Sowing the seeds of a better health care system

Tags: texas family physician, academy update, health care reform

By Tom Banning
TAFP Chief Executive Officer/Executive Vice President

Now that Democrats have lost their 60-vote supermajority in the Senate after suffering defeat in the Massachusetts special election to fill the vacant seat left by the death of Ted Kennedy, the fate of federal health system reform hangs by a thread. Will Democrats scale back the legislation and look for compromise, or is it back to square one? Whatever happens, one thing is certain: the problems plaguing the American health care system aren’t going away on their own, and they’ll likely get worse before they get better.

For a fresh take on the concept of health system reform as it’s been considered for the past year or so, read the most recent contribution by prominent physician and author Dr. Atul Gawande in the December issue of the New Yorker magazine. It draws historical parallels with early-20th-century federal efforts to reform America’s labor-intensive, fragmented, and unproductive agricultural economy.

The legislative reforms, which were ultimately and spectacularly successful, were in response to extreme inefficiencies in agricultural production which, at the time, were "strangling" U.S. economic growth and development. America’s agricultural crisis was a result not only of market inefficiencies, but an appalling ignorance about scientific farming methods and a lack of coordination that ultimately led to shortages of many crops, overproduction of others, high prices, limited choices, and uneven quality—pretty much everything that has been said about our health care delivery system.

While the reforms that revolutionized America’s agricultural industry dramatically improved production and efficiency, they also created some "painful dislocations" as the small, independent farmer was inevitably supplanted by large commercial operations. You don’t need a Ph.D. in history to draw an unsettling parallel with solo or small group practices or to see the trend lines—increased migration to employed settings, a median age that would already be contemplating retirement but for the free fall of their portfolios, the statistical impossibility of imposing quality measures on small practice environments, and mandated capital investments for adoption of expensive health information technology.

I can almost hear Willie Nelson warming up the band for a second act to Farm Aid to save the small physician practice.

The problems plaguing our health care system today, much like those that vexed the agricultural industry in the early 20th century did not occur overnight, they developed over the years and decades. Nothing about these problems is particularly revelatory. Fortune magazine sounded a familiar refrain in a notable op-ed in January 1970:

Much of U.S. medical care, particularly the everyday business of preventing and treating routine illnesses, is inferior in quality, wastefully dispensed, and inequitably financed. Medical manpower and facilities are so maldistributed that large segments of the population, especially in the urban poor and those in rural areas get virtually no care at all—even though their illnesses are most numerous and, in a medical sense, often easy to cure. Whether poor or not, most Americans are badly served by the obsolete, overstrained medical system that has grown up around them helter-skelter … . The time has come for radical change.

As history has proven time and again, no single act of Congress, no matter how well-intentioned, will solve all of the problems afflicting our health care system. Or as Dr. Gawande put it, "nobody has found a master switch that you can flip to make the problem go away." For the radical reforms that Fortune and other leading publications called for, the Nixon administration gave us HMOs. We all know how that worked out.

During this iteration of health care reform, the underlying Congressional philosophy has emphasized process over federal fiat. There has been an implicit recognition that the proposed reforms will take years if not a decade or more to implement, and the legislation appears to anticipate and expect trial and error, adjustment, and adaptation.

Perhaps the most important, if not the most abstract, legislative approach contemplates experimentation at the community level. In looking for the pony in what the critics have called everything but a pile of manure, Gawande argues that like their forbears who transformed farming from a cottage industry into an economic behemoth, medicine’s costly and dysfunctional systemic problems are better managed than resolved.

Gawande preaches the gospel of pilot projects, mini-experiments as an extension of best practices into the exam rooms and local hospitals where most care is delivered in relatively small volumes—one patient at a time. He counter-intuitively makes the case for the "hodgepodge" in both the Senate and House bills, rather than top-down federalized schemes.

We’re not necessarily plowing new ground here. About half the legislation isn’t a grand-design framework, but rather long rows of pilots that in many cases have already been field-tested, refined, and are ready to be planted. They include increased payment for primary care services, patient protections in the form of managed care market reforms, prevention and wellness initiatives, comparative effectiveness studies, medical home demonstrations, care management and chronic disease management pilots, and every kind of payment experiment from bundled payments to targeted incentives tied to outcomes.

While the legislation is far from perfect, and its future far from certain, there is broad, bipartisan acknowledgement that the restoration and expansion of primary care and specifically family medicine is integral to health system reform. Many if not most family physicians could be "shovel-ready" to participate and prosper in the various pilots, and with a little attention, we could see the pipeline of family medicine residents fill up as supply will inevitably race to catch up to demand.

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