The Jobbing Doctor, a primary care doctor in the UK, writes today about the British version of what Americans call “Pay for Performance,” or “P4P.”

He says something I’ve said many times before (like here, here, and here).  Which is this: incentives fail because they try to treat medicine as an assembly line process, when it’s not.

But what’s most interesting about his post is that it could have been written by a doctor from anyplace on the planet Earth.

The Jobbing Doctor talks about a UK program that started in 2004 called the Quality and Outcomes Framework, or “QoF.”   Now, the American “P4P” is a much more catchy name, so score one for American marketing.  But it doesn’t matter what you call it – that which we call a rose would, by any other name smell as sweet.

Or, as in this case, as sour.

According to the Jobbing Doctor, QoF has actually increased costs (or at least doctors’ income- he says it went up 33%) because the government seemed to have underestimated the extent to which doctors were already delivering high quality primary care.  He also notes that because the guidelines are so crude and so focused on certain illnesses, there are incentives to meet targets rather than understanding a patient’s medical condition.  It’s pretty much the opposite of what doctors are taught to do in their training.  And his complaints about QoF sound very similar to complaints from doctors in other countries about the impact of such well-meaning efforts by government and private industry.

Which is the larger point.

As Jobbing Doctor put it so eloquently, measures like these distort the practice of medicine and take it away from what is really important:

The other downside is that ideas like the QoF diminish a profession’s values and judgements, meaning that high quality care is not driven by an internal motivation for doing a good and valuable job well, rather we have to be driven by targets.  Targets are the antithesis of professionalism.

So the President gave a speech yesterday in which he said he would push, with Democrats in Congress, to pass a major health care bill through a process called “reconciliation.”

I don’t think most of us know what that is, exactly.  The meaning of it is simple, though: they can pass a bill with a simple majority vote.  They can eliminate a Republican filibuster in the Senate.  It’s been called the “nuclear” option, well, at least since Republican Trent Lott dubbed it that some years ago.

Some people are appalled that this could happen.  Should they be?

I don’t think so.

When the President said yesterday that “everything there is to say about health care has been said, and just about everybody has said it,” he may not be factually correct.  But in terms of the legislative process, he and the leadership in Congress have the power to decide that, in fact, it is true.  If they have the votes, that is.

So, at this point, it’s not about whether the plan is good or bad.  It’s about whether the President can get the votes to pass it.  There’s nothing illegal or immoral or unethical about that – it’s just democracy.  And it’s the worst system in the world….except for all the others.

Now, you can have a perfectly good discussion about whether reconciliation makes good political sense.  I suppose people who are prone to be angry about such things will be angry about it, and strong supporters of the President will like it.  But I don’t think this is the biggest problem, and I leave those politics to others.

The biggest problem is that it just isn’t going to deliver the transformative changes that you might expect given the huge commitment that’s been made to it, and the controversy surrounding it.  In spite of all of the soaring rhetoric, most Americans aren’t going to experience much change at all.  The problem will be that, after the dust settles,  people will be left asking “where’s the beef?”

Why will they ask this?  Because health care costs will continue to rise, and there will still be many millions of uninsured.  It’s because the fundamental problems that drive health care costs in America will remain essentially unaddressed.

We will still have an uncompetitive insurance market, and an increasingly concentrated hospital market.  We will still have an aging population that need increasing amounts of care.  We will still have all of the unhealthy lifestyles Americans live.  We will still have an extraordinary pace of new medical technologies and treatments that add new expense.  And we will still suffer with quality problems because we don’t let doctors have enough time with their patients.

This is the larger point.  We face major structural problems in health care, that can’t be “fixed” by a bill, no matter how long or how short it is, and no matter how many people vote for it or against it.  They can only be fixed in the way many other things get fixed in America, by the efforts of individuals and companies, charities and governments to chip away, bit by bit, to build a better future.  It won’t be easy or quick.  But no one should believe, even if a bill becomes law and a political battle won, that American health care has been somehow “reformed.”

The American Cancer Society says that men over 50 need to seriously consider whether they really ought to get screened for prostate cancer.  According to them, the risks of getting tested may outweigh the benefits of detecting the cancer, especially for younger men.  They say it’s a “complex issue,” but they understate how complicated it really is.

Like the recent controversy over breast cancer screening, the new recommendations add to the swirling morass of conflicting messages and priorities around health care in America.

Here’s what I mean.

In recent years there has been a big public effort to get men to educate themselves and get tested for prostate cancer.  For example, Major League Baseball has turned Father’s Day into its own prostate cancer awareness day.  Their central message: the disease is treatable if caught early, so talk to your doctor, and get tested.

