Why was I compelled to write this book?
The folks we elected to mind the store in Washington DC seem to be out of touch with the reality everyday Americans are living. They were elected to serve the people but both sides of the aisle appear to be acting as shills for lobbyists or in their own self-interest.
The American public knew it was time for a change in Washington. Candidate Obama recognized that our existing health care, economic and foreign policies were destructive. He linked the cost of our health care system with America’s economic collapse. He stated out of control spiraling medical costs were unsustainable. His judgment that economic recovery depended heavily on health care reform was correct.
Following the election of President Obama the political health care debate was filled with irrational rhetoric meant to incite the uninformed and ignorant. Lobbyists for big monied special interests and the politicians they purchased were able to block meaningful Health Care Reform. Big Pharma and Big Insurance lobbyists and their minions on both sides of the isle were successful in assuring the Health Insurance Regulation legislation passed was in their financial interest.
It was not pretty to watch. I knew Otto von Bismark, Prussian/German statesman of the 19th century, was correct when he said, “Laws are like sausages, it is better not to see them made.” Bismark was a social reformer who enacted German health insurance reform in 1883, one hundred twenty seven years before President Obama was able to accomplish similar legislation for Americans.
At the beginning of this process in early 2009 I knew it would be impossible to sit on the sidelines and watch the politicians make a mess of health care reform. I collected many books currently published by people believing they had identified the problems and had solutions to offer. All presented financial data documenting the American healthcare system is in crisis. Several authors had a shallow understanding of some of the causes. In my opinion, few had solutions that would work in the real world. I began writing Creative Design for Health Care Reform in February 2009. I submitted the manuscript to iUniverse on August 28, 2010.
The initial “editorial evaluation” was returned with suggestions for major revisions. I was told I had written two books, in different styles for different audiences. The editors recommended I split the book into a memoir recounting what, where, when and how I learned about the problems in our health care system and discovered how to fix them. I split the original manuscript and re-wrote the first book as a memoir in story form for the lay person. This first book should be available Spring 2011. The first draft title for the memoir became:
The Cause and Cure
America’s Health Care Crisis
A physician’s memoir.
By Roger H. Strube, MD
With Foreword by Wesley Wallace, MD
The second half of the original manuscript is a more technical description of the health care, health insurance and HMO segments of our medical-industrial complex and the drivers for our cost and quality problems. This book will stimulate discussion and debate between folks working in the industry and political wonks. A complete description of a diabetes disease state management program with documentation of results is provided. A discussion of the economic and political winners and losers is followed by a strategy for implementation of the solution. The Appendix contains the complete business plan for development and implementation of the solution. The second book should be available at a book store near you by fall 2011. The title for this second book became:
HEALTH CARE REFORM
Resolving the Cost and Quality Crises
in the American Health Care System
By Roger H. Strube, MD
With Foreword by David Willis, M.H.A., M.P.H
A Short Summary
Our present health care crisis is a two headed dragon. One head is the cost of our dysfunctional health care financing system and the other the cost of unnecessary and harmful medical care. The greatest portion of the entire health care crisis is physician driven. Virtually nothing happens in our health care system without a physician's order. Demanding patients, and Big Pharma TV ads, push the problem but, to repeat, nothing happens without a physician's signature. Our financial and quality crises are, "Just what the doctor ordered."
I understood our health care system was expensive and cost containment was possible when I practiced medicine. After several years of administrative medicine the epiphany came as I gained profound knowledge of the reasons American health care is dysfunctional and what is necessary to fix our problems. I would spend the remainder of my professional career attempting to improve the quality of health care and eliminate payment for medically unnecessary goods and services.
The extent to which the doctor orders unnecessary medical care is in the main, the result of the limitations of the human mind. The fact that we can not “know” enough medical science to make reliable memory based decisions is a large part of the quality crisis. Our inability to reliably access the critical small subset of medical facts that apply to a specific patient problem, out of the mass of medical Swiss cheese that is our memory, is another small piece of the puzzle.
Patients’ complaints that doctors do not listen to them and do not perform complete examinations put light on one of the critical causes of the health care crisis. Although doctors are trained in medical history taking and physical diagnosis (the findings of a complete physical exam), these skills are no longer honed by many medical students, residents or practitioners. Classical training of history and physical examination is to establish a tentative or working diagnosis. Laboratory and imaging studies are used to confirm or modify this initial impression. This no longer seems to be the case. Listen to the following NPR broadcast:
Most physician practice incident medicine focusing on a patient complaint of the day. Many physicians launch directly into chasing very expensive wild geese. A small percentage of physicians choose to pursue problems that will result in the highest return on investment for the doctor. Minimal or no time is invested in history taking or physical examination, the cornerstones of the art of diagnosis.
A patient with chest discomfort may have twenty or thirty thousand dollars of testing and procedures ordered and completed before a stethoscope is placed on his chest. After all, listening to a patients heart sounds is part of a $50 office visit. The doctor can charge the health care system over $500 for an ultrasound of the heart, necessary or not. If the physician owns the imaging equipment, it is more likely the unnecessary test will be done.
