The Health Care Solution – Understanding the Crises and the Cure by C. Duane Dauner, with Michael Bowker. Vision Publishing, Sacramento, California, 1994. 174 pages, $21.95.
by Del Meyer, MD
C. Duane Dauner, CEO of CAHHS, who recently favored us with an article on health reform, has a volume on the booksellers’ shelves discussing the health care crises and his recommendations for a cure. He relegates the government to a policy and supportive role stating, “Several of the government’s well-intentioned acts have contributed to our current health care troubles. Perhaps the most significant was the passage of Medicare and Medicaid in 1965.” Although the goals were humane and honorable, he continues that these laws “have contributed to the system’s problems…projections fell short of actual expenditures…the public views Medicare and Medicaid as a right, despite the government’s unwillingness to pay the bill.” He continues by citing both the government’s management of medical education and the research boom as having an undesirable effect with a great influx of specialists. This caused a shortage of generalist doctors, who are capable of meeting up to 75 percent of the public needs. “While free-market competition usually drives prices down, among medical providers it seems to operate in an inverse fashion – the more specialists there are, the higher the utilization, and thus costs.” U.S. hospitals have become 24-hour convenience stores, boasting more high-tech medical wizardry than found in many countries around the world. Some communities have more cardiac surgery units and MRI scanners than all of Canada. He also points out that government has a long history of enacting policy that contradicts the goals and values it espouses. “Although the US Surgeon General’s office issues warnings on the known ills from tobacco, the federal government subsidizes those who grow it.” Regardless of the reasons for such contradictory behavior, the reality is that government is ill-equipped to remedy the system’s complex problems and, therefore, should not micromanage reform.” He continues, “The government’s message has been almost arbitrary, changing seasonally with the political tides, with no overall long-term vision, direction, or focus.” We must change to positive personal incentives for providers rather than governmental attempts to change behavior through negative incentives, such as fines, regulations, controls, or restrictions. He recommends that hospitals rebundle their payments after years of unbundling all charges against insurance carriers.
After two chapters of understanding the change and the competition problem, the third chapter views the alternative solutions. The Canadian system, which is often held up as a potential model for the U.S., is struggling. In 1974, when the program was initiated, the federal government played a much larger role, paying for 60 percent of the health care system. Today, it pays for only 40 percent. The statistics are skewed because Canada, like some other countries, does not include long-term care institution costs or prescription drugs in its health care budget, while the U.S. most comprehensively folds all health care and long-term care costs into its reporting of health care expenditures.
While government-controlled systems have managed to keep a lid on costs, most have done so by rationing. In the past decade, Germany, Denmark, Italy, the Netherlands, Portugal, Greece and many other countries systematically removed several drugs and some services from coverage. In the mid-1980s the United Kingdom eliminated the right of adults to receive eyeglasses and in 1988, the right to free dental checkups and sight tests was also abolished. These countries found that transferring costs from the public to the private domain saved money by moving costs to the private sector, which then forced people to come face-to-face with the real costs of health care and reduced consumption.
The forward by Tip O’Neil reflects the public attitude toward us. Tip states the medical profession has gone from success measured by the quality of a doctor’s bedside manner to one where success is determined by the bottom line. Bedside manner is extremely important, but our success is ultimately determined by outcome of doing what we were trained to do. Other than that, he is accurately describing the hospital’s bottom line. In a recent health forum on public television, medical high technology was only rated 1 percent importance. That can only be explained by the fact that Americans consider a fluoroscopically monitored vascular catheter with a video camera at its tip looking at a plaque in the coronaries on another screen as a routine diagnostic test even though its unavailable to 99 percent of the world’s population.
The last seven chapters deal with Dauner’s health care solution. Even if you don’t agree with capitation, integrated networks, gatekeepers, and generalist physicians in control, it behooves all of us to be knowledgeable in these areas for his upcoming “essential public debate.” This is a worthy challenge for our society.