Over at The Health Care Blog, Dr. Richard Reece declares “the wonks are wrong”. In general, that’s a pretty defensible statement, no matter the subject, and by his picture, he’s old and wears a bow-tie, which lends some extra credibility.
Despite this, he’s half wrong.
Dr. Reece’s interpretation of “the wonkage” is this:
The system is terrible. It is fragmented. It is inefficient. It is too costly. It relies too much on specialists. Patients with chronic disease see too many over-paid specialists who don’t talk to each other. What we need is more well-paid primary care practitioners. They will provide accessible, continuous, comprehensive, coordinated, connected-electronically, and patient-centered rather than specialist-centered, care.
That’s pretty much the line we’re all being fed here in Doctorland. He goes on to describe a patient whose primary care doctor diagnoses her with diabetes and the patient then demands a specialist, despite lacking any reason to need one.
After a bit of analysis, Dr. Reece concludes:
In choosing doctors, patients still prefer to think for themselves, rather than having others think for them.
If their decision involves “waste” for the system, so be it. One person’s idea of waste may not be reality-based.
And here lies one of the biggest problems with our health care system. The “wonks” are right, we have a horrible health care system, full of waste, poor outcomes, fragmented information systems, and expensive care. The reason for this is, at least in part, our national ideology, well-encapsulated by Dr. Reece: “Who cares how crappy we are, just let everyone do whatever they want, and damn the consequences.”
This libertarian approach to health care is making us broke and killing us. That’s a bad combination. We need leaders, including physicians, to say, “No. That’s not how to go about this.” I have plenty of patients who want to go to chiropractors and whose insurance covers it, but I don’t refer to chiropractors because chiropractic doesn’t work. I also avoid unnecessary referrals to specialists because I am a specialist. When I’m out of my depth, I refer. If a patient wants a to see a specialist, or get certified for cannabis, or visit a chiropractor, they are free to do that, but they don’t need my blessing—for the most part, at least. If they have certain HMOs they do need a referral, and if I think it’s potentially harmful (like cannabis or chiropractic), I’m not going to refer them. They can still go, but they have to pay for it.
And that seems to me a very libertarian idea. Why should we as a nation, or an insurance company, pay for unnecessary care? If a primary care doc diagnoses diabetes and comes up with a treatment plan, but the patient wants an endocrinologist, fine: but they can pay for the unnecessary care.
What say you?