Dr. David Gratzer is a psychiatrist who has worked both in Canada and in the United States.  His first book, Code Blue: Reviving Canada’s Health Care System, was an award-winning prescription for the long waits and poor satisfaction currently plaguing Canadian patients.  In his current book, The Cure: How Capitalism Can Save American Health Care, Dr. Gratzer turns his attention to the troubles of the healthcare system on our side of the border.

Dr. Gratzer is certainly no apologist for American medicine.  He is quite frank about the problems we face, from skyrocketing costs, to the number of uninsured, to the increasing regulation of medical practice.  But Dr. Gratzer also trumpets the enormous achievements of American healthcare.  As he documents, nowhere in the world is one more likely to survive breast cancer, less likely to wait a long time for elective surgery, or more likely to spend more than 20 minutes with one’s doctor.

Ironically, faced with our current challenges American politicians increasingly look to Canada and to Europe for inspiration, even as Canadian and European governments are struggling with the consequences of their government-run healthcare systems.  Dr. Gratzer highlights the serious challenges in these countries, and how they are trying to inject competition and incentives into their healthcare models.

The Cure is a well researched and very readable analysis of what’s wrong with our healthcare system, and how to fix it.  Our nation tends to reject political extremes and is suspicious of revolutionary change.  The government-sponsored healthcare reform proposed by President Clinton’s administration met with widespread resistance.  On the other extreme, the Nobel Prize winning economist Milton Friedman in 2001 proposed a free-market reform of healthcare that would have eliminated government’s role in medicine.  Friedman’s plan would be politically impossible in the current climate.  Compared to these two extremes, Dr. Gratzer’s prescriptions are quite moderate, and therefore potentially achievable.  His proposals include adding competition to Medicare, reforming the FDA, and allowing patients to buy health insurance from other states.

For anyone interested in healthcare from a national point of view, The Cure is mandatory reading.

Tangential Miscellany:

I wish you a very happy Independence Day!

Yesterday’s Wall Street Journal opinion page (A17) had a column by Dr. Peter Bach entitled “How Many Doctors Does it Take to Treat a Patient?”.  Dr. Bach recently published a study of Medicare patients in the New England Journal of Medicine looking at how many physicians Medicare patients see.  The results painted a picture of fragmented, expensive and low-quality care.  The average Medicare patient sees seven different doctors in one year, including five different specialists.  These aren’t the sickest patients; these are the average.  Forty percent of patients have seven or more chronic conduction and see on average 11 different physicians.  Does all this care translate to high quality?  Sadly, no.  Fewer than 30% of people with high blood pressure in another national study had it adequately controlled.  Medicare expenditures, ironically, have never been higher, and may reach $500 billion in 2008 in physician services alone.  At the same time, reimbursement to physicians for each service has been flat for several years.

What accounts for a system that is increasingly unaffordable, but at the same time makes physicians feel under-valued?  How do we explain a system that has provided for exploding utilization of services while quality has not reached expectations?  Dr. Bach opines that the problem is the fee-for-service structure of Medicare.  He argues that since Medicare pays per service provided it is subsidizing quantity, not quality.  Patients are therefore shepherded to as many doctors as possible who deliver as many services as possible, with no incentive to coordinate, unify or improve care.

His prescription:  don’t tinker with the system by adding pay-for-performance, the latest policy buzz phrase.  He suggests overhauling the payment structure entirely.  I agree, though I would add that third-party payment for routine care is another fundamental flaw in the system.  When patients don’t pay for their own care prices skyrocket, healthcare is rationed, and quality suffers.  My post next week will review a new book that carries this idea further.

Thanks to my friend Justin K. for pointing me to the story.

This week’s New England Journal of Medicine publishes a health policy report about electronic health records (EHRs).  The article reviews the potential benefits of EHRs to patients and to physicians and laments that as of 2005 only about 23% of physicians used them.

