Healthcare reform has been at the forefront of national policy debate over the past year. And, for many years, there have been discussions about how to maintain the quality of care in the United States and actually to improve the quality, while increasing the access to care for everyone and simultaneously controlling the cost of that care. It is probable what even with all of his wisdom King Solomon would have had difficulty addressing this problem intelligently and/or intelligibly.
Many culprits have been identified for causing the "crisis" which has suddenly been discovered in healthcare. The fact is that most proposed solution are determined, or at least predicted, by the political affiliation of the one proposing the solution, to wit:

• If you are a Republican, you often don't like lawyers, and your solution to the healthcare crisis at least includes more tort reform. Of course, when you are aggrieved by an injury or error, you are not nearly as committed to that reform as you were when it was someone else asserting injury.
• If you are a Democrat, you feel supported by lawyers, and you do not think that tort reform is a significant part of health care reform.

The reality is that the areas of healthcare in which lawsuit abuse is a significant cost driver are few. While allegations of intentional, or willful neglect, are most often exaggerated, it is one of the strengths of our nation that anyone can seek redress of their grievance in the court rather than in the streets.

• If you are a Democrat, you are inclined to think that insurance companies are a significant part of the healthcare crisis. You want people to have a limited cost for their care but an unlimited access to care. You want insurance companies to be able to collect a limited premium while being responsible for unlimited liability. You want patients to be able to avoid insurance premiums for most of their life and then have an insurance company obligated for assuming the liability - not the risk but the liability - for the cost of care which has resulted from a life time of neglect.
• If you are a Republican, you are generally more inclined to side with corporations and with the insurance company but you are less inclined to recognize when insurance companies collect significant premiums but use questionable methods to limit their expenditure for the care required by their policy holders.

The reality is that insurance companies are not a significant driver in the healthcare-cost equation except as they insulate the client from the reality of the cost of their care and therefore create a demand for everything to be done because of no direct cost to the policy holder. Insurance companies need oversight and regulation but the Massachusetts experience is showing us how ineffective government often is at that process. Most of the insurance companies in that state are now not-for-profit. Their recent request for significant rate increases have been denied by the governor, causing them to stop issuing new polices and announcing that they may all be bankrupt in the next two years.

• If you are a Democrat, you not only want all pre-exiting conditions to be covered, you also want no life-time benefit limits - even though Medicare has and always had had lifetime limits on benefits - and you want everyone to have access to all health care technologies no matter how expensive and no matter whether there is evidenced-based support of the technology. And you are at least willing to place the responsibility for providing this care in the hands of the government.
• If you are a Republican, you believe in personal responsibility and you typically think that everyone ought to pay for their own care.

The reality is THE principal drivers of the increased cost of healthcare is technology and the growing demand of patients for that technology. The legitimate cost of healthcare is now out of reach of many citizens and without help they will not have access to care. The opposing reality is that the essential cost of the technological cost of care is such that even the government cannot assume the unlimited cost of that care. This problem will only grow as science extends the horizons of what can be done for patients. Eventually, the option for publicly supported care is going to be "rationed" care or "rational" care. (This dichotomy has been discussed in this column previously.) If we are going to solve the healthcare-cost crisis a reasonable balance between the Democrat's demand for public payment of all care and the Republican's demand of personal responsibility for all care will have to be reached.

Entrepreneurship vs Professionalism

As a new physician, and one that was poor, with a young and growing family, I had to work to make a living. I learned about the economics of healthcare in the school of hard knocks. As a resident in training, I worked one weekend in a community in Texas. Two physicians, one of whom personally owned the hospital, hired me to cover their practice for Friday through Sunday. One of my responsibilities was to make rounds on the 30+ patients in the hospital.

After the two physicians left town, I started the process. I found that none of the patients in the hospital had admission history and physician examinations, so I prepared them. I found that none of the patients had daily progress notes, so I wrote them. I also found that none of the patient had any need to be in the hospital so I completed discharge summaries, discharge planning and sent all of them home.

I felt like Tom Thumb, "What a good boy, I am." The weekend went well. I enjoyed one of my first experiences in "private practice" and even though I had one difficult delivery of a baby, everything went fine. Because my entrepreneur employer had one of the first cell phones - well it was more like a walky-talky it was so big - the hospital owner called me when he was an hour out of town and I was able to leave for home on Sunday evening.

The next day, at my university-based residency program, I received a telephone call. When I answered I heard a screaming, cursing voice, exclaiming that I had ruined this person. Shortly, I realized it was my weekend employer. He shouted, "I have called all of the patients you discharged and put them back in the hospital." I learned then about the economics of medicine. These people were not in the hospital for their personal health; they were in the hospital for the physician's economic health.

Fortunately, I believe this was an exceptional, albeit an egregious case, but unfortunately it was not, in my judgment, an isolated case. This experience crystallized in my mind the tension which exists in healthcare for physicians and other healthcare providers.

