The insurance industry has removed the joy from health care delivery with authorizations, documentation, guidelines for evaluation and treatment, diminished reimbursement, reimbursement delays, and denied payments. Physicians are now paid for what they write on the chart, not for what they do for the patient. Failure to document may mean fines or criminal charges. The legal system has rendered the medical record an abomination by requiring every piece of paper to be saved. We, as physicians, have lost control of our profession.
Patients are demanding quality health care. Health care practitioners need stability. If we allow the situation to go on, our government is sure to increase industry regulations. This may mean legislation expanding the scope of practice for allied health care providers, thereby circumventing physicians and undermining our control. If we do not want to become regulated government employees, we should initiate a major overhaul of health care delivery.
Physicians must band together to recommend an improved health care paradigm. Medicine is a unique profession. Supply, demand, and competition run counterproductive to cost-effective quality health care. Individuals, groups, and medical organizations must stop lobbying for their own special interests, and present a single voice.
STEPS TOWARD A NEW PARADIGM
The first step is to create a single body that will develop and implement the new paradigm. The American Medical Association, which receives input from physicians, state medical societies, and national academies, could serve as this organizing body. Once established, this organization would communicate with federal and state governments. To be successful, it must address seven key issues.
Cost containment
The government, the business communities, and the people cannot afford the escalating health care costs, particularly as there is no direct relationship between the amount that a country spends on health and the quality of health care provision. Many countries in the world achieve better health care outcomes at much lower cost than we do in the United States.
The toughest cost-containment issue is the rationing of health care. American medicine is the most innovative and advanced medical system in the world; yet, it is no longer possible to deliver the highest quality medical care to everyone. Were we to provide the highest level of medical care to everyone in the United States, we would easily consume in excess of 20% to 30% of the gross national product. Expensive medical treatments, particularly those with undocumented efficacy, are not justified for everyone. For example, we should not pay for expensive chemotherapy in the terminal stages of a malignant illness when its benefit is unproven. We need to establish a system that allows physicians to provide input to legislators who will make the tough decisions needed about a reasonable rationing system.
The excess of physicians
I believe that there are too many physicians in the United States. Physicians are incredibly clever, and if there is insufficient serious disease, they will find new diseases and new treatments. We must develop models and mechanisms to train and maintain the appropriate number of physicians.
Rational interventions
We use too many new therapies, drugs, and procedures of uncertain efficacy. Expensive antibiotics are often prescribed when less expense antibiotics are equally effective. Myriad new procedures are performed long before their clinical efficacy and appropriate indications are determined.
The medical profession must incorporate best practice philosophies. There are many excellent clinical pathways to treat common maladies such as diabetes, hypertension, and asthma. All too often we jump to the new and expensive medications and technologies long before trying these standard and less expensive treatments.
We should consider developing a Federal Medical Administration (FMA). Just as the Food and Drug Administration evaluates and approves the safety of medications, the FMA will be funded, perhaps by an arm of the National Institutes of Health, to oversee the evaluation and approval of new treatments and procedures.
The uneven distribution of physicians
We have too many physicians in coastal, urban locations and too few physicians in rural locations. We should establish a program that will redistribute access to doctors according to need. One option is that to maintain their licensure, all physicians would be required to provide 10% of their time to those without health care. Alternatively, the federal government could support all medical education. In return, all graduating medical students would spend 2 to 4 years working in underserved areas.
The uninsured
We have 44 million uninsured people. Improving access to health care is the most difficult problem we have to solve. Employers must provide all full-time, part-time, and temporary employees with insurance. Employers of migrant workers, including illegal immigrants, should not be exempt.
The involvement of our medical schools
Our medical schools should be strong players in the health care system so that future physicians will be capable of providing meaningful health care. To strengthen our educational sector, we need to downsize the medical school. Medical students must receive their basic sciences within the walls of the medical school, but they can receive excellent clinical training in the community.
If the FMA were developed, the organization could contract with medical schools to evaluate new medications and procedures. In addition, because medical schools are established to conduct medical training, they should be the primary continuing medical education providers. In return for providing these services, our medical schools would receive the financial support that they need from the government, sponsor of medical research, and postgraduate medical education.
Preventive medicine
Physicians seem to be increasingly focused on treatment instead of prevention. It is alleged that half of the asthmatics in the world own pets and very few practice environmental control. Children remain inadequately vaccinated. Obesity and unhealthy lifestyles are increasingly common. A portion of the health care dollar needs to be set aside for prevention. A special group should be developed to provide preventive health care. Every medical group, company, or health plan—and ultimately every person—should be assigned to a preventive health care unit. This unit, with input from the patient's personal physician, could develop preventive health care programs promoting lifestyle changes and good individual health care practices.
It is time for positive change. Health care professionals must band together and direct this change for the benefit of all. If we do not, we will lose all the power and privilege of making decisions that can shape health care.
Competing interests: None declared