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Journal of Long-Term Effects of Medical Implants
Abstract of "U.S. Health Care in Crisis: A Case for Treating the "Perfect Storm" with the VHA Model"
Jeffrey P. Weiss
SUNY Downstate Medical Center, 450 Clarkson Ave, Brooklyn NY 11203, VA New York Harbor Healthcare System, Brooklyn, NY
The United States is facing a crisis in failure of health-care delivery to all its citizens. In part this crisis owes its genesis to the problem that the business of medicine is the evil twin of the practice of medicine. This is not a new problem. Practitioners have faced this issue since the beginning of recorded time. The evolution of doctors as businessmen has inevitably followed limitations on net income inherent in widespread acceptance of reimbursement for medical services rendered by third-party payers such as Medicare, state Medic-aid, and insurance companies. Since such reimbursements are relatively fixed while practice expenses rise, doctors have either accepted lower net incomes or altered behavior to follow the dollar. Examples of the latter include seeing increasing numbers of patients within a fixed time period (placing increasing pressure on time spent in doctor-patient interactions) or investments in equipment designed to maximize monetary return per medical problem. Thus, whereas global reimbursement for treating a single prostate cancer with surgical extirpation may be in the range of $2,000, radiation therapy in treating the same individual gland may return 20 times that sum. Physician behavior may then be altered irrespective of actual outcomes, to invest in and employ radiation equipment in lieu of less remunerative surgery. Similarly, whereas physicians previously eschewed the idea of extenders such as physician assistants and nurse practitioners owing to placement of a barrier between physicians and patients, the same individuals may increasingly accept such extenders in order to improve financial practice efficiency. Other pressures on physician income have been mounting at historically unprecedented rates. For example, whereas the U.S. cost of living has increased by about 20% between 2000 and 2007, the average practitioner of obstetrics in Pennsylvania spent about $37,000 in medical liability insurance premiums in 2000 as compared with $145,000 in 2007, an increase of about 400%. Despite the latter, reimbursements for deliveries in that state have remained essentially constant. It is thus no surprise that many corners of that state suffer from a lack of obstetrical services. While many solutions to this essential problem are possible, application of the clinic model of health-care delivery employed in the Veterans Health Administration would eliminate financial incentives altering practice behavior; application of the Federal Tort Claims Act would curb frivolous legal action while preserving both patient legal rights and the health-care dollar. Quality assurance for physician performance could then be institutionalized by means of fair hierarchical oversight procedures currently in place, even allowing for physician bonus incentives based on actual medical performance and outcomes. Research into the applicability of the VHA model of health-care delivery to a putative U.S. national health service is urgently warranted.
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