The next step for reform

To reduce costs, doctors should be in charge of determining standards for health care

April 04, 2010|By James Burdick

The enthusiastic reception to President Obama as he has toured the country to publicize the health care reform bill is richly deserved. This historic law will help many Americans. In addition, even with the ink barely dry, he has already extended the vision. In a speech touting the bill in Iowa, President Obama promised care for everyone, which this law does not achieve. He talked of reining in the insurance companies, who will still continue to successfully wriggle out of restraints in this law. He committed to even more resounding reform for all Americans.

But the president will need some help in fulfilling these promises.

As a doctor, I am convinced that the country can have cost control and a doctor for every family. But we cannot do it with the present health insurance model. Even with "Obamacare," insurance companies and the fear of malpractice remain in control, regardless of what reforms are being touted. We need a professional process to define appropriate care that can move the decisions patients and doctors make out of insurance interference and into clinical reality. We have a proven example. Organ transplantation, my specialty, has a board of doctors and others that makes national policy for transplant hospitals and doctors. It is a public-private partnership, independent but mandated and overseen by the federal government. This model could apply to American health care more broadly.

Imagine American doctors being put back in charge of defining standards for health care and establishing incentives to observe these practices nationally. That would allow the country to achieve the cost-cutting reform that Americans want, based on professional expertise, not insurance company profits or a "government takeover."

Quality would be improved for everyone, since doctors are now hard-pressed to keep up with the profusion of standards from various sources. Professionalism notwithstanding, in arguable cases it is in the doctor's narrow self interest to go ahead and do an invasive heart study if the patient wants it -- and their insurance will pay. Best practices need to be provided in a manageable, authoritative way. For example, Dr. Robert Brook, professor of medicine and health policy at UCLA, has called for national implementation of the Rand UCLA Appropriateness Method, a proven professional guide for care decisions.

Care based on clinical criteria would control expensive, dangerous overuse. It could free the Congress to establish regulated insurance or single-payer funding, which would control costs by removing insurance profits and expensive administration. With part of the savings -- about $500 billion a year -- we could extend care to every American. There would be no premiums to pay, no jitters about employer health insurance contributions or insurance that doesn't pay when you get sick, and taxes would not have to go up. People could continue with the doctors they have now. Putting doctors in charge of national practice would solve the complex health care puzzle posed by a need to control costs, ensure quality and provide for everyone.

For the national program, Congress could create a board made up of physicians, plus other professional and public representatives. Many such federal public-private partnerships exist. The law creating this new board would have built-in federal oversight but would establish the board as a semi-independent entity, responsible for establishing and overseeing best practices for essential care because clinical decisions need professional authority. Cases when doctors do not follow the guidelines would be reviewed by the board. But with doctors making the rules and deciding on the validity of deviations, and federal oversight ensuring transparency and accountability, best interests of all would be served.

Board decisions would become national standards unless the government intervened in some instance. By law, the board's work would be transparent and therefore protected from medically irrelevant influence. An electronic health records system would provide accurate data for easily monitoring national practices without a vast bureaucracy. Uniform clinical practices would help control lawsuits. Within a year or two we could have national guidelines for the most common and expensive conditions. Standards would be based on data plus clinical expertise and would allow decisions for each individual patient's care. Private insurance for supplemental care could co-exist. This is how we can go beyond even the public option, minimize costs and have quality care for everyone. This is the help President Obama needs to fulfill his promises.

Doctors excel at taking responsibility for each patient. It is time for doctors to join together to take responsibility for care of all Americans.

Dr. James Burdick is professor of surgery at Johns Hopkins University School of Medicine. He had a career as a transplant surgeon and served in the Department of Health and Human Services as director of the division of transplantation, and is writing a book detailing his doctors' plan for health care reform.

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