Surgery News - September 2007 - (Page 4) S U R G E R Y NEWS • S E P T E M B E R 2 0 0 7 THE VISION Evolutionary Changes in Surgical Practice Augury for Surgery C O M M E N T A R Y: HYBRID HEALTH CARE 20/20 I We excel at managing breast cancer, tuberculosis, and cardiac probM . D. , FA C S lems, and we have many world-class n ancient Rome, an augur was a medical centers of excellence. But we priest who sought to interpret the also have more than 46 million peowill of the gods by studying the be- ple without health insurance. As Dr. Gawande has pointed out, havior of birds. Roman leaders asked augurs for their opinion of a planned most of the health care proposals to course of action in areas such as war, date share many features found in commerce, or religion. Today we use European plans, defining basic benethe term augury to indicate the com- fits that insurers must offer without ing of something good or bad. The penalty for preexisting conditions. root has also survived in the word in- Additional coverage would remain auguration, which brings to mind the available in competitive private plans, health care changes we can expect to with or without federal subsidy, and hear about when our next president is there would be shared responsibility for payments from employers having inaugurated. This detailed look at the etymolo- more than 10 or 15 employees. Cost gy of the word augur is also a cir- savings would be sought from pay for cuitous way of introducing “The performance and electronic medical 20/20 Vision,” a new section devoted records. These are not new concepts, but to evolutionary changes in surgical practice. These changes seem in- they are resurfacing as the winds of political pressure increase evitable as lifestyle-sensiand the public’s resistance tive residents complete to change lessens. their surgical training and If there isn’t going to be enter practice, new health more money in the syscare policies emerge from tem, and the next generaWashington, and estabtion of surgeons will belished surgeons find themworking fewer hours, selves competing with what will surgical practice cheaper providers of surbe like in 2020, and at gical services abroad. It’s no secret that health LAZAR J. GREENFIELD, what level of compensation? Your guess is as good care is generating a lot of M.D., FACS as mine, but informed disnegative press and media commentary. From the populist gad- cussion of the question is essential. In the coming months, we will defly Michael Moore, whose movie “Sicko” was released this summer, to vote “The 20/20 Vision” to a comthe sophisticated editorial of surgeon parison of health care proposals as and ACS Fellow Atul Gawande (New well as analysis and commentary by York Times, May 31, 2007), there is a knowledgeable surgeons and other swelling tide of calls for major professionals. Surgeons must become part of the changes in the way we deliver and pay solution rather than be considered for health care. With costs increasing about 8% a part of the problem. It’s too late to year to a projected 20% of the GDP simply show our scars and complain. by 2016, large corporations, unions, Some patients are already traveling legislators, major health insurers, and abroad for their operations. The augury of this scenario may be the public want to see a new system that provides coverage for everyone discouraging, but the worse fate is to without costing more. Needless to be looking in from the outside while say, this does not include an increase decisions are made. We need to become informed, and in reimbursement for surgeons. Per capita spending on U.S. health help to chart the course. Remember care in 2006 was $6,102, according to that the fall of Rome, according to the Organization for Economic Co- Gibbon, was accelerated by outoperation and Development—more sourcing the defense to barbarian than the amount spent in any other mercenaries who eventually turned country and twice the average of on the Romans (Daedalus 1976;105: $2,571 (Los Angeles Times, June 18, 153-69). Not that we would ever consider 2007). Yet the United States ranks 22nd in politicians mercenaries. Perish the life expectancy, loses more lives to di- thought. ■ abetes, and has higher infant mortality rates than Japan, Sweden, Nor- DR. GREENFIELD is Editor in Chief of way, Finland, and Iceland. SURGERY NEWS. B Y L A Z A R J. G R E E N F I E L D, is the best way care million indiWhatinfor the nearlyto47provide health viduals the United States who lack erage as well as political and fiscal feasibility. These aims could best be met through a hybrid approach guaranteeing all Americans a certain basic level of health insurance? Divergent viewpoints were presented health care. Universal care would include earlier this year by Dr. Kevin Grumbach objectives such as prevention of diabetic and Dr. Robert Moffit (SURGERY NEWS, complications and earlier detection of January 2007, p. 4). Dr. Grumbach pro- malignancies, thereby improving outposed single-payer universal coverage as comes and reducing overall costs. This health care safety net the most cost-efficient solucould be a government entition. Dr. Moffit advocated tlement program covering bamore incremental reform, sugsic preventive services and rougesting that working adults tine care. For children, this could be required to purchase might take the form of excoverage with tax incentives. panding the State Children’s Single-payer proposals sugHealth Insurance Program to gest that minimizing cost allow universal eligibility. For should be the top priority. The adults, coverage might be proClinton health insurance reform effort in 1993 failed large- BY HARI NATHAN, M.D. vided through an adapted form of existing federal health ly due to the notion—real or perceived—that it would restrict patient programs. To be fiscally feasible, the plan would and physician autonomy in an effort to rehave to offer moderate benefits, such as a duce costs. Historically, Americans and their physi- limited choice of providers and generic cians have resisted such interference in drugs whenever available. Patients wishmedical decision making. Single-payer ing to expand their choice of providers, proposals sacrifice choice to contain costs acquire additional coverage for namebrand prescription drugs, or otherwise while providing equal access to care. But these systems do not necessarily augment their coverage would be allowed guarantee equality. For example, several to do so. Perhaps employers could offer studies of the National Health Service in coverage for such options as a taxable benthe United Kingdom have documented efit, or individuals could buy private inthat utilization of specialty care, including surance for the added benefits. Allowing individuals to buy into the surgical care, is higher relative to need among groups with higher socioeco- Federal Employees Health Benefits Pronomic status ( J. Health Serv. Res. Policy gram or Medicare as their supplemental coverage would pressure private insurers 2007:12:104-9). And a single-payer system would likely to lower their administrative costs. Tax lead to increased waiting times for surgi- credits (not deductions) should be offered cal procedures and other specialized care, to offset the cost of acquiring additional as has been documented in the United coverage. Some might argue that this approach Kingdom, Canada, and Sweden ( J. Am. Coll. Cardiol. 1995;25:557-63; Can. J. Surg. would create a multitiered health care sys2005;48:355-60; J. Eval. Clin. Pract. 2004; tem in which those able to afford more coverage would have access to expanded 10:3-9). Americans expect to have technologi- services and potentially better care. It cally innovative, readily available choices would not be the cheapest solution. But in health care just as they do for other con- we already have a multitiered and fiscalsumer products. It is unlikely that they ly inefficient system in which some are will accept the limitations of a single-pay- covered by generous health plans, others are underinsured, and a growing number er system. On the other hand, a system of tax rely on a strained emergency medicine credits would work best for healthy mid- system to care for acute problems that dle-income patients and would benefit might have been avoided with approprius all by bringing these healthy patients ate primary care. We need a politically and fiscally feasi(and their dollars) into the insurance pool. But for sicker patients or single-income ble plan that achieves some level of unifamilies, especially poorer ones, even such versal coverage, not another ideological tax benefits might fail to offset the cost of battle that results in little real change. A private insurance. Additionally, such a hybrid system of universal health care system could accelerate the decline in coupled with supplemental coverage employer-sponsored coverage and poten- would be a pragmatic step forward. tially increase the number of uninsured individuals. DR. NATHAN is a fellow in the clinical In my view, health insurance reform research scholars program at Johns Hopkins must achieve some level of universal cov- University, Baltimore.
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