Monday, October 11, 2010

A physician schools Orszag on medical practice as it actually is

...Orszag is wrong to believe that the quality of medical care will be improved by forcing doctors to submit to "quality management," terminology borrowed from industry and embodying a process poorly suited to medicine. Doctors have been practicing continuous quality improvement since science was incorporated into medical practice in the 19th century. Lifelong learning, the continuous adaptation of practice to incorporate advances in medical science, and the detailed evaluation of untoward events were the standard practices of physicians long before they were discovered by industry and government. All medicine is evidence-based medicine; there just isn't evidence enough to provide all the answers, so experience and judgment are still critical to good outcomes. Current attempts by the federal government and others to measure medical quality by forcing doctors to submit to quality management by reporting on a long list of easily measured but often meaningless quality measures will not improve care. Mr. Orszag cites an example of this when he describes how a simple measure of quality led to the earlier discharge of patients from a hospital. However this may improve convenience, these simple measures can in no way assess the quality of anything but the simplest aspects of care provided by an individual doctor to an individual patient. Real quality assurance is still a task for experts. Reporting an airline's on-time arrival record is not the same job as figuring out why a plane crashed.

Mr. Orszag also makes the common mistake, seen especially in the media, of confounding the roles of doctors and hospitals. Doctors are not hospitals, and a hospital does not offer medical care. Doctors offer medical care, hospitals provide infrastructure and supporting services, and together they provide an environment in which patients can receive the care they need. A hospital cannot open a blocked coronary artery to avert a heart attack; only a doctor can do that. A doctor does not have the capital or expertise to build, staff, and run a heart catheterization lab; only a hospital can do that. The two elements go hand in glove, but the economic circumstances and work environment of the doctor and the hospital are different -- something that can't be ignored if the institution of a seven-day work week is desired to improve quality and convenience.

Mr. Orszag is undoubtedly an expert in Medicare finance, so he knows that physicians have been subject to federal price controls since 1992 and that practice costs for doctors since that time have gone up 54.8% while Medicare payments have increased only 11%. From basic economics he must also know that when the provider of a service is unable to recoup the cost of that service, the availability and quality of the service inevitably decline, and innovation ceases. Yet during health care reform, his plans for budget-neutral health care reform were based on cutting doctors' fees a further 25%. He must therefore believe that this huge additional cut in take-home income could be inflicted on physicians with no change in their behavior, that they would act as though they were in a free market and change their practices in response to public demand. This demonstrates not only deficiencies in his grasp of economics, but also a failure to understand human psychology. Instead of scolding doctors, Mr. Orszag should work to lift price controls, free doctors from stifling federal regulation, and let the free market once again provide incentives for them to innovate. If people are willing to pay doctors to provide elective services on Saturdays, doctors will provide those services. This is the American way, and it works -- something our federal government, and perhaps also Mr. Orszag, has forgotten.

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