The following is fourth in a series of ten articles that originally appeared in the Indiana Medical Society’s monthly magazine “The Bulletin.” As President of the Indiana Medical Society over the past year, Dr. McGoff wrote on a wide variety of topics, most importantly the current condition of health care in the United States. These articles will help illustrate Dr. McGoff’s views and beliefs. This article appeared in the February 2009 issue, just after the Presidential Inauguration.

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A few weeks ago, we were witnesses to a truly momentous event in the annals of American history. Barack Obama was sworn in as the 44th President of the United States, the first African-American to do so. He was swept into office with a message of “Hope and Change.” But due to the profound economic challenges facing the country, we should all “Hope we have some Change” left in our pockets after he fulfills all of his campaign promises. Sadly, many of those new, idyllic, first time, young voters will be shocked to find out that campaign promises are well, really just suggestions.

After his win in November, AMA Board of Trustee Chair, Joseph A. Heyman, MD, noted, “We think there’s that window of opportunity next year to really accomplish something.” The American Academy of Family Practice president, Ted Epperly, MD, went further and said he has never been so excited about a new president. (See comment above about overzealous expectations).

Throughout the campaign, candidate Obama pledged to save every family $2,500 on their health care insurance premiums with a combination of tax increases (those making more than $250,000) and savings from new information technology (IT), chronic disease management and decreasing administrative overhead. While I concur with the idea of trying to become more efficient, I am not certain that there is really $200 billion in savings to be found. For the life of me, I never figured out how IT solutions as touted by Obama, Hillary and even Newt Gingrich could produce such phenomenal savings. In fact, the recent RAND study that had been purporting this has been poked full of so many holes, it won’t hold water anymore.

Currently the United States spends $2.3 trillion on healthcare, some 16% of the Gross Domestic Product (GDP). Nearly every healthcare expert believes there are tremendous opportunities for savings. One recent survey of health care executives stated that they believed upwards of half of these expenditures do absolutely nothing to improve health. So in reality, there is plenty of money in health care, it’s just a matter of how it is being allocated. As I’ve asked in previous articles, why then do Americans rank 43rd in life expectancy and 29th in infant mortality?

If as physicians we step back and take a look at the typical cycle of life and our involvement, we will notice some striking simplicity. It all begins with an expectant mother, who if she follows closely the recommendations of her obstetrician or family physician, takes prenatal vitamins, does not smoke, drink or use drugs, she will in all likelihood deliver a healthy child. Through the early years of development, with close follow-up from a primary care provider, the usual immunizations and adherence to well-recognized general safety tips, that child should grow into a healthy adolescent.

Fortunately from age 18-40, if that same individual does not get hit by a bus or develop some malignancy, then little of the health care system is required except occasional episodes of care, i.e. fracture, pneumonia, appendicitis, etc. Interestingly the oft quoted number of 45 million Americans who are uninsured fall into this exact demographic. A coincidence?

As with any living organism, senescence sets in and the human body begins to develop those chronic diseases everyone likes to complain that we don’t do enough about like hypertension, diabetes, emphysema, etc. Finally at the end of this life cycle, there is a tremendous flurry of medical activity especially in the last six months of most seniors’ lives, that consume tremendous resources and produce little, if any results.

How does a better computer fix this system? There are certainly some efficiencies that can be shared between physicians caring for some 300 million Americans, as they sojourn this birth to death cycle. Our own Indiana Health Information Exchange (IHIE) is renowned nationwide for their work in providing IT solutions for physicians and health systems. But billions in savings?

Chronic disease management is as much a patient responsibility as it is a physician’s. In some respects I feel that doctors are caught in the same trap as public school teachers. Everyone wants quality outcomes, whether it is in education or healthcare, but even if we have the most qualified teachers or physicians, the results will be less than stellar with uninterested parents or noncompliant patients. While Indiana University’s basketball team may be at the bottom this season, the rest of our state’s nearly six million Hoosiers proudly continue to place in the top ten for smoking and obesity.

Decreasing bureaucratic overhead would be a godsend for any physician’s practice. A simple example of the contrary from an emergency physician’s standpoint; if a little eighty-year-old grandmother comes in with an acute myocardial infarction; I have to be sure and ask about her smoking habits and cause of death of her parents. If these important, irrelevant facts of the social history are not documented, no matter how sick she is, nor how much energy I expend treating her, my level of service (E&M code) will be downcoded. This is the kind of absurdity that gives me no comfort when I hear about expanding Medicare to all patients as Rep Pete Stark, (D-CA) espouses.

Lastly, President Obama would like to expand coverage. Again while truly noble, I believe that no one in America should be bankrupted by any health crisis. The simple fact of the matter is that if you increase coverage, it will result in increased utilization and services. The only way to save money in that model is with price controls, and I don’t see too many physicians buying into that process. Already more than 40% of physician practices take no Medicaid patients and 25% limit their Medi care participation. Try finding a physician to take care of these new patients, when the already pitiful reimbursement from government payers is lowered further.

So buckle up! With the economy in a tailspin, the deficit growing uncontrollably and no realistic, meaningful plan for healthcare reform, this roller coaster has just left the station. We are all eagerly listening with anticipation to that clickety-clack, clickety-clack of the clogs, as we ascend that first steep set of tracks. There are many who have high hopes and great expectations. As we go over the crest though, hold on, because it’s going to be a wild ride with many ups and downs and twists and turns, and if we are lucky, not a too-sudden stop at the bottom.