Medical Professionals Must Lead: This is Your Revolution–Atul Gawande

Writing on the New Yorker’s “News Desk” today, Boston surgeon Atul Gawande laid out the challenge that health care reform poses for hospital administrators, physicians, nurses and every other professional in our health care system. (By professionals, I mean people who realize that they must put the interests of a sick person ahead of their own interests. I have met pharmacists, lab workers, home health care workers and many others who take this responsibility seriously. In many cases, this is why they chose the job.)

Gawande writes: “What made the passage of health reform historic is that, after almost a century of effort to reverse this, hope has arrived.

“We as a nation—and in particular those of us in medicine—now have work to do to defend and deliver on this promise and to address the legitimate concerns about costs while making health care better for everyone. But that is the remarkable thing. We have finally been given the work to do.”

Yes, this legislation gives medical professionals an opportunity to take the power back from the for-profit corporations that now, to a very large degree, run health care in this country. Today, even nonprofit insurers and hospitals are affected by for-profits. They must compete with them, and thus, in many cases, they have begun to imitate them.

But health care professionals can help only if they understand that reform is all about rewarding  patient-centered, evidence-based medicine. Medicine should not be profit-driven. Those who think of medicine as a “business,” like any other, will be out of luck.

9 thoughts on “Medical Professionals Must Lead: This is Your Revolution–Atul Gawande

  1. You wrote that non-profit insurers and hospitals must compete with the for-profits, and in many cases, must imitate them.
    One primary reason for having the not-for-profit advantage is that non-profits are offering distinctive products and services from the for-profits.
    If they must imitate to comn\pete, their not-for-profit advantage should be revoked.
    This is due to their not offering distinctive products and services, for not competing on a different level.
    For example, offering the type of care that Maggie writes about that does provide value over and above the actual cost.
    We have to get to that level of care.
    If the public is not willing to frequent hospitals and physicians which are providing this type of care, and they are putting their patients interests before their own, they should maintain their not -for profit status and go out of business.
    Whosoever will lose his life, will gain it.
    What profiteth a man to gain the whole world and lose his soul?
    Don Levit

  2. Majority of doctors are in small groups, private practice, they tend to look out for their take home $$ which is what can be expected. If they start focusing on the most efficient care, shy away from unwanted referrals, make phone calls to follow up on patients etc will mean less income and more work. There is no way this would happen unless the system changes dramatically and values time and cut back on compensating procedures heavily. The only way to make this happen is when primary care feels value. The minor changes that are in the bill addressing this is like a drop in the bucket and doctors will claim that they over test because there is no tort reform.

  3. Ray:
    You seem to be describing what is the common variable under any health care system – self interest.
    You cannot expunge self interest from any participant – be they provider or provided.
    This is why any solution cannot be mandated, but must start within each individual.
    Somehow, we must be as concerned about the common interest as our own interest.
    Not only do these interests compete within each individual. We also have to live out the better part of our natures when we are surrounded by others who think only for themselves and their families.
    The health care issue is loaded with ethics.
    Unfortunately, while we have worked so hard to separate church and state, we have also separated money from ethics.
    Don Levit

  4. The time is way past due that two pernicious misunderstandings (or obfuscations) be put to rest.
    (1.) Professional compensation is not the same as corporate profits.
    (2.) Medical care is furnished by medical professionals, not insurance providers.
    Accordingly, medical professionals from top to bottom should be compensated exceptionally well according to market conditions. This means that from the highest paid specialists (surgeons, consultants, hospital administrators, etc.) all the way down to housekeepers, landscapers and food service workers, should be paid at the top tiers of their respective wage scales.
    Insurance companies are not the source of medical care. Their mission is to manage the costs. In the same way that we need architects, lawyers and cooks to run a good system, we also need insurance companies to help manage the expenses and spread the risk of expensive medical care. It is for that reason that one of the provisions of this legislation is that 85% of premiums is earmarked for medical expenses, and fifteen cents on the dollar is all that is allowed for administration, marketing, bonuses, conventions, and whatever else for-profit companies choose to do with their money.
    I’m still waiting for someone to drive home these two simple realities in a way that makes them stick.

  5. (The corollary to those two realities is that medical professionals who own or receive interests from for-profit enterprises to which they send patients are double-dipping unless they discount one place or the other. The financial world calls such arrangements by the misleading term “moral hazard.” It is misleading in that the “hazard” is not the arrangement but getting caught.)

  6. John:
    I agree with you that medical professionals should be compensated according to market conditions.
    Would you agree that market conditions would be what the market could bear, without any subsidies?
    That would apply to insurers as well as providers.
    Don Levit

  7. I have a hard time imagining mandates without subsidies. Too many poor people need health care. Aside from that, however, I am a firm believer in the importance of a competitive marketplace, and that goes for insurance as well.
    Having worked a few years in a not-for-profit community health care system consisting of five hospitals and other related facilities I have seen at least one system up close and personal. I watched the level of care and professionalism rise from middling to superior during my time there under the gifted leadership and vision of at least two or three world-class executives. It can be done with the right approach.
    At the same time, however, the place was awash with money and nested in the midst of a veritable ocean of for-profit clinics, group practices and high-end specialized services. It seemed to me the hospital system, though “not for profit” was aligned with the for-profit medical business community in a symbiotic, incestuous relationship. Everything was legal and top-quality everywhere you look, but somehow the thought of money-laundering came to mind.
    Three main revenue streams fed the whole enterprise, profit and non-profits alike: insurance, Medicare and Medicaid. I have no way to know the numbers but my sense is that the amount of revenue from co-pays and private pay from uninsured sources was incidental by comparison.
    With universal participation, new guidelines and constraints I see all three part of that construction becoming at least more predictable for everybody. It won’t happen overnight, but in time cost management will become more businesslike. The old approach of “throw a bunch of stuff and see what sticks” will be displaced by better stewardship of all resources.
    The American approach to health care has been a cloudy mess for years. The Armed Forces and VA are socialized. Tri-care covers dependents. FEBHC is for federal employees. Medicare, larded with pork, is a bloated mess, unable to negotiate with drug companies (unlike Medicaid and the VA. NIH does the heavy lifting in medical research but no longer allows the results to flow to the taxpayers footing the bill, wholesaling discoveries to be patented and retailed for years before generics are permitted.
    So the short answer to the question “Would you agree that market conditions would be what the market could bear, without any subsidies?” is “YES.”
    But I don’t see such a market emerging any time in the near future… probably not in our lifetimes.

  8. Yes, this legislation gives medical professionals an opportunity to take the power back from the for-profit corporations that now, to a very large degree, run healthcare in this country, very good information.