Wednesday, December 5, 2007

No Common Voice in Health Care

Being an advocate in health care is critically important in order to impact the three most vocal voices of change with regard to health care policy and positioning. These three voices are: government, business and patients and their families. If these groups are to effectively improve both quality and service in the health care sector, we must ensure that they have clear and accurate information to redesign the health care delivery system appropriately.

Reaching a consensus on this issue, however, is getting increasingly difficult, because there is no common voice in health care today. It would be wonderful if one person or a small group of people could stand before our federal and state lawmakers and say, “This is what patients want and this is the reason why,” or “This is what physicians want and this is the reason why.” However, getting this consensus is almost impossible today. Younger physicians think differently than older physicians. Highly-paid specialists are thinking very differently than lower-paid primary care providers. And women physicians, understandably, as a group, often think differently than their male counterparts. Because of this difference, we have seen a declining membership of physicians in the American Medical Association (AMA), which in part is caused by the fact that some physicians believe an association cannot represent the myriad voices that are being expressed. This issue also permeates the common voice for the continuum of health care.

It would be ideal if hospitals, physicians and nurses could stand as a strong, cohesive component of the delivery system and say in unison, “This is what we are thinking, and this is what we want to happen.” However, as health care has gotten increasingly complex, as capital needs have risen with the introduction of more and more technology and as federal funding has decreased (only exaggerated more recently by the extreme amount of expenditure required by the Iraq war), the polarity between these groups has been increased. Obviously, this is because if the federal government is to give more money to physicians, they must take it away from hospitals, and vice-versa. Hence, when we come to the table to advocate for increased funding, the solution is often one that enhances polarity and therefore further decreases our chances of finding a common voice.

For example, before CMS instituted its current reimbursement system based on DRGs, we were cost reimbursed, so hospitals earned money by keeping patients in the hospital longer as the result of a daily fee, and physicians made more money because they were paid a daily visitation fee. In the current DRG system, however, hospitals are rewarded for getting patients out of the hospital quicker, and physicians have lost a revenue stream. Therefore, giving one group more money necessitates taking it away from another group and has heightened this polarity.

This challenge also permeates the clinical arena, and is obvious particularly in such areas as end-of-life issues and the treatment of people with life-threatening or potentially terminal diseases. Although most people when not directly involved with a serious illness would indicate that quality of life is much more important than quantity of life, when they are in the midst of a personal experience with a terminal illness that involves themselves or their families, they often develop the reverse position and many times opt for treatments and procedures which are expensive and in fact useless.

Getting consensus around treatment protocols and care management--although improving--is still challenging.

So in the end, while consensus is challenging in many arenas and advocacy remains very important, advocating for the appropriate care for the poor will be essential when the redesign of health care becomes a reality. Hopefully this will occur with the election of a new president, but regardless, we all must realize that coming to the table with a strong consensus from all of the three voices will probably be impossible.

So what’s my answer?

It goes back to a very simple position that I believe I have expressed in the past: we must choose people to represent and participate in redesigning the health care delivery system who are analytical, open to listening, can interpret and understand the data, can have their minds changed by persuasive discussions and will always keep what is best for the patients and their families as their ultimate priority.

At this point, we cannot depend on a consensus regarding health care reform to be our guide. If we wait to hear the common voice regarding health care change before we create the direction for tomorrow, I am fearful that we will have waited too long.

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