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Hernando Today

Health care reform: The 'care' side of the story

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John Reiniers

Special to Hernando Today

Published: November 2, 2009

There are endless parts to the analysis of health care. It is incredibly convoluted, yet nobody has tried to simplify the task. A macro analysis bifurcating the structure or system, with all its political baggage and inevitable bureaucracy, from the actual health care delivery with its doctoring, technology and pharmaceutical products would be a good place to start.

The politicians and the media have focused only on the former with such elements as a public option, selling plans across state lines, the elimination of pre-existing conditions as an underwriting consideration, compulsory health insurance, the role of business, health information technology and so on. Important considerations, but little attention has been paid to pulling cost out of the health care delivery service itself. It is estimated that $600 to $800 billion of cost can be attributed to waste or over-utilization in the delivery of health care - not the structure.

In my view, this is where we should have started - by picking the brains of real doctors in the trenches, rather than listening to the politicians and lobbyists. Where to start? Go back before the era of technological specialized medicine. Start at the beginning.

When I was in law school, I clerked in a circuit court in the 1950s to get some real-life exposure to trial procedure. One negligence case resulted in a surgeon from rural Texas testifying about a lumbar laminectony he did, based upon a "clinical diagnosis." This surprised me, even back then. This topic should be considered in any reform efforts. It deals with the history of, or philosophy of medicine, and must be addressed by physicians - not lay people. This trial occurred long before the imaging era - years before CT scans, and MRI technology were invented.

Let me quote from Dr. Saul Seidman M.D., F.A.C.S., neurosurgeon and author, who went to medical school in the 1950s:

"The clinical diagnosis is the foundation of medical care. Or at least it was. The clinical diagnosis is the result of an intelligent and attentive physician listening to the patient, asking pertinent questions and reaching a conclusion as to what is troubling the patient. In the early days of good medical care, an educated and attentive physician could make a correct diagnosis 85 percent of the time. With no help from MRI scans, CT scans, laboratory tests, X-rays or other diagnostic testing, the correct diagnosis would occur in the hands and mind of what I call a 'real doctor.'"

This is a powerful statement that requires policymakers to analyze the economics of health care in the context of our parameters for quality. Do we want to incur the staggering cost of a health care process that meets the very highest standards? (Every medical test known to man.) Seidman's point really is that modern medical care is geared towards a series of billing events, not a diagnosis. This is also true in the legal business too, where associates are told not to bill in increments of less than 15 minutes - even for a one minute voice mail - and the focus is on prolonging the legal matter rather than a successful outcome.

Seidman started practicing in an era when health care was 6 percent of the GDP. It's now at an unsustainable 17 percent, and rising. To be realistic, technology and pharmacology - properly used - are a boon to the healing business. His biggest gripe though is that government and bureaucracy have driven up the cost. About 500,000 people are employed by Medicare and Medicaid. None of these people provide medical care. They simply absorb tax dollars - and ironically their job is to make sure that tax dollars are properly spent. But in that process they drive up cost by grinding out more regulations.

In trying to reinforce this point Seidman reminds us that the British National Health Service (NHS) is the third largest employer in the world behind the Chinese Red Army and the Indian National Railway system - 1.4 million strong of which only 7.9 percent are physicians! They are a formidable voting bloc which blocks British health care reform. If we extrapolate from a British population of only 61 million, our government health care work force would exceed 7 million registered Democrats, which is precisely why Democrats insisted that all airport security workers be federalized. They are now 11,000 members of the American Federation of Government Employees union.

Seidman's point is that prior to Medicare and Medicaid the health care system worked. Physicians donated time and the county hospitals took care of the poor. "People of all economic levels got care." Times have changed.

Most doctors probably no longer think of their profession as a calling, which I'm sure would be heresy to Dr. Seidman. That being said, there is no excuse for not beginning any analysis of reducing health care costs by starting with an analysis of the "clinical diagnosis in the new millennium" by a panel of experts to gage its relevancy in this new era of medical technology.

The point is there is no easy answer to reform, but we need to start on the care side of the ledger, not with the structure and politics of the system. Every health care provider has a dog in this fight and is a part of the problem. Let us not forget the trial lawyers, too. But we have to depend upon physicians, not politicians, to start the "healing process."

This should be a long slog - if done right - and not simply a political exercise by the Democratic Congress to get a bill on Obama's desk to sign in time for the 2010 elections.

John Reiniers, a regular columnist for Hernando Today, lives in Spring Hill.

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