Will the Safety Net, Flexnerian Medicine and Special Interests Trump Reform?

Flexnerian medicine, the reigning paradigm in medical research and practice, owes its name to a man who counseled against what it has come to mean over the past 60 years. In 1910, education reformer Abraham Flexner of the Carnegie Foundation issued an eponymous report calling for the reorganization of medical training. But in his report, according to this intriguing essay by Michigan State University medicine professor Howard Brody, he specifically eschewed "trying to make medical students memorize large quantities of basic science facts."

No matter, medical training has emphasized precisely that and Flexnerian medicine has come to mean the highly detailed search for the biological causes of disease so that highly specialized physician-researchers could discover and deploy targeted cures. And, as a depressing essay in today's New England Journal of Medicine by Columbia University public health professor Lawrence Brown points out, "innovation and specialization became integral to medical education and to U.S. definitions of high-quality care."

Brown offers the Flexnerian mindset as one of three reasons why he believes, despite the sturm und drang over health care in this year's election cycle, reform isn't at hand. Nothing in reformers' bag of tricks "holds much promise of disrupting these formidable medical-cultural continuities," without which, "new efficiencies and savings" are impossible.

Brown also cites the largely overlooked safety net for the uninsured, comprised of "public and voluntary hospitals, community health centers, public health clinics, free clinics and services donated by private physicians." Their very presence "drains moral urgency from the health care reform enterprise." Or, to quote President Bush, the uninsured "still get care."

The final roadblock to reform, in his view, is the lack of real concern by the special interests in the game, specifically, the business community, the insurance industry, and providers (hospitals, doctors, drug and device companies, equipment suppliers, and the rest). All fear the costs of reform will hurt their bottom lines. "The axis of opposition that has throttled reform in the past still concurs on three points: that reform should not make big government much bigger; that the costs of reform ought not to fall on them; and that other items on their agenda take precedence."

The best we should hope for, he argues, is some expansion of Medicaid and/or the states' Children's Health Insurance Programs (S-CHIP) to cover some of the uninsured. "No one knows how to infuse moral urgency into the push for universal coverage, make the system's medical style markedly less expensive, and thrust reform to the top of the agenda for powerful interest groups," he concludes.

That's not right. The moral urgency is there. Until the economy became wobbly, every poll suggested health care insecurity was the top domestic priority for most voters. The problem is that not everyone shares that agenda. Specifically, organized medicine and the special interests that influence medical practice have done quite well, thank you, as health care has soared to 16 percent of gross domestic product while health care outcomes lag other advanced industrial countries. Why should they care deeply about reform?

There are lots of tools in reformers' toolboxes for holding down the skyrocketing health care costs while delivering higher quality care. To name just a few: comparative effectiveness research, evidence-based medicine, focusing on prevention, and a strong government presence with negotiating power to hold down costs. And then there's the reforms that rarely get mentioned in the august pages of NEJM, such as reorganizing physicians into salaried group practices to remove the incentives for daisy-chain referrals that can needlessly run up costs.

The nation's premier medical journal this morning offered up its pages to a perspective that cautions reformers to aim low so that a few more people will get insured, as if getting providers a few more paying customers should be the only goal of reorganizing the insuring and delivery of health care. Correcting a dysfunctional yet stable health care system is beyond imagining and politically infeasible, in Brown's view.

Maybe. The broader business community's support for reform is only lukewarm because until recently there was plenty of cash around to support endless increases in health care insurance premiums. But if the looming economic slowdown is deep and long, with corporate profits, salaries and bonuses entering a prolonged slide, the business community's willingness to hang together with the still profitable insurance and drug companies -- not to mention high physician salaries -- may evaporate.

The corporate sector's first choice for reform would be some variant of the Republican plans -- put the onus on individuals and allow "consumer choice" to shrink the market. This is rationing by income and antithetical to public health, but it would be a solution to rising costs.

But if one or the other Democratic Party candidates gets in with a Democratic Congress and slashing health care costs becomes a corporate imperative, then reformers may gain the necessary ally for enacting meaningful reform.

Posted by gooznews at January 24, 2008 09:00 AM