Tonight was the second of six sessions in the UCSF Mini-Med School on health care system reform. I missed the first thirty minutes, as I was traveling back from the Librarians Association of the University of California (LAUC) Spring Assembly in Palm Desert, CA. I can't get enough of this blogging stuff, so I blogged the second assembly in a row. I even tweeted at this assembly, albeit infrequently.
I wish I had been there for the entire talk, but what I heard was worthwhile. At tonight's lecture Dr. Thomas Bodenheimer spoke about ways to contain health care costs. He was very good about engaging the expertise of the audience (one man in the crowd works for the VA and is very informed about the issues under discussion, or at least he has been the first two weeks) and admitting when he wasn't sure about something.
His ideas are likely to be familiar to health care observers:
- Reduce administrative costs [Canada's are lower]
- Reduce costs in high cost areas [There is wide variation in cost of care throughout the US, with no appreciable effect on health outcomes]
- Here Dr. Bodenheimer introduced Roemer's Law, which is that an empty hospital bed will soon be filled. Supply creates its own demand in health care, just like a juggernaut and with no real relation to quality or need.
- Stop performing care that does more harm than good [Perhaps as much as 54% of angioplasties are unnecessary, according to this 1997 article]
- Most controversially--Pay primary care physicians more, specialists less. Dr. Bodenheimer, a primary care physician, argued effectively that better primary care would lead to less costly specialist referrals and an overall improvement in health. Former Senator Tom Daschle, who would now be Health and Human Services Secretary were it not for those pesky back taxes he owed, agrees with this. And so does President Obama.
- Background: Only 7& of new MDs become primary care physicians (or a similarly low number), because specialties like cardiology or oncology pay much better. Dr. Bodenheimer feels that the primary care physician should be a first line of defense, with specialists playing a critical but less central role. I'd extend this further, saying a more robust public health system would go very far to improve health care.
I almost left when the closing Q and A began, but I'm glad I stayed. In response to one question Dr. Bodenheimer lamented the fact that the medical education system, of which UCSF is "part and parcel," shuffles so many promising physicians towards lucrative specialties and away from more socially beneficial primary care. He blamed this on the heavy role of NIH dollars in health sciences education; the NIH funds research into new treatments and therapies, which by definition assumes specialization. And thus the old-fashioned skills of taking medical histories and learning the holistic needs of a patient suffer.
This made me think about the open access debate in a different way. A crux of the case for open access is that taxpayers have the right to read the articles they paid for. This is still true, but what if what the NIH funds is flawed? The entire biomedical research enterprise in the US needs some rethinking, if what Dr. Bodenheimer says is true. And if so that's a more pressing concern than maximizing access to research articles, although that will always be important too.
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