To show how important it is to get started with this at the right age, a key spokesperson is 51-year old baseball legend Ozzie Smith.  Ozzie says men as young as 40 need to start thinking about it, and to “take the plunge” by the time they are 50.

Ozzie says men as young as 40 need to start thinking about it, and to “take the plunge” by the time they are 50.  Star slugger Jim Thome, 39, has also been recognized by the player’s union for his work on prostate cancer.  Even President Obama is doing his part.  The 48-year old had a PSA test as part of his physical exam.

Now the American Cancer Society says that most men don’t need to start even talking to their doctor about this until they are 50.  It’s all very confusing.  And when you listen to people like Warren Buffet saying we need to declare a “national emergency” to control health care spending, you might start to wonder other things.  Like, if these screenings cost money, and may not be all that necessary, is someone going to use recommendations like these as an excuse to just stop paying for screenings?  After all, aggressive screening saves only about 6 men out of every 1,000.  What’s six lives in 1,000 when there’s money at stake?

Still, I respect that there is a real medical issue here, and so does the American Cancer Society.  They say that doctors need to spend the time to educate their patients about the risks and benefits of testing and to help their patients make the right decisions for themselves.  This is good, but there’s a bigger problem: time.

According to CNN, Dr. Herbert Lepor, chairman of urology at NYU Langone Medical Center in New York, put it well:

[I]t is impractical to suggest that a primary care physician who has 15 to 20 minutes to spend with a patient fully explain all the pros and cons of screening in the course of an annual physical.”How do you present this to a patient? You can’t possibly spend an hour discussing this,” Lepor said.

During the same 15- or 20-minute physical, the physician also has to discuss issues like blood pressure, diabetes, exercise and diet.

So we come back to the same old problem.  Medicine should be about a doctor and a patient working together to get the best outcome.  They need time with each other to do that.  But our system has different priorities.  It says, health care should be about trying to stop doctors and patients from spending too much money.

It’s a mistake.  And what it means is that all the well-intentioned efforts by people like Ozzie Smith, Jim Thome, President Obama and the American Cancer Society to help people get things right end up lost.

UPDATE: Advocacy groups complain that complex new guidelines are confusing men about prostate cancer screening.

Warren Buffet is talking and reform opponents love what the unofficial Obama adviser has to say.  He says the President should scrap the whole thing and start over.

He says health care costs are a “tape worm” eating at American competitiveness.  His prescription: a “united effort,” a “national emergency” that will allow us, finally, to focus on “costs costs costs” above all else.

Buffet is a brilliant man, and he makes a very good point about how botched the sales job on reform has been.  But he’s missing something very important:

We have been focused on health care costs in America.  For decades.

It’s true.

The entire system of managed care, under which we all live, was created for the purpose of controlling costs.  The number one priority for employers (well, at least private ones) is controlling costs.  And yet costs have continued to rise.  It’s not because people aren’t trying – there are lots and lots of different ways in which organizations have tried to control costs – some of which work well.  The trouble has been that by looking at everything in medicine through the prism of money we are distorting the way medicine is supposed to work.  Instead of it being about how to make sure a doctor and a patient are able to work together to get the best possible outcome, it’s about making sure the doctor and the patient don’t spend too much money.  It’s a mistake, and it seems to only make things worse.

But there is a larger problem with reform.  American health care isn’t really a “system,” and so trying to reform “it” is pretty impossible to do.   It’s like saying we need to reform the automobile “system” in America.  Are you talking about roads, or mileage standards, or unions, or executive pay, or manufacturers, or parts suppliers, or foreign companies, or state governments, or the financing companies, or dealers, or what, exactly?  Maybe individual players in this market could – and do – focus on “costs costs costs,” but as a market there’s no coherent way really to do that.

The trouble begins when you start to look at health care as a system and try to come up with ways to reform it.  It’s why there has been such a yearning for simple, easy to understand rhetoric to explain reform to a skeptical public.  No one has found anything that works, and so reformers find themselves in a political quagmire.

A great sage once said that one of history’s classic blunders is to get involved in a land war in Asia.  Perhaps to that ought to be added, never try to comprehensively reform American health care.

UPDATE: CNN reports (h/t James Taranto) that a White House adviser yesterday called the latest health care push “the last helicopter out of Saigon.”  Not good.

Today the Commonwealth Fund came out with a chart that it says is a “grim reminder” of what happens when health care doesn’t get reformed.

If only we had listened to Richard Nixon or Jimmy Carter.  We would have saved tens of trillions of dollars in health care spending.

Click to enlarge

Never mind that Nixon and Carter’s big cost savings were supposed to come from price controls.  Which, 4,000 years of history tell us, don’t work. It makes you wonder about that flat line in the alternate universe in which Nixon or Carter got their plans passed.  Beware of charts promising simple descriptions of health care problems.

