Harvard Business Review gets it wrong…and right
On my quest to educate myself on the business of medicine, I picked up the April issue of the Harvard Business Review, which had a spotlight on health care. Well, I want to fix health care as much as anybody, so I forked over the $16.95 for the issue. Some of it was good (a review of Gawande’s Checklist Manifesto, already reviewed here) but other parts made my hackles rise. (Yup, still got those hackles!)
Jeff Levin-Scherz, MD, MBA, assistant prof at Harvard Medical School and School of Public Health, was the chief hackle riser.He wrote an editorial on pages 72 and 73 on 5 items that “drives high health care costs–and how to fight back.” Here are a few choice picks from his list:
- “Payment schemes that reward excess”: “he advocates that we all join HMOs because salaried physicians perform fewer procedures. No matter that many patients and physicians hate HMOs and capitation. Dr.Levin-Scherz must not have practiced in these institutions. Talk about another way to drive young doctors away from primary care! Practicing in capitated systems is very restrictive, and takes away a value that most physicians hold dear–autonomy! (Mentioned just earlier in the issue!)
- “Small practices, fractured care.” The good doctor states that small practices should integrate in to large multispecialty groups to “improve communication and accountability.” He also notes that such large groups are better able to leverage IT infrastructure, and use “non-physicians in a team approach.” Basically, he sees the answer to rising health care costs is to make all physicians employees that can be forced to be the head of a “medical home” and supervise a group of health care extenders. (God, do I hate that word!) Yes, large group have leverage in investing in items like EMRs (which by the way have NOT been demonstrated yet to improve health outcomes!), but the physician as employee model again shrinks one of the hardest working, motivated, driven workers in the American system to that of line worker. Physicians have huge intellectual capital, and minimizing that by enforced group membership lays waste to a huge resource.
- “A few patients cost a lot.” Yup, they do. He advocates that complicated patients go to”centers of excellence” to receive care from those with “disease specific expertise.” Would those be the specialists that he says are costing too much money? (Yes, he decries specialists’ salaries, and suggests that compensation be increased to “attract doctors to general medicine.” I am all for increasing internists and family practice compensation, but that is just one factor in why these specialties can’t attract young physicians. To be honest, primary care can be a real drag, with relentless hours and countless regulations. Dr. Levin-Scherz appears to ignore this fact.)
I do agree with some of Dr. Levin-Scherz’s observations and suggestions such as increasing transparency in pricing (a head ct in the US costs $950, but can be had in Canada for around $500.) He also notes that the price of LASIK surgery has fallen because it competes on price. Dr. Levin-Scherz ignores the elephant in the room: Americans want “everything done”, and don’t care how much it costs, as long as it doesn’t cost them. I am responsible for meeting this expectation, and am forced to abide by insurance regulations and malpractice pressures. Dr. Levin-Scherz neglects to mention that controlling these factors would go a long way toward controlling costs.
