Opinion - Whatcom View

POSTED: Thursday, Nov. 26, 2009

Local retired doctor offers health care reform ideas

As a retired physician and a patient with significant disease recently requiring extensive work up and hospitalization, I realize our health care system is broken. Most physicians would agree we can reduce costs of medical care without sacrificing quality, with seven primary steps, as follows:

- Tort reform: I was on a committee that helped write the bill for medical tort reform in Alaska. The committee included doctors, lawyers, and other citizens who gave preliminary ruling on potential medical malpractice suits. Legitimate cases proceeded, but the committee advised against those that did not have firm evidence of malpractice. Patients had the option of proceeding with either ruling, but none did if the committee ruled the suit was not justified. Consequently, in Alaska, malpractice premiums plummeted. For example, obstetrician's premiums dropped from over $100,000 per year to under $10,000. This saving is miniscule compared to the savings that would result if doctors ceased ordering medically unnecessary tests just to protect themselves in case of a lawsuit.

- Physician-Run Critical Committees: The restraint of trade ruling in the Supreme Court in the 1970s has essentially eliminated the supervision of physicians by other physicians but it "threw the baby out with the bath water," and assumed malpractice suits could control quality. Because of the complexity of medical care decisions, physicians are more effective in controlling bad physicians than members of a typical jury. Formerly, hospital physician committees reviewed all physicians with significant critical care complications. Each specialty had its own critical care committee and any physician with a significant increase of complications immediately had his privileges removed until it could be demonstrated he was qualified to safely proceed with the questioned procedure. This usually required further certified training and supervision by the physician staff until patient safety was assured.

- Mandatory co-payment for all medical care, except in extreme emergencies. I observed in my private practice, and in the work I did for government medical care that abuse is rampant when care is entirely free. Even small co-pays cut doctor visits almost in half. This can be quickly verified through a study Medicaid or the Alaska Native Health Care System.

- Empowerment of medical personnel who are not physicians and removal of unnecessary direct supervision. Allow nurses, lab techs, physician assistants, nurse anesthetists, etc. to do procedures and evaluations for which they are qualified. Currently many professionals are forbidden to provide services for which they are well trained, without direct MD supervision, for fear of litigation. An example is nurse anesthetists. Most surgeons would agree they are at least as safe as MD anesthesiologists on routine cases, but they are only allowed to practice under MD supervision, at the prevailing MD's fee. This would save approximately 50 percent without any reduction of quality of care.

- Committee review of treatment options: Patients suffering from diseases with many treatment options should be evaluated by a high level (usually a medical university) committee to determine the appropriate treatment options, without fear of litigation. Currently many conditions are treated in overly aggressive, expensive ways. Prostate cancer is an excellent example; surgical removal stands up best in court even when it is not medically indicated, based on best current medical evidence. Costs of over treatment are considerable, and in most instances less treatment is actually safer for the patient.

- Payment of physicians by salary rather than fee for service: Studies have shown costs at the Mayo Clinic, where physicians are salaried, are about 30 percent less than other major medical centers, and the payment plan is likely the major factor.

- Payment restrictions: Only medical care that has been scientifically demonstrated to be effective by double blind studies should be covered by insurance. Many treatment options, popular with patients, have never been shown to be clinically effective, and they represent a vast abuse of health care dollars.

These seven measures would result in huge savings without sacrificing the quality of care. In many cases, care would be improved. But the first step must be tort reform; without it, key people involved in the other steps would be too fearful to proceed.

Bruce Wolf is a retired doctor who lives in Blaine.