In 1965, three momentous events took place in the United States, Carolyn Ann Bellue graduated from college and in August of that year she married James L. Holly. In that same year, the United States Congress instituted Medicare. The third of these events, which was intended to provide healthcare to a vulnerable segment of our population either created or coincidently signaled the future tension which would exist between physicians as professionals and physicians as entrepreneurs.

This dilemma, i.e., doing what is best for the patient and/or doing what is best for the physician's income, would become one of the principle driving forces in the cost of healthcare. It would become more significant than lawsuits, insurance companies and even the cost of technology as a driver of the rapidly escalating cost of care. However, this driver could not exist in isolation. It required the collaboration of patients who increased their appetite for more and more care and who associated more care with better care, thus causing them to seek out physicians who would do everything they wanted. It also required the collaboration of the first health insurer - Medicare - which has a public policy and a political base to health decision making - which created mandates for care and then complained about the cost, or then tried to control the cost, of that care.

This and the expansion of scientific investigation and knowledge brought to the forefront evidenced-based medicine. This is where medical decision-making is not based on the physician's personal experience, or the patient's person desire, but it is based on outcomes which have been measured and observed in controlled studies. While the roots of care-decision being made upon the basis of scientific evidence actually goes back into the mid 19th Century in western Europe, it took on a new intensity in the period following the time of the institution of Medicare. With a new payment plan for care which had previously been given for free or at a drastically reduced fee, the opportunity for economic growth and abuse was put into place.

These circumstances created an ethical dilemma for physicians which infuses every healthcare decision they make. It has created a magnet for physicians from all over the world who are drawn to America to get the best training available in the world and then to stay to make the most money practicing medicine which is possible in the world. In Texas, physicians are required to take at least a one-hour ethics course each year even though they are faced with 8,760 hours of ethical challenges every day. This resulted in the Stark I legislation in 1992 which limited physician referral to facilities which they owned. There have been subsequent iterations of the "Stark laws" some of which have hurt innovation in healthcare but all of which originated from by the ethics facing those who provide a service for which they create the demand.

What happens when a healthcare provider becomes more entrepreneur than professional?

1. They spend more energy and effort on finding new ways of making money than new ways of improving care.
2. They see their patients as commercial opportunities - such as customers for vitamins and other "add on" products - than they do as people who trust them with their lives.
3. They are less interested in providing service than in selling products or procedures.
4. They lose the joy of being a physician and see their profession as a career rather than a calling.
5. They order tests and procedures not to protect against lawsuits but to produce revenue.
6. They limit their practice to those who are well insured, or well "healed," rather than seeing those with the greatest need.
7. They provide the rationale for the government take-over of healthcare and have no one but themselves to blame for their losing the right to lead healthcare delivery.

Conclusion

The good news is that most physicians are still healthcare professionals. Even when they are engaged in appropriate and balanced entrepreneurial activities most physicians still care deeply for the person of their patients and only provide the care the patient needs.

The solution to the problem for physician is:

• First, know that this ethical dilemma exists.
• Second, know that no one is immune from self-interest.
• Third, commit yourself to learning and practicing evidenced-based medicine. Personal experience and/or personal prejudice are the fountain heads from which entrepreneurism overtaking and overcoming professionalism.
• Fourth, realize that the root of healthcare innovation today, such as "Medical home" or "health home," is the reestablishment of professionalism as the driving force in healthcare, which is the only force which can consistently overcome the potential excesses of entrepreneurism.
• Fifth, take care of those who do not contribute to your "bottom line." Few things are as fulfilling as providing care for someone who can provide no benefits, financial, social, commercial or personal to you.

As a patient, you can contribute to the solution of this problem by:

• Allowing your physician to tell you to wait. Many procedures and/or surgeries can be avoided by "watchful" waiting. Your Physician will need your collaboration to do this safely and securely.
• Allowing your physician to practice evidenced-based medicine, which means that antibiotics will not be prescribed for every fever you have.
• Making end-of-life decision and allowing your physician to practice the rational healthcare of not using every heroic and extraordinary method to prolong physical existence without any quality or quantify of life being achieved. This means you will have to give your physician guidance about what you don't want to happen and make sure your family is prepared not to override that decision in the crisis and emotion of the moment.
• Asking your physician if he/she owns an interest in a facility to which he/she is referring you and if so what are the comparative costs of care elsewhere.

This is a big subject and this is a brief introduction, but it can be a start of a discussion which can lead us all to a kind of healthcare which will recover the personal relationships and the satisfaction of healthcare delivery and healthcare receiving which some of us can remember from 50 and 60 years ago.

Admission to Medical School

My school of medicine has a remarkable admission process. First, it is determined that you are capable of doing we work required to be successful in the rigors of medical education. Then, it is determined if you have every made a difference in the life of another. You are seeking admission to a profession which has as its fundamental motive making a difference in the lives of others. It is reasonable to know if you have every taken the initiative to do that. It is reasonable for all healthcare providers to ask themselves if they still go to work everyday desiring to make a difference in the lives of others.