The national debate about health care is heating up rapidly. We're already hearing a lot about whether we'll have the political will to pay for universal coverage (see, for example, this editorial in yesterday's New York Times). But what we really need to do - for the sake of patients, doctors, and the soul of medicine, is to contain costs, not to figure out how to get more money so we can spend even more. Putting more money into the health care system will simply continue the trend towards unhappy and demoralized doctors.
Here's a back of the envelope thought experiment:
(1) Approximately 17% of the U.S. population is uninsured.
(2) But our per capita spending on health care is 40% higher than the next most costly OECD country, while our health status statistics are mediocre.
(3) Experts estimate (and most practicing physicians agree) that at least 30% of the care we deliver (and the costs we incur) are unnecessary.
(4) If we dropped our OECD disparity from the highest OECD expenditure by 1/4 we would save 10% of our per capita spending.
(5) If we eliminated 1/4 of the unnecessary care we would save 7.5% of our per capita spending.
(6) Saving 10% + 7.5% would cover the uninsured.
In my view, what our health system needs is a budget, somewhere in the zone of our current level of expenditure, with increases capped midway between the Consumer Price Index and the projected health inflation trend. Were this to happen (alas, it almost certainly won't) I would predict that in five years we would see an improvement in physician morale and patient satisfaction, both of which are low in the U.S. compared to other countries.
Without a budget we can confidently predict that the cost trend will climb into the economic stratosphere. And faced with continuing health care inflation we'll try to put on the brakes with new forms of external control. That's what we tried in the 1990s with insurance company driven managed care.
Almost 20 years ago Kevin Grumbach and Tom Bodenheimer wrote a brilliant article - "Reins or Fences: A Physician's View of Cost Containment." We can try to tame costs by jerking providers by the reins. But we clinicians won't like that, and when we're unhappy our patients are unhappy. Or we can build budgetary fences and say to doctors, nurses, hospitals et al - "you're smart folks and you care about patients - here's an overall budget...please make it work...for patients and the public."
Faced with a realistic budget we health professionals, over time, would get our act together. We'll organize ourselves into systems like the Mayo Clinic, Geisinger, Kaiser Permanente, and Harvard Vanguard, the group I practiced with for 33 years. Physicians in these accountable group practices are happier with their careers, their patients do better overall, and the per capita costs are lower.
That's the direction we need to go in. But it won't happen without a budget for our health system. That shouldn't be impossible to achieve - we budget for everything else we pay for!