Still, chart or no chart, it’s a very bad sign for a reform plan when its supporters try to drum up support by linking it to Nixon and Carter.

But the chart does beg another question:  why does the U.S. spend so much more?

There isn’t one answer, just like there’s no unitary health care “system” in the United States.  I’ve written a lot about before, so today I just want to focus on two points.

Other industrialized countries have restrictions on access to care that would be unacceptable to Americans.  We got a tiny taste of what this is like when that group came out earlier this year with a recommendation that women not get mammograms until they were 50.  There was an immediate uproar, and the group ended up re-writing its recommendations.  As an aside, it’s why some people think that a single-payer America would actually spend more on health care, since politicians would never vote for real restrictions on care.

To see what I mean, all you have to do is look at what is happening in state and local governments.  State and local government employees enjoy some of the most generous benefits packages in the country.  As the Boston Globe reported today:

A six-month review by the Globe found that municipal health plans, which cover employees, retirees, and elected officials, provide benefit levels largely unheard of in the private sector. Copays are much lower. Some communities do not force retirees onto Medicare at age 65. Many citizens on elected boards – some after serving as few as six years – receive coverage for life, too.

As medical costs across the board rose over the past decade, municipal health care expenses exploded, draining local budgets and forcing major cuts in services, higher property tax bills, and billions in new debt.

Some cities and towns around Boston are spending close to 20% of their budgets on health care costs.  Some towns spend more than $30,000 per year for family coverage – with almost 90% of that covered by the employer.  Large private employers pay about half that much on average for family coverage, and cover much less of the premium.  And it’s not just happening in Massachusetts.  Governments – for whatever reason – do not have in place the kinds of benefits offerings that have helped slow the growth in health care costs in the private sector.

So of course there should be some kind of reform in America.  But while politicians are arguing about a grab-bag of issues they aren’t grappling with the huge opportunities to improve health care costs right in their own backyards.

So the big, long health care summit in DC is over- here are my quick five quick reactions to it:

1.  It should have happened a long time ago, but it couldn’t have. It was a substantive conversation.  David Gergen said that, intellectually, “the Republicans had their best day in years” (he meant it as a compliment).  The bills that came out of Congress probably would have been a lot better if they had been discussed like this before they were drafted.  The trouble is, representatives on both sides weren’t at all up to speed on health care back then, so they couldn’t have had a conversation like this.  So we end up with bills first, smart talk later.  I think there’s a movie coming out about that kind of thing next week.

2. It was still riddled with silliness. Nancy Pelosi said the plans would create 400,000 jobs “almost immediately,” and would overall create millions of new jobs.  Meanwhile, John Boehner kept insisting that the plans were a “government takeover” of health care.  It wasn’t clear if Pelosi or Boehner were talking about the House bill, the Senate bill or the President’s new plan.  Actually, it wasn’t clear what they were talking about at all.  What always surprises me is the extent to which many politicians just say stuff that they can’t possibly believe to be true.  It’s one reason why a lot of people don’t want to trust them with important things that directly affect their lives…like health care.

3. You can’t put reform in a box and say you’re for it or against it. Well, I guess you could do it literally with the 2,000+ page bills, but I mean it figuratively.  They talked about a huge number of topics.  The uninsured, medical malpractice, rising health care costs, Medicare, Medicaid, comparative effectiveness, health insurance premiums, insurance mandates, state versus federal insurance regulation, interstate sales of insurance, pre-existing condition exclusions, uncompensated care, over-use of the ER, and on and on and on.  It’s the trouble with the so-called “comprehensive” plans- there’s no “system” to comprehensively reform.  So the bills aren’t “comprehensive,” they’re just long – a giant collection of stuff that will impact the health care system, some for the good some for the bad.

4.  It’s another cog in the anxiety machine. The fact that all of America’s top leaders, in the midst of a terrible economy and two wars, would meet for an entire day about health care sends a message that this is a hugely important issue.  And it is an important issue.  But the trouble with reform from the beginning has been that voters don’t understand what’s happening and are worried about it.  Today, as a friend suggested to me, was like porn for policy wonks.  But I think to regular people it just sounds like trouble.  Something big is happening which I don’t understand but which I know will affect me in ways I’m not going to like.  I’m sure representatives from vulnerable districts didn’t like it when the President said near the end that if the voters don’t like it they can vote in November.

5.  Republicans shouldn’t misread what’s happening. Republicans clearly have read the polls showing opposition to the reform plans.  But like in Massachusetts, rising support for Republicans isn’t because Americans are suddenly turning to their ideas.  I think voters just want this long, long, long health care saga to end.  As James Carville might have said, it’s the health care, stupid.

