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Pieces of Eight


Willson Addresses Statewide Medical Issues

Dr. Charles Willson, clinical professor of pediatrics at the Brody School of Medicine at ECU, was recently installed as president of the North Carolina Medical Society. Following is an edited version of his remarks to the group’s House of Delegates Oct. 16:

Over the next few minutes that you have graciously allowed for me to speak, I will describe the major issues and then set out a treatment plan for your thoughtful consideration. These issues are complex and if the answers were easy, we’d have already made the fix.

Here are the headlines:

Charles Willson

“45 million Americans have no health insurance.”
“Up to 100,000 Americans die each year in our hospitals from medical errors.”
“Half of personal bankruptcies in America due to health bills.”
“Bush administration asks Congress to cut $10 billion from Medicaid.”
“Medicare projects 30 percent cut in physician reimbursement.”

“American Medical Association considers North Carolina to be in crisis over professional liability.”

Physicians are only one part of this dysfunctional health care system, but we are the natural leaders and have the knowledge and influence to effect significant change.

Now, I heartily agree that for many Americans with full medical insurance, our health care system is the best in the world. But 45 million uninsured Americans do not have access to medical care when they need it. Study after study has shown uninsured patients wait longer to access medical care, often end up in emergency departments clogged with other uninsured patients and certainly don’t spend money on preventive services that will keep them healthy.

As the most democratic, innovative and affluent nation ever, we have the resources to fix the problem. We just don’t have the political will. Sure, any program that provides health care coverage for all Americans at an affordable price will be expensive, but I suggest the money is already in the system. We need to spend more wisely -- less on technology and administrative costs and more on prevention and wellness. In pediatrics, we learned long ago that preventing an illness costs much less than treating it once acquired.

Another statistic I’ve heard repeatedly is that a person spends 70 percent of his health care dollars in the last three months of life. Some may argue that we don’t know when the last three months of life have arrived, but for many our medical interventions merely prolong dying. Let’s move some of those dollars forward in a person’s life to pay for prospective care to identify genetic, lifestyle and environmental risks to a person’s health. Dr. R. Sanders Williams, dean of the Duke School of Medicine and a college classmate of mine, spoke eloquently of the promise of this concept at a meeting in Baltimore last spring: Every American, upon reaching adulthood, should have a prospective care visit and be given a individual life plan for preventive care and health promotion. Young adults will know what their ideal weight is, how much exercise they need and what foods to eat or avoid. To do this, traditional primary care offices will need to be retooled, and employers will need to buy insurance that covers this prospective care evaluation. For business, the payoff will be healthier employees who perform better with fewer sick days.

Now, let’s talk about reimbursement. The health care financing system in our country is crumbling. Everyone agrees that health care costs too much. Since physicians are generally seen as being affluent, insurers and government bureaucrats keep trying to bring costs under control by cutting physician reimbursement. This is folly. Physician reimbursement represents only 9 percent of their costs. But prescriptions, orders and treatment plans lead to more than 70 percent of health care spending.

Our Community Care of North Carolina Medicaid program put physicians in a leadership role. In CCNC, we have shown that by giving physicians incentives and resources such as disease management protocols, case managers and utilization data, we have improved access to care for our most vulnerable patients, leading to cost savings for the state. Pay-for-performance will replace fee-for-service and the cynical capitation payment model. Pay-for-performance is not a bad idea so long as it doesn’t penalize the practitioner who doesn’t have the resources to meet the benchmarks.

Meanwhile, our primary care practices and medical schools are caught in the vise of declining reimbursement from insurers, projected cuts in revenue from Medicaid and Medicare, and escalating costs for liability insurance and office staff. Physicians seeing the poor and uninsured will be hit hardest. We must rally behind these physicians and medical schools and fight for their existence. … Many of you participate in free clinics or see indigent patients for free in your office, and I applaud you. But this is only a stopgap measure. We need a health care system for all Americans.

Rising insurance premiums continue to drive physicians into early retirement, to practice defensively and to abandon high-risk but potentially life-saving procedures. We at NCMS have continued to forcefully articulate this crisis to our state leaders, and several suitable bills were introduced this year. Unfortunately, our opponents made sure none made it to a vote. If a solution cannot be found, our citizens may find that in their time of utmost need their community no longer has an obstetrician, orthopedist, neurosurgeon or trauma surgeon to help them.

For physicians to be credible in our request for tort relief, we must show we are acting to reduce medical errors. As you know, a bad outcome does not imply a medical error, and most medical errors are caused by system failures rather than bad doctors. Unfortunately, liability risk limits the discussion of bad outcomes. As a citizen and a future patient or the husband or father of a patient, I want to know that my family will not suffer the same system failure that someone else suffered last month or last year. The NCMS Quality Committee is working to identify how to seamlessly implement into the office setting best practices that eliminate errors.

My care plan for the maladies described in the opening headlines is professionalism. … From the initial call to our office where a human voice could replace the recorded options to the checkout counter where a structured payment plan could replace the collection agency, we must show that we care for the patient as an individual. When seated in front of the patient, we must look him in the eye and listen with our hearts. When called after hours, we must do more than say, “Go to the emergency room.” When a mistake or a bad outcome has occurred, we must tell the patient what went wrong and that we will do all we can to make things better. That’s the type of doctor I want for me and my family. That’s the type of doctor who is not likely to be sued for malpractice. That’s the type of doctor a patient will pay without second thought. That’s the type of doctor a patient will go to the legislature and fight for.

My second prescription is caring for each other. We are all facing difficult times professionally and financially. Let’s sit down and understand our colleagues rather than pointing fingers. Let’s agree to tackle the issues of the uninsured, medical errors and health care costs using what’s best for the patient as our benchmark. Let’s work to facilitate access for our patients to needed technology but condemn the overuse of resources for defensive or financial reasons. At the end of life, let’s advocate for a peaceful, comfortable death in place of a few more days on a ventilator. Let’s instruct our patients on risk-avoidance and healthy lifestyles rather than waiting for the inevitable disease to appear. Let’s practice what we preach and attend to our own physical and mental health as well.

While these ideas are not new and I can’t promise quick success, I can promise that your North Carolina Medical Society will work with any and all who are willing to craft solutions. I welcome your ideas and critiques. I will be the lead dog when and where our profession needs me, but I will represent this House of Delegates and not myself. Our society has the strength, credibility and reputation to lead this effort. …

This page originally appeared in the Nov. 18, 2005 issue of Pieces of Eight. Complete issue is archived at