The reasons for the slow adoption of EHRs provide an instructive illustration of deep problems in our healthcare marketplace.  EHRs are expensive, but they hold the promise of allowing better patient care, fewer medical errors, and eventual cost savings.  In the delivery of any other good or service a new technology that offers these benefits is adopted quickly and becomes ubiquitous.  That’s why pay phones and LP records have nearly vanished; they were replaced by cell phones and CDs.  Why then the stubborn persistence of paper charts?  The reason is the dysfunctional way in which most healthcare is bought.  The cost of the vast majority of care is paid not by patients, but by third parties, either private insurance companies or government entities.  These payers also set the price that can be charged for services.  Unfortunately, this applies not just for major unforeseen expenses, like catastrophic illnesses or hospitalizations, but also for routine and preventive care.  The effect is that there is no financial incentive for most physicians to increase the quality of the care they deliver, just the quantity.  If the price for the service is fixed, doctors can’t make more by taking better care of each patient; they can only make more by seeing more patients.  So why would doctors invest the time and the capital in an EHR that provides better care?  Any cost savings resulting from better health would benefit the insurance company, not the doctors.  Paper charts after all, are worse for patients, but don’t slow the doctor down.

It’s only when patients pay for their own care that the competition and balance present in all other marketplaces returns to healthcare.  When patients and physicians set the price, patients have a strong incentive to ensure that the care they pay for is excellent, and physicians have a strong incentive to invest in whatever technology will deliver quality care.  That’s why our office had an EHR from the day we opened in 2003.  While national physician groups were lobbying for government or insurance subsidies for EHR purchases, my partner and I simply bought one, confident that what was best for our patients would eventually be best for our practice.

It’s you, our patients, who make possible our EHR and our dedication to old-fashioned attentiveness powered by twenty-first century technology.  Thank you.

Tangential Miscellany:

A happy Father’s Day to all us dads!

“I think I have bronchitis.  I probably need some antibiotics.”

All primary care doctors hear that phrase very frequently.  A patient develops a productive cough that lasts for several days, malaise, and slightly elevated temperature.  Then the patient sees her physician with a clear and predetermined expectation of the correct treatment – antibiotics.  Knowing that antibiotics are not indicated for acute bronchitis, the physician is then forced to balance practicing appropriate evidence-based medicine with satisfying the patient’s expectations.  To some extent, this dilemma of physicians is self-inflicted.  A generation ago, antibiotics were routinely prescribed for acute bronchitis, and an entire group of patients have therefore grown up misinformed by previous physician practice.  The myth that green phlegm necessitates antibiotics also became well-entrenched at that time, leading patients to think that they are being prudent by only demanding antibiotics when their phlegm becomes colored.

Many unseen problems arise when patient expectations deviate from good medical practice.  Unnecessary antibiotic use leads to increasing bacterial resistance, which is now a serious global problem.  Antibiotics can also sometimes cause serious side effects.  But perhaps the most subtle problem is that taking unnecessary antibiotics strengthens the patient’s perception that this is the correct treatment.  The patient would have recovered at the same time regardless of whether any medication was prescribed, but when recovery follows an antibiotic course, the belief that one caused the other becomes unshakable.

I’m certainly not advocating a return to the bad-old-days when physician authority and paternalism ruled supreme and patient preferences were disregarded.  I’m just suggesting that the best care is delivered when the doctor listens carefully and the patient has an open mind.

To that end, here’s a wonderful (and short) review of acute bronchitis written for patients.

Tangential Miscellany:

Two bad trends in our society, our increasing litigiousness and our increasing faith in the potency of vitamins, collide to produce this ridiculous story.

Sciatica is the common term for lower back pain that radiates down one leg.  It is a very frequent cause of missed work and disability.  Sciatica is almost always caused by a lumbar disk that has been pushed out of its normal location and is impinging on a nerve.

The typical treatment for sciatica is anti-inflammatory pain medication and physical therapy.  Most patients recover entirely with this conservative therapy.  For those who continue to have pain, injections to numb the effected nerve frequently provide at least temporary relief.  Surgery is usually only considered as a last resort, when the other treatments have failed.

A new study in this week’s New England Journal of Medicine may change the order in which these interventions are considered.  The trial enrolled people who had severe, disabling sciatica for 6 to 12 weeks, and randomized them to immediate surgery (within two weeks of randomization) or to conservative treatment.

The good news is that a year later, both groups did very well, with little disability and good pain control.  So in the long term, either solution is very good.  Interestingly, in the early surgery group about 10% of patients recovered before surgery could be performed, again highlighting the good prognosis of this disease.  In the group assigned to conservative treatment over a third eventually required surgery anyway because of unremitting pain.

The important difference between the two groups was that the group assigned to early surgery achieved pain relief much sooner than the group assigned to conservative treatment.  While both groups eventually did fine a year after randomization, the surgical group had more prompt relief of symptoms.

So in patients with severe symptoms from sciatica, we should at least start considering surgery sooner, and patients should be reassured that either treatment path eventually yields good results.