Physicians have a love/hate relationship with technology. We love to order very expensive, high technology tests whether they are necessary or not. A physician who owns the equipment or is invested in the company building the toys, or owns part of the facility where the test is to be done, is more likely to order the test or imaging. Physicians love technology that makes them appear to be on the cutting edge of medicine. Using well defined evidence based clinical standards to justify use of this expensive technology may help make a diagnosis or help appropriately treat a patient. Many times use of high tech testing and services just puts a budge in the physician’ wallet with no benefit, and sometimes harm, to the patient.
On the other hand, administrative technology that helps improves management of a patient’s illness or improves the quality of care seems to be shunned. Electronic medical record (EMR) systems and computerization of a physicians office are not inexpensive but will result in reduction of unnecessary medical care. Duplication of testing procedures may be eliminated. The less a physician does, the less the doctor is reimbursed. The return on investment that might help physicians provide quality, low cost care is negative. It is difficult for any physician with common business sense be in favor of EMR technology that improves the quality of health care.
Our physicians’ error rate is about fifty percent. In a 2003 RAND Corporation investigators published their landmark health services research article in the New England Journal of Medicine. Elizabeth A. McGlynn, Ph.D., and others published the study, “The Quality of Health Care Delivered to Adults in the United States.” It quantifies that an average patient with a broad range of chronic health challenges has a 55% chance of receiving medically necessary care and the remainder receiving care that is not medically necessary, and possibly harmful. I think they were conservative in their estimates of the magnitude of unnecessary and harmful care delivered. Fortunately we physicians kill only eighty thousand patients a year through mistakes, errors in judgment, etc. These errors come it two varieties:
1. Failure to do the "right thing." This includes all the unnecessary medical services usually referred to as “abuse” and all fraud. Most of our financial problems result from physicians failing to do the right thing.
2. Failure to do the "thing right." These errors include all the sins of omission or commission where physician errors in process, procedure or technique result in harm to patients. These errors injure patients receiving both necessary and unnecessary care. For example, patients undergoing either necessary or unnecessary procedures may contract MRSA infections because physicians or other medical personnel do not wash their hands.
Most physician errors in decision making result in simple over utilization or delivery of medically unnecessary care. Such care is not appropriate, effective, or efficient. Usually no one dies. Only other people’s money (OPM) is wasted. Some call this "abuse" but most of these errors, classified as not doing the “right thing,” are not always the doctor's fault. Physicians have been educated and trained to rely on the dysfunctional global subjective memory based decision making process.
The failure is a system problem that can not be solved by trying harder or attempting to “know” more. We simply don't know what we don't know and can never know enough. The human mind can not effectively apply the small amount of required medical science, to the unique problems of the patient, in real time. The physician and patient are on mission impossible.
The must know-it-all philosophy is the direct result of our medical education and training. Physicians are trained to make memory based critical decisions as we practice incident medicine. Physicians are essentially piece workers managing disjointed individual medical events. The Fee for Service (FFS) reimbursement methodology reinforces this piece work mentality. "Physician Driven Health Care" would simply perpetuate the error rate and the escalating cost.
Similarly, patients don't know what they don't know. “Consumer Driven Health Care” is not possible. The competition discussed in these scenarios is between insurance companies and health care plans. These entities have no control and simply finance whatever the doctor orders. Competition over quality care will not work for health care consumers until report cards for physicians and hospitals, documenting scores for quality measures, are published . Fat chance this will happen. I have been there and attempted that. Neither physicians nor hospital administrators are willing to have their report cards or dirty laundry aired in public.
The bill recently passed by congress and signed by President Obama is not health care reform; it is increased insurance regulation. It appears to me the bill was written by Big Pharma and Big Insurance. On the positive side, it is the nose of the reform camel in the tent.
Most Americans recognize that the skyrocketing cost of our present health care system is not sustainable, but we need to understand increased insurance regulation will not solve the basic problems driving our crisis. Because of our continuing financial crisis, these books are timely and urgently needed. The public must hold the federal and state governments accountable and assure our politicians take action to reform our health care system if America is to restore our competitive position in the new world economy.
The Manuscript Becomes Two Books
The manuscript for the first book was submitted in January 2011. The Cause and Cure for America’s Health Care System Crisis - A physician’s memoir...is an insider’s perspective of our medical-industrial complex written for the lay person. It takes you on my journey of discovery through the maze that is our health care system. The problems and their solutions are described so the public may understand and take political action. This book should be available during late winter, 2011.
The second book, Creative Design for Health Care Reform explains the real causes of our crisis, the solution, and how to implement real reform. It is written to provide the health care industry professional a fresh perspective on the causes of and cure for our health care system ills. A cook book for a comprehensive diabetes disease state management program is provided. The Appendix presents a complete business plan for the development and implementation of the technology necessary to resolve our cost and quality crises. The final draft of the edited manuscript and finalized book cover art work were submitted to iUniverse in February, 2011. Look for this book in early summer, 2011.
I have attached sections of my books referred to as, “Front Matter” by my publisher, iUniverse. Dr. Wesley Wallace wrote the Foreword for the first book. David Willis helped edit and wrote the Foreword for the second book. The Preface, Acknowledgments, Table of Contents and Author’s Biography for Book One and Book Two may also be viewed. I attached a copy of my resume to document the education, training and experience qualifying me as an “expert” on this topic.