The final word: Health care reform and our shared professional ethics

Monday, May 01, 2017 12:51 PM
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Matthew Wynia, MD, MPH, FACP

Not long ago, reports of unsafe and poor quality care proliferated, and a dysfunctional malpractice system prevented the learning necessary to improve. Millions of Americans were locked in jobs for fear of losing their insurance. Others found their coverage didn’t include basic needs like mental illness or pregnancy care, or their insurers found creative ways to rescind coverage after illness arose, or health plans would cut off coverage when a patient with a devastating illness reached a lifetime coverage limit. Many millions of people, especially the roughly 30 million Americans with a pre-existing condition, were priced out of the insurance market altogether, leading to almost 50 million Americans having no health insurance.

In those days, I frequently had to tell uninsured inpatients that our hospital was functionally unable to provide any follow-up outpatient care – they would have to seek care at the county hospital and figure things out on their own after discharge. Those conversations were heart wrenching, and they were guilt-inducing. One need not be an old-timer to remember the bad old days of 2013.

Today, the situation is far from perfect – there are physicians who say some trends have even gotten worse, with persistently strained state Medicaid budgets, rising premiums, narrow physician panels and high deductibles – and the threat that they could get much worse again is very real. Organizations that have proven extremely valuable in developing safer and more effective and efficient care are at significant risk. Recent budget proposals include the complete elimination of the federal Agency for Health Care Research and Quality (AHRQ). The Patient Centered Outcomes Research Institute (PCORI), created by the Affordable Care Act (ACA), is on the chopping block along with the rest of “Obamacare.” Replacement plans for the ACA might let insurers charge much higher prices for people with pre-existing conditions and coverage could, once again, exclude very basic services. Even the NIH and the CDC are endangered by proposed massive funding cuts. Perhaps worst of all, tremendous uncertainty reigns in the health care world. 

And yet, this is also a time of remarkable opportunities. Having worked so painstakingly and for so long on the digitization of health care,  some doctors are finally poised to actually capitalize on information technology. It’s possible that big data, deep learning and new partnerships could emerge that might help us create continuously learning health care systems. What’s more, many novel technologies, from genomics to pharmaceuticals to surgical approaches and devices, are raising hopes for improvements in human health and well-being that were only recently the stuff of science fiction.

How any of these issues will evolve is uncertain, but three things are clear: the threats are not new, every risk also brings opportunities, and our profession is ready.

We are ready because organizations representing physicians, including CMS and the AMA, have been toiling in the trenches of health reform battles for many years. And we have known the challenges we faced would not end, because improving the health care system is a complex adaptive challenge, not amenable to simple or quick fixes.

In a complex adaptive challenge, every proposed solution, even if worth pursuing, can be expected to raise new issues and problems of its own. That’s why health reform is almost always about taking small steps forward, sideways and sometimes backward – it’s never about one big change that will solve everything. Treating complex adaptive challenges as merely technical problems that can be fixed with a single intervention would reflect a fundamental misunderstanding of the type of problem we face.

Most importantly, CMS and AMA leaders have realized that the hallmark of complex adaptive challenges like reforming health care is that different groups of people see them very differently, typically disagreeing on the basic causes of problems as well as on most proposed solutions.

In that light, our organizations recognized an existential risk of increasing tribalism in medicine around specialties or around political parties as health care reform options are discussed, rather than professional coalescence around our shared core values.

In response, several years ago we moved beyond simply responding to and arguing about individual proposals, to articulating sets of shared core ethical principles to guide our actions, regardless of the particular problems or opportunities that might arise. CMS created a comprehensive matrix of principles to guide advocacy and policy around health reform, emphasizing universal coverage, access to a basic set of health care benefits, transparent and participatory quality reporting and more.

Medicine will continue to face challenges and opportunities, both in politics and in science – that is the nature of the important work we do. The patients we serve are counting on us to work together, and to hold fast to the ethics that guide our profession.



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