The Worst of All Possible Worlds     4/97

by Del Meyer, MD

We must indeed all hang together, or, most assuredly we shall all hang separately.
                                                          Ben Franklin, at the signing of the Declaration of 
                                                          Independence, July 4, 1776

As physicians we have spent many years after college in training programs learning how to manage the health care of our patients. Since 1966, we have been given considerable latitude and even encouragement to do that without regard to cost. If we even mentioned trying to conserve expense, we were criticized as either denying our patients the highest possible level of care or even trying to play God. The hospital’s favorite doctors were the ones who spent the most money on their patients. Peer review letters were sent to other doctors asking why they didn’t get an extra ECG or CXR or ECHO, or MUGA, or electrolytes or consults from specialists who in turn would spend even more money. Many of us came from training programs where we "worked up" a patient doing test after test, sparing no cost, until the patient got well and left by the front door; or exhausted our efforts and left by the side door in a white ambulance to a convalescent hospital; or succumbed to the rigors of diagnostic tests and treatments and left by the back door in a black "ambulance."

Third party payment, e.g. Medicare with Medigap, which doesn’t require personal financial involvement, brought many elderly patients back from the convalescent hospitals to the acute hospitals to have their bunions excised; (you can’t even see if the feet are straight in the casket) asymptomatic gall stones removed; renal failure reversed three times a week with artificial kidneys in octogenarians; hearts rejuvenated in nonagenarians when their resting cardiac output of 4.0 liters never went beyond 4.5 during maximal activity of eating or defecating.

Some in our ranks felt that what we did was so important that the public would be willing to spend even more on health care. When industry rebelled, the judgment was that we have failed in our job of providing cost effective management of health care. The insurance industry regrouped and developed the "For Profit-HMOs" to help us do our job in managing costs. Since they couldn’t understand how to manage health care, they learned how to deny payment. One family doctor told me last week his billing cost quadrupled during this time because everything got denied at least three times and usually on the fourth attempt he got paid. The FP-HMOs have not improved access because the number of uninsured increased from 37 to 42 million.

We all have wide variations in cost of care. It has been shown, even in government controlled medicine as in Canada, that the variation in how doctors manage the care of patients has a 400% to 1600% range. For some of us, a workup can cost a few hundred dollars and for another doctor the evaluation of the same problem will cost a few thousand dollars; and for still another doctor a few hundred thousand dollars. Medicine has become so sophisticated and technical that there is an endless array of tests that we can do to rule out nearly every conceivable possibility. But medicine is never 100% certain. Our clinical judgment has to tell us what is reasonable. Any physician that requires 100% certainty in everything really has no clinical judgment.

The trillion dollar health care budget in this country has triggered the onslaught against us to lower costs. Since it has not been easy to lower costs, let us first look at how easy it would be to increase it--even double it--under the guise of quality care. A good example is in the treatment of elevated cholesterol. In my training, a 300 level was considered normal. In the 1970s, that was reduced to 260. In the 1980s to 230, and in the 1990s to 200 or as low as possible. One aggressive physician suggested he could justify putting up to 100 million Americans on cholesterol reducing drugs. The average cost would be about $1000 per year for a projected USA expenditure of $100 billion dollars. The newer medications for hay fever, asthma, peptic disease, hypertension, arrhythmias, depression, anxiety, insomnia and a host of others all fall in this same range of costs. A few practice guidelines at $100 billion and before long we’ve added another $1 trillion without much difficulty. Would a $2 trillion dollar health care budget really result in a significant improvement in our country’s health? That is no longer the issue. Now it’s simply to reduce cost under the illusion of maintaining quality. I’ve even heard the delusion of "lowering cost" and "improving quality" simultaneously. So that their delusional thinking never gets identified, these planners project that three-fourths of psychiatrists are no longer needed in this new environment and should be crossed trained or retired.

Reducing costs is elusive. At the last managed care meeting of my MCO, the doctors couldn’t identify a way to lower cost without affecting quality and no one took the initiative in showing how this could be done effectively. The HMOs and the health industry have shown their ability to decrease costs but not in a patient sensitive manner--a very bad scenario for our patients. The government, through medicare and medicaid, have demonstrated their inability to manage health care. They have even tossed this albatross to the FP-HMOs. The FP-HMOs have taken the same amount of money the government would spend on medicare, to not only provide medicare services, but also vision care, dental care, pharmacy care plus another 25-30% for profits. FP-HMOs simply don’t pay for these new drugs. If medicare would have covered 80% of generic prescriptions like other outpatient services, these patients would not have converted to HMOs, and the costs would have been reasonable.

Dr Relman, editor emeritus of the New England Journal of Medicine who spoke in Sacramento a couple of years ago, said, if doctors decided to reduce costs, they could be the most effective force of all. If they don’t, some one else will--and did. By being cost effective, we could have continued as the captain of the health care team--in the best of all possible worlds--as the true professional guardian of patient’s health. Instead we are being forced to provide assembly line medicine--in the worst of all possible worlds--as hirelings. Our patients generally do better when we’re in control of their care and fare worse when someone else dictates their care.

Then again, the worst may be the best that we can achieve unless we start pulling together. We will never agree on everything but we had best get the dialogue in high gear. We can do that best through the CMA. We can probably come to a two-thirds consensus which is better than Congress or the legislature could hope to accomplish. But we should probably insist that CMA have at least a two-thirds support of members on every issue to avoid disenfranchising physicians. When the merger mania eventually causes the FP-HMO industry to collapse, all of us will be in the same boiling kettle. By then it may be too late. So lets get our colleagues who have strayed from our ranks back on the health care team and start pulling together. There really is no alternative.