How to Fix Health Care: Four Weeds to Remove

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Dennis Degnan / Corbis

Want tomatoes? The plants need sun, water, soil and air. And you have to get rid of the weeds — they want the sun, water, soil and air too. As this winter of our country's discontent melts into planting season, our government would do well to take this lesson from the garden. Especially as it applies to medicine. The doctor is a surprisingly fragile plant, in real danger of being strangled by a number of aggressive species. Here is a short field guide to their identification:

Scores of agencies police doctors. Thousands of people make their living doing it. They give us yearly tasks that doctors, on pain of ending their careers, absolutely must do: 10-page reappointment forms, written exams, blood tests, physicals. Every hospital we work in, every HMO we sign up with does this too. Every year. Every 10 years we have to take our boards again. (Imagine if lawyers had to pass the bar exam every decade until they quit.) And there are yearly federal and state licensures and safety exams, fire exams, infection-control exams, malpractice-insurance exams, queries about crimes we're assumed to have committed and disabilities we must prove we have not developed.

Of course we need to know that doctors are healthy and competent. But the system is redundant and takes up way too much of our time — and many doctors believe it's largely for the benefit of the regulators themselves. A unified federal credentialing agency could pull those weeds right out and leave the country with 5% to 10% more doctoring at almost no cost.

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From where we sit (and doctors think they're the ones who are in the best position to know what malpractice means and when it happens), there is little or no correlation between doing bad stuff and getting sued. We also observe that none of the countries whose medical systems are held up to us as better than ours has any malpractice system at all. And the cost of defensive medicine is enormous — much higher than published estimates.

We're also much less likely to do charity work when we can lose our homes in the process. This is a serious problem for the uninsured. Most doctors are pretty decent folk who actually like what they have spent their lives learning to do, and they wouldn't mind doing some free work. As a group, though, we tend to be quite risk averse. We worry about the downside — it's where we live. Our insurance premiums can be crushing: it's $240,000 a year for a neurosurgeon in New York now. One way or another, it's an expense that gets passed down to all. Can our country afford this luxury at this time? Want more medical care for less money? Get the lawyers out of our garden, and find a better way to sanction bad practices without damaging everyone. (See the top 10 medical breakthroughs of 2008.)

The Medical-Billing Industry
It costs a typical doctor about 10%, right off the top, to collect fees from the HMOs and other insurance companies he or she has to deal with. This is due to the ultra-complex set of rules and regulations those companies have established to "control costs" (read: to pay us less while their executives take home more) and the billing staffs we have to hire to deal with them. This money does nothing for patients; it's a health-care expense that produces no health care. It could easily be eliminated with simple, intelligent, centralized payment rules. The result would be at least 5% more care for the money.

Computerizing Everything
It's a complex topic that boils down to this: If we who do the medicine thought more computers would save us money, we'd buy them ourselves. In fact, sometimes we do. But the federal mandate to computerize and centrally connect the entire country's medical records has little chance of saving money for anyone except the lucky insiders who sell the computers, software and support. Aside from their costs to us, electronic records are time-consuming — a constant distraction from patient care. They also put doctors on a slippery ethical slope; it's pretty easy to bill more for the same services with a good EMR program. They are a dangerous weed being advertised as fertilizer.

There are problems: the byzantine system of Continuing Medical Education, medical advertising, the HMOs themselves and our top-heavy system of hospital administration, to name a few. More on these during growing season.

Read "The Year in Medicine 2008: From A to Z."