Responsibilities of the Patient, the Doctor and the System/Skin in the game

Over the last many weeks we have discussed a number of pros and cons regarding the Affordable Care Act (ACA). Whether we want to argue the nature of free health care for all and the constitution, the fact is that health care for all is a great concept. Yes, our health care system is broken or sick and that it is considered to be the most costly with an extremely poor return on investment. Why?

The answer is simply yet complex. Our rights, our freedom, and desire to make money, allow us to make bad decisions and with no cost consequences. We demand expensive CT scans or MRI’s when we get headaches at no cost to each of us and “forcing” the health care worker and the health care system to provide these expensive tests to cover “their behinds” so that they won’t get sued or to reduce their liability.

Traditional medicine and our freedoms are making us sick. We as a notion lack self control and the results are that chronic diseases such as heart disease, stroke, cancer, diabetes, and arthritis are among the most common and preventable of all of the problems on the US.

I site the Mark Twain quote: “The only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you druther not” That is, the four modifiable health risk behaviors that we just fail to improve are the lack of exercise or physical activity, poor nutrition, tobacco use and excess alcohol consumption. As Ron Graham further discusses in the Healthcare blog, these health risk behaviors are responsible for much of the high health care cost, illness, suffering and early death related to the chronic diseases that we discussed. Consider that the latest reported obesity rates is the US is 27.7%. Unbelievable!

How then can we improve the health care system if we “give” insurance coverage without consequence for bad behavior?

Also, we should think about the behavior of the health care worker.

Their behavior also has to change. But how do they do that if they are always worried about malpractice. The future of the health care system under the Affordable Care Act will depend on quality and quantity will not be paid and possibly be penalized. So, we need to make sure that physicians, nurse practitioners, physician assistants and others deliver the best health care efficiently and cost effectively without fear of lawsuits.

How will that be possible? Working on a book over the last 4 months on clinical process improvement, my co-author, Dr. Paul Gurny, and I realize the need for improving the clinical process through analysis, using strategic tools, benchmarking so that clinical protocols and critical pathways/ standards of care are established. Then as long as the care givers utilize these pathways/ protocols they are somewhat protected and the delivery systems are utilized to promote the best care for the patient, again, effectively, efficiently, cost effectively and resulting in the least number of errors and complications. Health care is in constant flux, but not all of the latest “improvements” are effective and some are so costly with minimal impact to good care to the most important factor in the equation, the patient.

How else do we promote great care and protect the health care worker, specifically the physician, who has the highest malpractice premium. Remember, this malpractice premium has to be paid before the physician can see even one patient or operate on any patient. Many physicians withdrew their memberships from the American Medical Association (AMA), because as physicians they were counting on the AMA to push for a number of important aspects of a new health care program including tort reform (malpractice reform), cost effective education for physicians and protection from continual discounting of their services. Consider the cost of the education of a physician. The average debt incurred by a physician in their education averages to about $325,000. Now consider that the payment for the services for the physician has been discounted continuously over the last 20+ years. Also, the new members if the insured under the ACA, were enrolled in the Medicaid system, a system that reimburses the physician at around 10 cents on the dollar. How then do they pay back their loans? How then do they pay their malpractice insurance premiums or the overhead of the offices including the new demands of an electronic medical record system (EMR), which on average costs the practice $30,000 per physician per practice? With the health care system if you don’t have an acceptable EMR the system will penalize the practice a minimum of 1% of each reimbursement.

The cost of medical education is out of site and we need to look at improving the system mirroring the European education system, which is supported partially or completely by the government. Also, the foreign education of the physician is often reduced from 8 years to 6 years. This alone makes the education of the physician more cost effective.

Tort reform, although not enacted has seen a crack in the malpractice legal armor. A number of states, currently 12, are in the process of working through “apology inadmissibility bills” where the physicians’ expressions of apology, sympathy or responsibility inadmissible in medical liability cases.

Idaho and five more states either have passed or are introducing standard of care protection acts, where the physicians will be protected from exposure to new causes of action based on whether the physician complied with quality and delivery improvement initiatives (remember Dr. Gurny and my book, clinical process improvement) outlined by the ACA.

These new laws as well as the proposed bills introduced in Congress would ensure physicians to excise their clinical judgment without the potential for medical liability claims based on quality reporting programs, performance metrics imposed by the ACA as well as those developed by strategic planning and process improvement.

In summary the ACA has a tremendous potential if modified to include improvement in a number of parts of the health care deliver equation. If patients don’t

Patients need to be involved with their care and need to see both benefits for good behavior as well as penalties for bad behavior to improve their health. The patients that ignore their health care providers and remain obese, continue smoking and eat without care letting their diabetes continue out of control need to pay more into the system. The healthy that “do the right things” to remain healthy, exercising, eating responsibly and never smoking or if they do smoking, involving in cessation programs, need to receive benefits with lower premiums, etc.

Doctors and other health care providers need to modify their behavior also to deliver cost effect quality care or suffer penalties for their bad behavior as well as bonuses for good behavior.

I believe the Republican Party has seen the light in trying to get the law thrown out and now sees the frailty in this strategy. Since it is law we all need to look to the future and make the future health care system effective and sustainable, delivering excellent care to all. Look to the Veterans Administration health care system to realize what can go wrong and build a better program.

Voters educate your selves and vote smartly, ignoring the media hype and lies! We are all part of the problem and all part of and responsible for our future.

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