselves.

One smart move already under way is the shift to electronic medical records, a central information bank of medical information and patients' histories. Many EMRs build in "best practice" alerts to inform clinicians about which treatments are backed by sound evidence. They also have warnings that inform doctors about possible drug interactions when prescribing multiple drugs. Features like these can be reviewed, updated and changed as new medical evidence emerges.

EMRs also serve as a communication tool between doctor and patient. In my practice, we use an EMR that allows patients to e-mail us. Studies have shown a great deal of patient satisfaction and cost savings from e-mail communication, which can reduce unnecessary office visits, and allows doctors to spend more time with needy patients. This has certainly been true for my practice, where we have been using EMR since 2006.

Not all doctors are sold. Time columnist Dr. Scott Haig recently expressed his dismay with EMRs. "If the cheerleaders -- including the one in the Oval Office -- are right, computerized medical records will save us all," he wrote. He lamented how he was his forced to adopt an electronic medical record, at which point he was "confronted with the downside of uploading every medical judgment," and how an "[EMR] is a lot harder than writing out orders on paper, takes far more time, and in too many ways is just not as good."

He is right that EMRs, while a great leap forward, still have a way to go. Glitches can occur, duplicate work and confuse a healthcare team. But with proper training and diligent documentation by doctors and other healthcare providers, EMRs can help provide better care. In our EMR, we have a "Preventive Health Prompt," which alerts providers to what screening tests patients need. One day, a woman in our system visited her eye doctor. The doctor's medical assistant noticed that the patient was due for a mammogram. She persuaded the patient to let her book it, and when she had the test, her doctor discovered early stage breast cancer. She was treated early and cured.

Dissent like Dr. Haig's, and how the president confronts it, will have a lot to do with how reform fares. That's because doctors, by the tests we order, drugs we prescribe and surgeries we perform, are the biggest consumers of healthcare dollars. The problem, though, is that like a bad investor, we don't get much return on our money.

Take a look at the following map, the Dartmouth Atlas of Health Care, which shows the variation in Medicare spending per capita, in 2006, across the U.S. In this country, we spend an average of $8,000 per person on healthcare, more than any other place on earth. Now, if we were to overlay a map of the quality of care that patients receive over the map of per capita spending, we would see that those areas with the highest per capita spending perform most poorly. Pouring money into the healthcare system doesn't necessarily translate into effective treatment.

There are a lot of ways we've tried to explain away that inverse relationship, but according to the Dartmouth Medical School physicians, it has nothing to do with regional variations in health, access or the manner in which doctors are paid. Rather, says Dr. Elliot Fisher and his colleagues in a recent article in the New England Journal of Medicine, "the causes … lie in how physicians and others respond to the availability of technology, capital and other resources in the context of the fee-for-service payment system." Translation: If you build it, doctors will come, with their checkbooks. The Dartmouth team showed that doctors in high-spending regions were more likely than their counterparts in poorer areas to commit to spending more money on tests, referrals or admissions to intensive care units for not-so-intensive conditions.

The president is also pushing for more transparency, and again EMRs will help. In 2011, Medicare and Medicaid will begin providing annual funds of up to $65,000 per doctor and $11 million per hospital. The money will allow us to share data and report outcomes through EMRs, and create standards so that different hospitals can talk to one another, an important and eagerly anticipated move that will reduce redundancy in care that occurs when patients go from one doctor to the next.

Obama's plan has other features that will change the way we practice. One of the most relevant is comparative effectiveness research. Obama has committed $1.1 billion to head-to-head tests of drugs. The tests will be conducted by independent and nonprofit medical research institutes, and determine which drug is best and most cost-effective for a disease, despite what a pharmaceutical company claims.

Comparative effectiveness research has already paid dividends. A 2002 study published in the Journal of the American Medical Association compared three classes of heart disease drugs -- diuretics, ACE inhibitors and calcium-channel blockers -- commonly prescribed by doctors. As it turned out, the older, cheaper class of diuretics was superior to the more expensive ACE inhibitors and calcium channel blockers. With Obama's increased investment in comparative tests, hospitals, doctors and patients could reap huge savings at no expense to quality care.

Obama's plan also includes sticks along with carrots. He will be prodding hospitals to provide better care by reducing payments to them when patients are readmitted with complications from their original hospital stay.

Will doctors buy it? Are we ready to change? So far, Obama's plan has the support of our biggest lobbyist, the American Medical Association. But you know what they say about the devil and the details. When pressed on the News Hour about how doctors will have to change, Nancy Nielson, AMA's president, seemed to sidestep the issue. "This is, frankly, a shared responsibility," she said. "Every one of the stakeholders in all of this enterprise is going to have to be able to come to grips with, 'Let's look at how we can do things more efficiently.'"

At some point, the president and his healthcare team will have to stare doctors down. That's not going to be easy, as the AMA has a long history of winning political battles in Washington when it's concerned about its own.

But while there is a generation of doctors who resist the inevitability of what's to come, I can assure you that there's a new and forward-thinking class of physicians who understand and yearn for the reforms Obama is promising.

By Rahul K. Parikh

Rahul K. Parikh is a physician and writer in the San Francisco Bay Area. He wrote the Vital Signs column on Salon in 2008-2009. His pop culture-medical column, PopRx, runs on alternate Mondays.

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