The Symptoms or the Disease

Through the late fall of 2007, we yet again experienced governmental dysfunction on display in Washington, D.C., regarding important healthcare issues. As Congress and the president bickered over whether to extend and expand federal funding of health insurance for children (the program known as State Children’s Health Insurance Program or SCHIP), the prospect of a 10% cut in Medicare reimbursement for physicians’ services, effective January 1, 2008, loomed as an ever-more-likely scenario with each passing day. This cut ensued from a budgeting mechanism used by the federal government known as the Sustainable Growth Rate (SGR), a truly Orwellian term for a mechanism that provides neither growth nor sustainability of healthcare services provided to patients by physicians.

Practicing rheumatologists, already struggling to cope with several years of no increase in the Medicare fee schedule—effectively a significant decrease—reached their boiling point. The ACR’s advocacy list serve reflected a palpable mix of frustration and anger. At times I thought my computer screen was becoming hot to the touch! At the last minute, a budget compromise averted—or at least delayed—the 10% cut and replaced it with a whopping 0.5% increase, but only until July 1, 2008. What happens after that is anyone’s guess.

We Can’t Ignore the Underlying Disease

Rheumatologists know that when a patient is sick, it’s a mistake to simply treat the symptoms without determining the basic nature of the patient’s illness. When faced with an elderly patient who has fever, proximal stiffness, headache, and visual loss—potentially a case of giant cell arteritis—a rheumatologist would never be content with prescribing analgesics and the use of magnifying lenses. Instead he or she would obtain a detailed history, perform a thorough physical examination, order appropriate laboratory tests and diagnostic procedures, and even begin definitive treatment while collecting all necessary data.

One could make the case that, in trying to cope with the issues of the moment—such as threatened cuts in physician reimbursement triggered by the SGR—we have become preoccupied with the symptoms and are in danger of neglecting the disease. It’s not that difficult to see that the allocation of resources within the healthcare system of the United States is gripped by a multi-system disease. This disease may not yet have a catchy eponym, but it is defined by several serious and uniquely paradoxical features, including the following:

1. Our country spends more on healthcare, per capita, than any other country, and a greater proportion of our gross national product on healthcare than any other country, yet our life expectancy, infant mortality rate, and other meaningful measures of health lag behind many other nations;
2. Healthcare costs are rising faster than the general rate of inflation, yet the number of uninsured Americans keeps growing;
3. Enormous waste of healthcare resources on expensive tests and procedures of dubious or marginal value is well documented, yet inexpensive interventions of proven benefit are not consistently used;
4. As physicians, we have far better tools to diagnose and treat disease than in the past, but struggle constantly to surmount hurdles to the use of these tools for the benefit of our patients; and
5. Although the prevention and management of chronic disease are clearly the dominant healthcare needs of the population of the United States, the current reimbursement structure fails to provide adequate resources to support the professionals who could meet these needs: primary care physicians, “cognitive” specialists such as rheumatologists, and other healthcare professionals who are essential for the care of such patients.

All of these points have been exhaustively documented, so why belabor the obvious? Because until these problems are fixed, we need to keep attention on the untreated, pervasive, and deeply rooted disease that is undermining the viability of our healthcare system. To not do so would be to neglect part of our responsibility to our patients.

How to Cure Our Healthcare Ills?

The 2008 presidential election process, which is highlighting healthcare reform as one of the top issues for public debate, may provide an opportunity for more substantial examination of potential treatments for our healthcare system disease—let’s call it HCSD for short. A variety of therapeutic strategies have been proposed, and several clinical trials are underway at the state level. The exchanges on the ACR’s advocacy list serve during the past few months demonstrate the diversity of opinions among ACR members regarding the right treatment or cure for HCSD, ranging from transition to a single-payer system to more modest adjustments of the current healthcare reimbursement structures. This range of viewpoints highlights one of the problems in defining a clear therapeutic plan: the inability of the medical profession to achieve internal consensus about what should be done.

The ACR has not proposed a unique and comprehensive plan for reform, but it has crafted a series of position statements that emphasize the importance of patient access to appropriate care. Arguably we should be doing more to provide a prescription that would effectively treat HCSD, and this is an ongoing challenge for several of the College’s standing committees, the ACR board, and the officers. In attempting to tackle HCSD, we need to focus on changes that produce increased value from healthcare expenditures. To do this we need to be willing to take on the issue of how much of the healthcare dollar is consumed by administrative costs and the costs of competitive behavior of health systems—both those that are openly “for profit” and those that are supposedly nonprofit but that behave otherwise. And what about pharmaceutical prices, and the degree to which these prices are driven up by marketing costs—and not just marketing to consumers but also to physicians?

Any reforms that we advocate, especially those that could benefit our specialty and our members, must also be in the best interest of our patients. This has always been the policy of the ACR and must continue as a guiding principle that underlies all of our positions. And we need to be realistic about the role of a relatively small subspecialty society in tackling the “macro” issues inherent in HCSD. At times our interests and those of our patients are best served by our participation in collaborative advocacy within larger professional organizations such as the AMA, which is clearly on record concerning the need to abolish the SGR. However, often we do need to act on our own.

The past few years have seen a significant augmentation of the ACR’s advocacy activities: repeated visits to Capitol Hill by ACR officers, board and committee members, and other ACR members with an interest in advocacy; greatly increased allocations for professional lobbying and advocacy counsel; and the formation of RHEUMPAC. Concurrently, the ACR has worked hard to develop our relationships with federal agencies such as the Food and Drug Administration, the National Institutes of Health, and the Center for Medicare & Medicaid Services. We speak clearly, consistently, and coherently on the range of issues that are important to our members, including our clinical practitioners and our academic researchers. And we communicate much more with each other, whether on the advocacy list serve or in the pages of The Rheumatologist.

There are other things that each ACR member can do: participate in our visits to Capitol Hill, call or write your elected representatives in the House and Senate, and contribute to RHEUMPAC. Also, as physician-citizens, make thoughtful choices in November as well as in the remaining primaries and caucuses, with the need to cure HCSD as one of your high-priority issues.

Dr. Fox is president of the ACR. Contact him via e-mail at [email protected].