The biggest domestic policy challenge facing the United States is not education, the gutting of the Voting Rights Act, or the defense budget. No folks, the greatest challenge is controlling health care costs – a fight that our country has overall been losing, and one that is having devastating effects. The increasing cost of health care leads to reduced funding for education – thereby raising the costs of tuition, particularly at public colleges and universities, and increasing the debt load carried by graduating students. The wages of our middle class citizens – the people this country was supposedly built by – are continually strained by the rising costs of insurance premiums and health care, reducing take home pay and economic activity. Health care consumed nearly 18% of GDP and accounts for the largest part of the federal budget, making it one of the drivers of our nation’s long term debt.
Unfortunately, there is no magic bullet. Don’t get too depressed by that – clearly something as complex as controlling the costs of health care shouldn’t have a simple solution. One need only look at the myriad pages of the Affordable Care Act to know that health care legislation is never easy or simple. In order to win this battle, health care cannot rely on one single policy fix but rather on a series of reforms.
No, winning this battle requires a transformation in the way we deliver care in this country. It means making more cost and value conscious decisions in medicine, and focusing on keeping people healthy rather than being reactionary when people get sick. This transformation requires delivery of care in teams rather than individuals and coordinating that care between different sets of teams and systems. It requires making customization 5% of what we do instead of 95%. And it means being open and honest about the quality of care delivered and at what cost.
All of these changes require the active participation of physicians. The bad news is, according to a recent study published in JAMA, physicians aren’t ready to lead. In fact, physicians blame others for the expense of health care. A sample of over 2500 doctors was asked to rank different entities as either having major, some, or less responsibility for reducing health care costs. Respondents rated the following groups as having major responsibility: trial lawyers (60%), health insurance companies (59%), hospitals/health systems (56%) and pharma (56%). 98% of respondents felt that patients had either major or some responsibility. Only 36% felt that physicians had major responsibility for reducing health care costs.
The problem is that we know physicians ARE actually responsible for the vast majority of health care costs. Even though physician income only accounts for anywhere between 10 and 15% of health care expenditures, physicians drive much of the rest, with estimates as high as 80% of health care expenditures coming from physicians. The most costly healthcare instrument turns out to be the physician’s pen… and increasingly the mouse button. If physicians truly drive 80% of what our nation spends on healthcare, physicians must be part of the solution to controlling costs.
Bioethicist and writer Ezekiel Emmaneul probably said it the best in his editorial in the same JAMA issue.
And yet, physicians must lead. They are the captains of the health care ship. Physicians’ decisions determine which patients are seen in the office, how frequently, and by which practitioners; which patients are hospitalized; which laboratory tests, diagnostic procedures, and surgical operations are administered; which medications are prescribed; and which patients will be visited at home for care. Implementing these  transformations cannot occur without physicians’ active participation and engagement. If physicians oppose these changes, reform will fail.