The Voice of Great Events
The voice of great events is proclaiming to us. Reform if you would preserve. - Franklin D. Roosevelt, 1936
The voice of great events can be heard throughout our nation's health system. The list is long and grows daily - gene research, breakthrough technologies and devices, the development of vaccines against certain kinds of cancers, and more. However, are we listening to the voice of other great events - skyrocketing health-insurance premiums, 40 million uninsured citizens, time constraints imposed by managed care, outdated information systems, increased regulatory oversight, and out-of-sight malpractice litigation? Are we looking at the health crisis in our country, a crisis manifested in the fact that more than half of our population is obese and that rates of diabetes, asthma, and obesity are rising among our children?
Physicians are heeding the voice of these great events by ceasing to perform high-risk services. Some have closed or relocated their practices to escape escalating malpractice insurance premiums and many have participated in walkouts and slowdowns - heretofore unprecedented great events with a big voice. Several weeks ago, physicians in Florida, New Jersey, Mississippi, and West Virginia closed their offices and postponed nonemergency care to hold protest rallies and lobby their elected officials.1
Nursing homes struggle to pay ridiculously high insurance premiums (assuming they are lucky enough to find an insurer who will sell them a policy). Hospitals battle to provide care amid an unparalleled nursing shortage. Private insurers that are already dealing with severe financial and regulatory constraints, as well as public programs like Medicare and Medicaid, face a Congress determined to cut more. Watchdog organizations such as the General Accounting Office and the Institute of Medicine agree that the US healthcare system desperately needs to be reformed. And then, of course, we hear the wailing voice of looming great events such as war and the threat of bioterrorism.
Unless and until we pay attention to the great events that cry out to us, our health system is threatened. What would happen, for example, to our ability to care for patients who are already ill if the US experiences a multisite attack? On-going emergency response would be strained in an already over-taxed system that, if prolonged, could be overwhelmed and ultimately devastated.2
Physicians blame the legal system for frivolous lawsuits and excessive awards for injured patients and push lawmakers to limit jury awards and restrict patient lawsuits. Malpractice attorneys argue that insurance companies are charging more for their premiums to make up for their own financial losses in a "down" economy. Others believe that limiting payments for pain and suffering caused by medical errors will not prevent the errors from happening in the first place, because it is the framework within which the physician must work - not the physician - that contributes to so many errors.2 Clinicians have too many patients and too little time and lack the ability in the hours allotted to evaluate lengthy patient histories, calculate complex drug dosages and interactions, or provide the emotional and psychological support needed by their patients. "Bad things can happen even when good doctors do the best they can."2
The model of independent practice association (IPA) health maintenance organizations (HMO) with large physician and hospital networks is the dominant structure that delivers managed care in our country. Part of the services they provide supports their member physicians through protocols and education, along with treatment support directed at quality improvement and the like. The plans often use data they or their intermediaries collect to provide member physicians with information about performance relative to their peers and benchmarks. A survey of 2,982 physicians3 who were contracted with HMOs found that general practitioners (generalists) received more attention in the form of clinical practice guidelines and disease management programs than did specialists enrolled in similar HMOs. The survey revealed that insurers appear to make more aggressive efforts to influence care provided by general practitioners than to influence care provided by specialists. Of the physicians surveyed, 28.2% reported that a health plan's prior authorization process delayed a hospital admission within the previous 6 months by 28.2% and 18% reported that hospital admissions had actually been denied in the same time period. Specialists were more likely than generalists to report a delay because of prior-authorization requirements. Of physicians who had admitted a patient within the previous 6 months, 25% had requested an extended length-of-stay and nearly half of those requests were denied.
Another voice to which we must respond with reform is the way medical communication and documentation is collected and processed. Most practices use outdated paper charting and handwritten documentation to record information, subjecting communication with other providers to delays and errors. Even though improved information processing methods are slowly emerging for various sites of care, medicine has been one of the slowest communities to adapt data automation into its daily work.
The voices of these great events are speaking loud and clear: Our nation's healthcare delivery system is in deep trouble. It is flawed, inequitable, too expensive, too exclusive, and increasingly difficult to maintain. We are spending more but getting less. Perhaps, as one researcher2 believes, basic research is not going to solve our problems. We need a coming together of all vested parties - healthcare providers, policy makers, consumers, insurers, researchers, economists - to think outside of the box for ways to respond to the voices. Only then will our healthcare system have the ability to care for our elderly, underprivileged, and all facets of society in times of peace and in times of war.
1. Wiebe C. Doctor walk-outs highlight need for malpractice reform. Medscape. February 10, 2003. Available at: www.medscape.com/viewarticle/449219. Accessed: February 26, 2003.
2. Barclay L. Vision to restore the American health system: a newsmaker interview with Floyd E. Bloom, MD. Medscape. February 14, 2003. Available at: www.medscape.com/viewarticle/449476. Accessed: February 26, 2003.
3. Christianson JB, Wholey DR, Warrick L, Henning P. How are health plans supporting physician practice? Health Aff. 2003;22(1):181-189.
