Number one - and this is a strong objection, out there in the minds and mouths of a lot of doctors - is:
"There's a lot of ways of getting from Point A to Point B in medicine. Different ways may be right for different patients. There's no one-size-fits-all approach; every doctor agrees about that. If the government gets in the way of standardizing outcomes, what's to stop it from standardizing practice - from dictating how I practice medicine?"
The answer to this, again, is a hard problem that looks hard. Obama has already asked specialty societies to define their three costliest conditions (for neurology, it's probably stroke, Alzheimer and diabetic neuropathy, in that order; you could make a case for headache and back pain, too, if you think back pain is primarily neurological) and to propose ways to standardize the process of caring for these ailments and to propose ways to limit their cost effectiveness.
There are some problems with this. AAN, God bless them, acts with the interests of neurologists in mind. That is its charter. It's not going to want to propose things that impoverish neurologists.
But it is going to want to propose things that improve patient care. Doctors are really all about improving patient care. We're taught that from the first day of medical school. That's why we exist. Sick people get cared for, one way or another. Even if a sick person is dumped out in the gutter to die, that is a health-care-delivery model of what to do with sick people: diagnose them as sick, and then treat them by dumping them in the gutter. The doctor, then, is supposed to improve patient care. There is so much compassion and wisdom and knowledge in the medical and nursing and ancillary sectors of our industry. Everyone's on board with that. There are docs who study their whole lives to know the best, most cost-effective means of treating a stroke and maximizing good outcome for minimum cost. Empower them to make their recommendations the law of the land.
Unfortunately, politics being what it is, recommendations like that are very political. What if the doctor-expert referred to above says, "Put everyone on Plavix, put no one on Aggrenox," and then it turns out that the maker of Plavix has paid him $1 million in speaker fees?
Obama is not a tyro. He is not unexperienced in politics! He is not unaware of conflicts of interest. I hate to say this - I am gritting my teeth as these words come out - but, really, think about it: Who better to handle politics, than a politician? And in case you haven't noticed, our government is increasingly made up of politicians these days.
Strong ethics protections need to be in place at every step of this project, or it will fail and fail spectacularly and fail commensurately with the inadequacy of the protections.
Number two. We've talked a lot about cost reduction. Across the board cost reduction must occur. If it does not occur, our society and economy will collapse. NY Times says docs have to get on board. Agreed.
Honest docs, practicing in good faith within the guidelines, must see their economic position boosted. Venal, corrupt, self-referring scumbags must die. But it's not that simple. The bottom line is, the current situation doesn't let honest docs practice. If I didn't do a few EMGs for carpal tunnel from time to time, my practice would lose money. I can live at the comfortable standard a doc ought to enjoy - if I own all my own diagnostic equipment and keep that equipment humming happily.
Make sure I can make that kind of income practicing right medicine, first. Now, once that's accomplished, now take away my EMGs and EEGs and carotid duplex revenues. Do it incrementally, or you will lose your doctors in this transition. You don't see it, but you are already losing them. The best and the brightest are opting out of taking care of sick people because they don't want to become corrupt scumbags and they don't want to be played for suckers either. This trend has to be undone immediately.
That hypothetical venal, corrupt scumbag across town I compete with? He donates $50,000 to the local hospital auxiliary annually (if I tried to compete with that, it would bankrupt me, incidentally.) He finds a way to refer all kinds of healthy people to other docs for bullshit procedures. Unlike me, he is WEALTHY. And as a result, he's well-beloved in town by the hospitals and the docs who refer to him and a lot of people listen to him, even though he has no idea what he's talking about.
If all that the next proposal does is ratchet every physician's payment down equally, it will fail. It will just drive the least wealthy docs out of business. Unsurprisingly, these are not going to be the docs most culpable for that portion of soaring healthcare costs that are physician-driven. A lot of honest docs have been driven out of business already by this strategy. This leaves us with what's left; a lot of docs who've already proven their skills and ability to game the system to their own profit. They adapt. A lot of grumbling about the current plan is coming from these docs, who feel like they're playing chess with Jabba the Hutt and at any moment he might decide to upset the table and crush them with his tentacle.
The last 40 years have taught docs a profound lesson: overdeliverers flourish; they enjoy the blessings of wealth and popularity and prosperity for themselves and for their children and for the servants that staff their vacation homes. Meanwhile, honest docs have a saying - we've all heard it: "No good deed goes unpunished."
This problem isn't going to get unwound easily or gradually. It's going to take care and diplomacy and difficult negotiation across the country. And it's going to take a show of good faith by the government. Maybe start by boosting physician reimbursements 25% for a year or two while the kinks get sorted out. Give us a safety net while we participate in our grand experiment.