HOW TO MAKE HEALTH CARE DELIVERY MORE EFFECTIVE, EFFICIENT, AND AFFORDABLE WITHOUT INSISTING ON ‘COOK-BOOK’ MEDICINE

A Message From Dr. Eric Radin to my colleagues for the benefit of our patients:


Few attempts by the government to reform health care delivery have been successful. Massachusetts-Health is proving everyone can’t be insured without lowering the cost of treatment. The debate over President Obama’s attempt to cover the uninsured has discovered the same thing. It is too expensive. This suggests it will require a cultural change of our heath care providers to accomplish reform.

In our current medical culture it’s almost impossible to control runaway health care costs. Attempts at spending caps were successfully blocked, appeals to professional pride didn’t work, and mandatory continuing medical education failed to make health care delivery more affordable.

To lower the cost, and hopefully to increase our national quality of care, we need to make health care more effective and efficient. But accepted practice protocols, although generally useful, should not be expected to include patients toward the ends of the bell-shaped curve that all biology is described by. What will it take to improve our clinical results and lower the cost?

First, since healthcare is acting like a business, treat it as a business. This idea, proposed in 2006 by Porter and Teisberg in their book Redefining Health Care, and recently updated in the lead article in the July 9th edition of New England Journal of Medicine (NEJM.361(2) ;109-112), are a business school critique of our health care system. It suggests a business-type solution, pay for value. Value in the marketplace has always been judged by consumer satisfaction, related to what was bought and what it cost. Porter and Teisberg recommend paying doctors bonuses for value received, defining value as clinical outcome divided by cost. To avoid paying for quick fixes and preventable relapses, pay some of the fee initially; pay the bonus for value when the outcome and total cost become apparent. This should encourage innovation and limit high-tech, high-cost treatments to those who require them.

Second, encourage real competition between providers as well as health care centers. Publicize success, by diagnosis, to the public on the Internet. Rank every practitioner and medical group practice. Public pressure and patients preferentially flocking to high value providers, plus substantial bonuses for increasing value should bring about the beneficial cultural changes needed. It is a concept that makes the medical profession shudder but would be a boon to the sick and injured.

How can outcome be fairly judged? It would seem best by using functional criteria: Has the patient returned to his/her expected full activity? What activities of daily living can the patient accomplish that he/she could not accomplish before the medical intervention? How have the appropriate clinical measurements responded to the treatment? How does the patient rank his/her recovery? It is important, as well, to publish the methods used by the innovators to increase value, so other practitioners and their patients and the system can benefit from the same measures.

So, instead of detailed protocols, those who deliver heath care would be able to rely on well-rewarded innovation and well-publicized competition instead of payment schedules, forced discounts by insurance companies and cookbook-like protocols. Research in evidence based medicine, best practices, comparative treatments, and team effort should all be energized by the value payment incentives. Rather than using these findings to hamstring medical practice, value payment incentives should free practitioners to use their judgment to practice value-driven care. Medical judgment could be maintained.

Widely advertising the value of their treatments by diagnosis, should make American health care more efficient, effective, and affordable without destroying the profession. Good medical practice will be allowed to remain something of an art, built on the scientific data of what works when.

The country wants affordable health care. Currently we physicians are the deciders of what treatment our patients receive and thus directly and indirectly control the costs. Wouldn’t it be better for the medical profession to decide how to lower the costs of care rather than have the government and other third parties do it? My colleagues need to admit that that time is running out for the status quo. Our present health care delivery system is no longer sustainable. By now, it should be obvious that health care delivery will be more closely regulated. If my colleagues and I don’t change our ways, someone else is going to do it for us.

Eric L. Radin, M.D.
Marion, MA

The author is orthopedic surgeon and an Adjunct Professor at Tufts University School of Medicine.