I must take exception with two items proposed by Tim Pawlenty’s  Washington Post OpEd piece “Five Ways to Reform Health Care.”

The unreality of healthcare metrics and costs …

(1) Incentivize patients to be smart consumers: When people buy food, clothes or cars, they compare prices and quality. Why should health care be any different? In Minnesota, we've created incentives for public employees to be wise health-care consumers and given them the information to make smart decisions. Under our system, if patients go to a high-quality, low-cost clinic, they pay less; if they don't, they pay more. As a result, the vast majority has migrated to more cost-efficient health-care providers, and we've seen zero or small increases in premiums since 2005. Any federal reforms should similarly make quality and costs more transparent, and incentivize smarter health-care decisions.

One, due to the vagaries of the human body and the situational nature of medicine, comparisons of cost and quality are almost impossible to make in the field of medicine. A great doctor treating severely ill patients will always have poorer outcomes than a mediocre doctor treating lesser cases. Certain people fall beyond the norms and thus require more complex and costly care.

Two, cost accounting in the medical profession is a complex formula of reimbursements, deliberate overcharging by altering treatment codes and allocated costs which have little or nothing to do with the level of care being provided.

Three, medicine is all about physician trust – not the cold review of the cost/outcomes of a mythical “average” patient which does not exist in the real world. If a competitive system is used and the results are made public, is it not common sense to realize that the Administrators will be incentivized to fudge the results and shortchange patients in order to “make the numbers?”

Four, are they speaking about “cost efficient healthcare providers” or simply “low cost” providers who may have managed to game the system or, again, shortchange patients?

And five, exactly how do you incentivize a patient to take a more proactive stance when it comes to their healthcare? Like all other services, you have quality, cost and delivery – and you can select only two of the three items when making your choice. Most people are not into self-diagnosis or the time and effort to pick a medical provider who will be providing services in the future. Cost comparisons and outcome statistics will change over time. So it really is a “low cost” crapshoot on whether or not your choice was correct.

Politicians know nothing about either performance or costs as their goal is to seek political advantage, not great healthcare …

(2) Pay for performance: Under America's current system, health-care providers are rewarded for the number of procedures they perform, not for performance. As a result, the system encourages unnecessary tests that increase costs. In Minnesota, we started an innovative program to measure and set performance metrics for providers and make the results public. We are changing our payment system to reward quality rather than quantity. Congress should pass reforms that allow people to stop paying for procedures and start paying for results.

This last line, “Congress should pass reforms that allow people to stop paying for procedures and start paying for results,” is utter bullshit. For the great majority of people, they pay for healthcare via insurance premiums, they do not pay for procedures and they certainly don’t pay for results. They have no way of knowing when they buy their policies that the doctors selected/accepted by the insurance carrier (HMO) are top-notch or hacks. People have no way of knowing whether their selections (PPO) are going to yield particular result or not. Truth-be-told, these politicians are speaking about reducing the costs of medicine for the insurance carriers, not about providing acceptable outcomes to individuals.

And who is to decide a test is unnecessary – the idea that many tests are performed by physicians as self-protection against malpractice suits is, at least in my mind, secondary to the amount of reimbursement money they receive for ordering tests at their own or allied facilities.

Perhaps, one of the most expensive ideas in healthcare is that you need a “gatekeeper” to route you to “specialists” who are needed to interpret and explain the results. It was this “gatekeeper” who was to hold costs down by providing care at a lower cost than a specialist and keeping a patient from getting unwanted or unneeded costly treatments. This appears to be mostly a failure, so why not simply go back to the concept of a family doctor – and not a gatekeeper. Someone who was interested in you rather than meeting productivity and cost containment goals.

Bottom line …

We need to be extremely careful what the state mandates in terms of healthcare. They are not looking out for the patient – but their own political futures and the sustainability of the political system as they pander to the special interests in big pharmaceuticals, medical device suppliers, diagnostic labs, insurance companies, etc.. In fact, the patient may be dead last (pun intended) on their list of considerations.

In the final analysis, the idea that “common things happen commonly,” is a deadly paradigm when it comes to that single patient whose medical condition is beyond the boundaries of the “norms” and requires individualized and specialized care. The idea of a non-medical clerk, or more likely a computer system, denying care (actually denying reimbursement for care) based on “best practices” is an anathema to me. And to the patient whose life is on the line.

A practical example can be clearly demonstrated with senior citizens. Here we have an aging population with an increasing number of ailments and with an increasing risk of poor outcomes. Just studying the numbers would seem to justify giving palliative care pain pills while waiting for the patient to die. And that’s exactly what the “best practices” are likely to yield.

Me, I would much rather place my healthcare in the hands of a caring doctor or nurse-practitioner than in the hands of a cold-blooded “death panel” who must decide if I am rich enough, famous enough, well-connected enough – or a member of a union – to allow me to live or get that needed hip transplant.

Be careful when you place your life in the hands of a politician. They are more concerned with their personal and political future and the support of their party and the special interests than they are in saving your life.

-- steve

Reference Links …

Tim Pawlenty - Five ways to reform health care - washingtonpost.com