No Payor System

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.

Our common understanding is that universal healthcare will provide us all with access to competent medical care. We expect that should we become ill; diagnostic tests, surgery, and life saving medications will be readily available. This we expect without equivocation.

But healthcare has taken on a different meaning.

Whenever reporters present documentories on universal healthcare services in Europe or elsewhere they ask three standard questions whose answer in America is an embarrassment. But are the expected answers so reasonable?

Of all the pressing domestic issues in this election year, a successful resolution of the problems in healthcare will have the most enduring effect. Any effort to clarify the issues involved therefore deserves thoughtful consideration. “Sick Around the World,” presented by Frontline, does attempt an even handed comparison of universal care in five countries. Its premise is that among these programs we may find useful suggestions to apply to US medicine. In his summary the narrator, T. R. Reid, identifies three common practices used by these nations to organize their healthcare. First, insurance company profits are limited or eliminated. Second, everybody is mandated to buy healthcare. Government must then provide subsidies to the poor. Lastly, providers (hospitals and physicians) must accept fixed prices.

What does the responsible physician bring to the table? Each physician has an innate belief that his patient’s welfare must come before his own. This healthcare system would have collapsed long ago if this were not the case. The flaw lies in the misalignment of self-interest. To correct it there must be an economic focus through which the diverse interests in healthcare can be resolved.

How do risk-bearing physician owned medical groups provide this focus?

Why should it seem to be a paradox for physicians to manage healthcare? Many blame physicians for the system’s failure. Deterioration in cost of care, ease of access, and availability of services all seem to point toward the profession. Yet it is the constancy of the physician’s dedication that sustains healthcare. Despite steady erosion of income and increased bureaucratic intrusion the profession soldiers on. The myriad factors which sustain the current US system are nicely described in the New England Journal of Medicine by Lawrence D. Brown. But he missed one critical factor. All of the compensating factors he mentions depend upon the input and even generosity of physicians. The system continues to function because the profession consistently places the welfare of its patients above its own. There is an essential iniquity in a society that exploits the humane spirit of its medical profession to sustain its failed healthcare.

As our healthcare system crumbles the mantra of cost containment still emanates from the ruins. Few aspects of healthcare escape this indictment. Physicians, hospitals, pharmaceutical companies and even insurance companies are all cited for their contribution to spiraling cost. But we seem unable to recognize that it is the organization of healthcare itself that creates the problem. As long as the belief is held that fiscal responsibility for care of patients can be divorced from the delivery of that care this chaos will continue. The frenzy to contain cost focuses upon care givers. If only they can be constrained healthcare will be affordable.

This is clearly not an effective strategy.

Why don’t Americans have universal healthcare? There are many reasons. Their genesis lies with the ideals of our Founding Fathers. The Declaration of Independence crystallized their aspirations for the nation they created. Central to their beliefs was a unique notion of the individual’s relationship to society. They recognized that life, liberty and the pursuit of happiness are indistinguishable: they are part and parcel of our humanity. By including the pursuit of happiness they recognized a critical feature of our human existence. We are intelligent beings capable of infinite patterns of thought. With this declaration we are at liberty, individually, to find our most satisfying use of that intelligence.

Controlling healthcare cost seems to be impossible. Attempts at constraint imposed by government or managed care fail to show any indication of success. In their wake access to care becomes more difficult. What is the problem?