Common Purpose

Evidence of healthcare's disintegration is all around us. Over utilized services, disenchanted physicians and rationed care by governments and insurers leave little doubt that the current approach to the delivery of medical care is a chaotic failure. Why? Every aspect of western medicine is divided into unrelated economic segments.

Physicians rely on a concept of fee-for-service which is only valid if patients are directly responsible for buying their care. They are not.

Businesses buy and insurance companies sell healthcare as a financial instrument. Medical care is the commodity traded. Does either party have any direct responsibility for that care? They do not.

Governments provide access to medical care based upon their own judgment of its value. They set fee schedules, ration access to care, and deny access to new modalities of care without reference to their merit. One would expect an external standard against which this determination of value could be objectively measured. There is none.

All rely on controlling cost. But cost is not a measure of value. It is only a measure of one participants concern for its own welfare. This is the source of chaos. We need to move away from a system in which all parties worry about their own cost toward a system that can determine value. We need a price. Universal care based upon what it is worth to society, not what individual segments of the marketplace are willing to accept as their cost.

How do we measure the value of health? The exchange between patients and their physicians is its only source of value. The satisfaction of their mutual needs establishes a relevant price. It is this direct exchange between them that creates a true and verifiable medical marketplace.

To establish this price requires a bold step. Physicians must become the insurer. To accomplish this they must form full risk bearing medical group practices. But this fiscal responsibility also creates new opportunities. Now physicians can organize the delivery of medical care on a rational medical and economic basis. Their perspective on patient needs will enhance this nation's ability to develop a sustainable universal care.

This union of fiscal and medical responsibility will force a sea change in the perception of incentives throughout the system.

As physicians assume responsibility their primary objective must be to eliminate all non-productive activities. Resources must efficiently benefit patients. It will soon become apparent that fee-for-service drives the systems inefficiencies. Medicine has become too complex an endeavor for it to be sold as piece goods. It is the composite wisdom of the profession which is now of value. Fee for service, intended to reward the individual, only serves to interrupt the flow of expertise. Efficient medical care will thrive in a culture built on sharing. Elimination of fee for-service as an incentive is therefore a critical step.

A cascade of events will follow. In the absence of an emphasis on personal gain, medical groups will identify and eliminate redundant and outmoded practices which no longer serve useful medical purposes. Insurance driven solutions such as tier 4 drug co-insurance N Engl J Med 2008;359:333-5 designed to limit the availability of cutting edge medical science will be rejected. The physician's desire to treat illness will dictate that the group's economic efficiency support the availability of these expensive treatments. It will become clear that each physician's real incentive is founded upon human need. This is medicine. This is the environment that will drive a humane healthcare reform.

In this new marketplace, price compels all participants to focus their incentives upon a common purpose; good medical care.