Have you wondered how healthcare reform will play out? You only need to look at how healthcare has been laid out by the World Health Organization (WHO). The International Classification of Disease also known as the ICD is the coding system that is used to classify diseases. It is published by the (WHO), and it is also the basis for reimbursement for hospitals and physicians.
There have been several iterations of the ICD. The most recent is ICD-10. Seven countries have adopted it to date. The first country to adopt it for clinical use was Australia in 1998 then Canada in 2000. The most recent country to adopt it was Thailand in 2007. The United States is scheduled to adopt it in 2013. Just in time for the major pieces for the healthcare reform pieces to take effect. The mad rush to pass healthcare reform makes a lot of sense when this time table is taken into consideration. It finally brings the US healthcare system into the global healthcare system overseen by the WHO.
How will our healthcare system change when 30 million new people will be covered and will need healthcare? The system in British Columbia, Canada provides an example of what we can expect. They have adopted a healthcare system that has clinical treatment guidelines set forth by a protocols advisory committee. Our healthcare reform system also sets up an advisory panel that will use evidence based medicine.
These advisory panels set up treatment flow sheets that will make it easy for healthcare providers such as physician assistants to provide care. Now I understand how Governor Rendell can make the statement that he did a couple of weeks ago that health care providers are “just as good as primary care physicians”. Although we have a shortage of physicians, the statement is clearly based in the premise that anyone can use algorithms to cookbook medical care. All you need to do is connect the dots.
This is great until you apply it to the real world. Take for example the treatment of middle ear infections or sore throats. I have treated many children who finally get referred to an ENT after months of recurrent ear infections after they have speech delay and/or are not doing well in school because of hearing loss from the chronic infection. I have also treated adults with hearing loss that resulted from childhood ear infections that were never definitively treated as children with ventilation tubes. What is lost in these guidelines is the fact that in some patients surgical intervention is cheaper in the long run because it can solve the underlying problem instead of managing the symptom.
The one size fits all approach takes away the importance of individualized medical care. Although these guidelines are based on research they will inevitably lag behind research, and that will have a negative impact on patient care. For example, the Canadian Advisory Panel guideline for the treatment of sore throats is not true. “With the exception of rare infections by certain pharyngeal bacterial pathogens (e.g., Corynebacterium diphtheriae, Neisseria gonorrhoeae and Arcanobacterium haemolyticum), antimicrobial therapy is of no proven benefit in the treatment of acute pharyngitis due to bacteria other than group A streptococcus”. I just drained an abscess on a patient who was not placed on antibiotics because the strep test was negative. He actually had a staphylococcal infection. This blanket application if applied to other diseases such as screening mammograms and other ailments can lead to people falling through clinical cracks and getting sicker requiring more expensive and invasive care. The practice of good medicine will always be unpredictable and will require the ability to practice the art of medicine.
A preview of the future:
- the payment set up with covered medical services in British Columbia
- Physicians in the US are already being paid using this system of bundling charges. The Canadian fee schedule is similar to rates paid by Medicaid. If healthcare reform leads to the implementation of the ICD-10 fee schedule with the adoption of these lower rates, it will likely lead physicians in private practice to drop out of the system in order to stay in business. Quite simply, adding this to the ever rising overhead and malpractice premiums will simply be overwhelming.