Health Reform: Freedom and Responsibility for Physicians

Harold S. Luft, Ph.D, of the Palo alto Medical Foundation Research Institute and the University of California, San Francisco (Luft:) recently published a New England Journal of Medicine paper, "Health Care Reform - Toward More Freedom, and Responsibiity, for Physicians" (N Engl M Med 361;6 NEJM Org 8/6/09). His  concept of "more freedom and responsibility" particularly resonated with me, because it is consistent with research which I performed as a Fellow of the Health Research Council of the City of New York in the 1960s (HRC) ), which demonstrated that health care organizations under physician leadership and professional control provided patient care far more effectively and efficiently than non-physician led organizations.  My years of practice and organizational responsibilities in a large physician practice (San Jose Medical Group), as hospital chief of staff, as a member and officer of the board of trustees of a large health system, and as a director of the California Hospital Association, confirmed my academic conclusions: physicians must have the freedom (a right) to practice medicine, the responsibilities (obligations) consistent  with a highly professional exercise of those responsibilities, and  must organize themselves (with adequate capitalization) to accomplish the goal of appropriate patient care in the public interest.

 Luft is pessimistic: he doubts the ability of government to slow health care cost growth. He views insurers' (including a public system) tools for health care cost control to be only two: financial disincentives for patients and fee reductions for providers, neither of which have reduced historic health care inflation. He proposes a two-prong system consisting of  universal coverage for high cost services (the 60% solution - my term, not his) , such as hospital care and ongoing care for chronic illness, and a reorganized ambulatory care (the 40% solution) system. Hospitals and their physician systems would receive bundled payments to be allocated internally under each system's unique internal arrangements under the 60% solution. Ambulatory physicians and groups would receive payment at usual and customary rates. Luft proposes measures to avoid conflicts of interest, a highly sophisticated care and outcome information system and other strategies to encourage high quality outcome achieval with high level efficiency. His focus is on rational incentives for patients, physicians, other providers and institutions.

Patients, in ambulatory care, would chose programs meeting their own health care needs, financial capacities and philosophies. Credit-card type fee payment, from the program level chosen by the patients, would be processed just like any commercially existing credit card (drawing down the program pool left for use by the patient), eliminating ravenous administrative overhead. If patients wanted more care, they would  buy a plan offering more; if they felt they could get by with less extensive and expensive ambulatory care, they would save money through Luft's structure.  If they become very ill, requiring hospitalization or ongoing chronic care, they would be covered through the 60% solution pool.

Luft's paper deserves to be read and widely discussed. Whether his rational and sensible approach can be implemented in an environment of  inflammatory politics, economic uncertainty, greed, ego-involvement and scant attention to serious ethical issues, is something for each reader to consider. Check with your local medical library for the New England Journal's August 6 edition, pp. 623-28.

9/1/2009 - Link to cited article: Link to article: http://ihps.medschool.ucsf.edu/News/news/luftnejm.pdf