How Do We Make Doctors Better?

This week I visited a particularly charged part of the health care reform debate: Doctors' pay. The reason to focus on doctor pay is simple: to change the way we pay for health care, we'll have to change the way we pay the people providing us the care. Even Obama has criticized the "warped incentives" that reward doctors' for over-treating patients. But let's set aside the question of how to make doctors poorer. How do we make doctors better?



The New York Times' invites a group of medical professors and doctors into their Room for Debate to think through the issue. For the most part, the ideas boil down one big concept: Share more information to avoid unnecessary, even duplicate, treatments. But there are other ideas that could find their way into comprehensive health care reform. Here's a sparknoted version of their biggest ideas.

1) More Sharing, Less Overtreating
Doctors need to share more information on what works. Dartmouth's Elliott Fisher suggests organizing health systems like Grand Junction, Colorado. Atul Gawande made the same point, praising Grand Junction for combining low costs with "some of Medicare's highest quality-of-care scores." Gawande wrote:

The doctors agreed among themselves to a system that paid them a similar fee whether they saw Medicare, Medicaid, or private-insurance patients, so that there would be little incentive to cherry-pick patients. They also agreed ... to meet regularly on small peer-review committees to go over their patient charts together. Problems went down. Quality went up. Then [they created] a community-wide electronic-record system that shared office notes, test results, and hospital data for patients across the area. Again, problems went down. Quality went up.

2) Single-Payer All the Way
Don't tinker around the edges with this public option nuttiness, say Steffie Woolhandler and David Himmelstein of Harvard. Just go straight to a single-payer, like Canada, that limits entrepreneurial awards (a good thing?) and cuts down on the bureaucratic paperwork that takes up almost one-third of US health spending. Sure there's not as much profit to go around (Canadian physicians make about half their American counterparts according to this graph), but if everybody is covered, we don't have to spend billions of dollars on patient research to keep people out.

3) Fewer Ridiculous Law Suits

One big slice of the unnecessary health cost pie, says J. James Rohack, is medical suits. Doctors will stop overtreating once they stop fearing the implications of not exhausting every possible option of treatment. That's the result of "defensive medicine" that's only a rational reaction to the looming threat of our ambulance-chasing legal system.

4) Fewer Specialists
We pay doctors more to sew a facial wound than to diagnose a heart attack, says Liam Nore, a blogger and ER doctor (not simultaneously, we hope). That's crazy. We've set up an incentive structure that encourages specialists to make more money from new technologies, which drives costs higher while skimping on primary care, where preventative measures offer the most cost-saving. Nore concludes:

Better-compensated primary care specialties would attract more doctors who would be able to spend more time with their patients. They would require fewer expensive diagnostic tests like M.R.I.'s and rely less on specialists. Accordingly, the use of expensive and invasive procedures would decline. Prevention, wellness and chronic disease management would be encouraged: enhancing quality and patient satisfaction, but at a far lower cost.

The whole article is here.