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If I Could Make Up My Own Rules...

By Dr. Raag Airan
. 1 Comment(s)


Seeing as a frontrunner for the Republican presidential nomination can gain traction with a tax plan borrowed from SimCity, here's what I would do if I could run my own SimHealthCareSystem:

1. Cut the link between employment and insurance. Pass tax subsidies directly to the individual buyer and let insurance companies lobby individual consumers to provide their services. If you want a private system and gain the benefits of the invisible hand you need as many separate buyers making individual choices as you can get.

2. Make national HealthIT standards to allow secure, easy transfer of medical data between providers. I can easily stream Hulu to my iPad while flying at 35,000 ft, yet I can't transfer CT results across town without pulling teeth and growing a few grey hairs. Part of the reason I can do the former is the IT market has made standards for how such data transfer needs to happen and each corresponding piece of software has to hew to those standards. When private actors don't make those standards, government and international engineering bodies step in to do so. We need similar standards so we can transfer medical lab data and imaging results with ease. Without those standards and infrastructure we will continue to repeat labs, imaging, and even biopsies simply because it's too hard to get the results from Outside Hospital and because we have strong fee-for-service incentives to do so.

3. Make having a living will and palliative care consultation required for anyone with an expected lifespan less than 10 years from the present. Maybe I'm just sensitized from particular experiences as an intern, but I feel inappropriate end of life care is an epidemic in our country. With standard end-of-life counseling we have the tools to prevent unwanted and unneeded ICU stays and all the corresponding morbidity and pain that follows. End of life counseling isn't "death panels", it's good medicine.

4. Medical liability reform. I'm one of those that believes medical tort reform can have a big, positive impact on reining in costs due to defensive medicine. Not because of actual rates of medical tort use, but because the perception of a hostile litigation environment is used as much as an excuse for overutilization as a defense from litigious patients. So I would consider the standard tacks: caps on non-economic damages, specialized medical courts, etc. But, I would add a wrinkle: make physicians liable for non-indicated tests and therapeutics they order. If every time you have sign an order you have to weigh the probability of being sued for doing something against the probability of being sued for not doing something, hopefully the two will cancel and you will just consider the medical appropriateness for writing that order. And, consulting services can use yet another approach for blocking a procedure they don't think is entirely appropriate: "I can't expose myself to the litigation."

5. Make a national priority list for studies to establish evidence-based guidelines and have oversight for those studies run out of the NIH/FDA. Why do we wait for academic institutions and pharma/biotech companies to gain interest in and run a study comparing two therapeutic strategies? There are plenty of important questions out there about how two existing therapies stack up for treating a common disorder. So instead of waiting for a company or university to develop a particular (read: financial) interest in a therapy and run a trial to see if it works, have the NIH make a priority list of what needs to be studied, publicize it well, and put out RFAs to run that specific trial. Guidance on what needs to be studied and how can be taken from the FDA who will ultimately have to use that data in judging efficacy and safety. These studies would provide the data necessary for implementing effective evidence-based guidelines.

That’s my wishlist. What’s yours?


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  1. Cilla Mitchell

    Tort Reform is a legal weapon used in Texas against Texans ever since Governor Rick Perry signed the 2003 Tort Reform Act. When there are laws on the books preventing the common man from getting accountability, no telling what will happen.

    Providing a link to a video showing the collateral damage left behind Tort Reform.

    If link is not accessible, just Google Cleveland Mark Mitchell, then click on youtube Cleveland Mark Mitchell December 12 1950 - April 26 2008.

    Thank you for your time,

    Cilla Mitchell

    A Texas nurse and vet

    My wish is for accountability.

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