Within a handful of miles of the birthplace of the American Revolution, a new revolution was being fomented the last week of April.
The Avoiding Avoidable Care Conference wasn’t so much about the epidemic of unnecessary medical care or the costs of unnecessary care. It was a rallying cry to the medical community, and to doctors in particular, to reclaim the profession of medicine from the country’s market-dominated healthcare system.
“There is a moral absolute in medicine to help and never to wrong the patient. No such moral absolute can be found in the marketplace,” said renowned cardiologist Bernard Lown, founder the Lown Cardiovascular Research Foundation, one of the organizations sponsoring the conference.
“Caveat emptor – let the buyer beware – is its underlying admonition,” he continued. “The warm and fuzzy rhetoric that ‘patients come first’ is a transparent marketing ploy.”
“The real problem is actually corporate control and the drive to make money,” said David Himmelstein, MD, a public health professor at the City University of New York during a presentation on payment mechanisms and overutilization. “As long as you have large powerful firms that make more money by raising revenues by increasing costs and can influence our political process we will have rapidly rising costs.”
“Greed has caused the problem,” he said. “… rather than manipulating greed, we need to disable it.”
The conference was organized by the Lown Cardiovascular Research Foundation and the New America Foundation and co-hosted by the Institute of Medicine. It was the brainchild of Vikas Saini, MD, president of the Lown Cardiovascular Research Foundation, and Shannon Brownlee, author of “Overtreated,” and acting director of the New America Foundation’s Health Policy Program.
An audience of about 150 (mostly doctors) met to discuss the issues contributing to unnecessary medical care – which, by some estimates, runs into the billions of dollars – including defensive medicine, volume-based payments, lack of evidence, poor reimbursement for primary care services, the preponderance of waste in the system and the pros and cons of payment reform as the panacea to the system’s troubles.
But it was ethics – not the nuts and bolts of the issue – that ruled the conference, which was held over two days at the Academy of Arts and Sciences in Cambridge, Mass., an independent policy research center founded in 1780 by Revolutionary War heroes such as Samuel and John Adams.
“How can real reform happen in the practice of medicine when reform is not really in the interest of many practitioners themselves?” asked Saini at the start of the conference. “Many of us advocate for maintaining the integrity and autonomy of the medical profession in the midst of healthcare delivery reform, but many physicians are seriously conflicted. Putting it another way, the health system can’t change without doctors, but do enough doctors have an interest in change?”
It is a tremendous act of leadership when clinicians provide care that is in direct conflict with their economic interests, said Don Berwick, MD, former administrator of the Centers for Medicare & Medicaid Services.
“We need the professions to rise to this,” Berwick said. “I don’t think it’s going to happen in Washington. I don’t think Washington understands healthcare production. How could they? It’s only the people who give the care and who use it who, in the end, can change the way care is delivered and rescue it.”
Berwick suggested that getting rid of the waste in the system would go a long way to rescuing healthcare. Other solutions offered by presenters and members of the audience included creating a single payer system, payment overhaul, elimination of for-profit care, transformation of the medical education system and across-the-board – for patients as well as the medical community – culture change.
The type of revolution discussed during the conference will be hard-fought, but it is one that can only be waged by the medical community said Dolores Mitchell, executive director of Massachusetts’ Group Insurance Commission, the agency providing insurance coverage to the state’s employees and their families.
“Physicians and hospital executives have to become the stewards of society’s resources and those resources have to be acknowledged as being limited,” she said.
“Leadership is about disappointing your own people at a rate they can absorb,” she said, paraphrasing leadership experts Martin Linksy and Ronald Heifetz. “If you are to succeed, there will have to be some of your own who will be disadvantaged. It cannot really be win-win for everyone.”
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