When Danny Williams, the Premier of Newfoundland and Labrador, mysteriously disappeared to the United States for heart surgery, it was a scandal in Canada.  Why, asked many Canadians, would a government official abandon the Canadian health care system in his own time of need?

The secrecy surrounding where he went and why only added to the sense that he knew the was doing something bad for his political health.

Now he’s talking, and he’s saying things that I suspect sound pretty radical for Canadians.  Politically, he’s almost forced to say it.  But I wonder if he really needed to be in the fix he is in.

The problem was that Williams needed a heart valve replacement.  He decided he wanted it done in a way that involved a small incision in his arm-pit instead of using the more traditional, sternum-cracking technique.  They don’t do the minimally-invasive approach in Newfoundland and Labrador, so he knew would have to leave his home province one way or the other.  After talking to a doctor in New Jersey, he decided that the right place to go was Mt. Sinai Hospital in Miami, Florida.  There is a doctor there who has apparently performed thousands of these surgeries.

As Williams put it:

“This was my heart, my choice and my health,” Williams said late Monday from his condominium in Sarasota, Fla.”I did not sign away my right to get the best possible health care for myself when I entered politics.

Well, ok.  But what about the fact that the same surgery actually was available in Canada?

“I would’ve been criticized if I had stayed in Canada and had been perceived as jumping a line or a wait list. … I accept that. That’s public life,” he said.  “(But) this is not a unique phenomenon to me. This is something that happens with lots of families throughout this country, so I make no apologies for that.”

Here’s where I wonder if the Premier actually knew that the same surgery could have been done in Canada.  For example, there is a major hospital in Vancouver which does these procedures.  How much better would it have been for him to go there?  He could have had his surgery and been released from the hospital just in time to go to the Olympics.

You know, there are a lot of TV cameras at the Olympics.  The Premier could have used this as a chance to talk about how the Canadian health care system had served him.  It would have been a political gold mine for him, and not just in Canada.   Instead, he announced he’s going from Florida to Vancouver tomorrow, where he will be hounded by controversy.

How could this happen?

Well, the problem of figuring out what to do when you’re sick is hard, no matter who you are, or what health care system you live under.  You suddenly have to try to become an expert in your condition.  Of course, you really can’t.  There’s no way you can replicate all the years of education and training and experience that a doctor has.  And so there will be big gaps in your knowledge about your condition.  Do you have the right diagnosis?  Are you looking at the right treatment options?  Are you with the right doctors?  Do you really understand the risks and benefits of the treatment?

In our work at Best Doctors we have collected a great deal of data from the several million people we cover in North America.  More than half of those who call us are people, like Danny Williams, who are facing surgery and aren’t sure what to do.  It’s a serious problem, and one for which there are very few solutions.

So in this sense, Premier Williams is right.  His problem – how to make sure you are getting the right diagnosis and treatment – is not unique.  It’s something that families thought the country and throughout the world deal with every day.

Barely a week after Massachusetts Governor Deval Patrick said he wants state controls on the price of health insurance, President Obama apparently wants to do the same at the federal level.  Both men must believe it’s good politics, because there are about 4,000 years of evidence that it’s not good policy.

But the trouble for reformers has never really been about policy.  It’s been about a fundamental misunderstanding of how people view health care and the very bad things that happen when you give people the impression you’re going to mess with what they have.

In this sense, the reform bills are like perpetual anxiety machines.  Contraptions that continually produce more public anxiety than they consume.

But why is this?

Well one of the surest ways to create anxiety in someone is to make them feel uncertain about something important to them.  It’s one reason why companies suffer from problems with morale in tough economic times.  If a company doesn’t level with its employees about what’s happening, smart employees start to assume it must be because the news is bad.  Otherwise, why wouldn’t the management come out and explain that everything is ok?

So what are big companies telling their employees about the health reform bills?

I spend a lot of time talking with health benefits executives.  These are people in charge of communicating with employees about everything from the economy to the future of their companies to health benefits.  Most of the people are very smart, pragmatic businesspeople, with lots of experience in health benefits.  Yet they don’t really understand what the bills is Congress are meant to do.  They can only be honest with their employees about what health care reform might mean to them: “we’re going to wait and see” is what I hear from most of them.  What else could they say?

Now, think about what that means to an employee who is listening to all the political rhetoric and wants to know from his employer what the real deal is.  Will I get to keep my doctor?  Will my wife’s treatment be interrupted?  Will I still get to take the medication I want to?  Can I still take my kid to see the specialist at the teaching hospital?  “We’re going to wait and see” means “I don’t know, maybe.”  And that makes people very anxious.

How anxious?  Anxious enough for Massachusetts voters to elect a Republican Senator.

That’s pretty anxious.

So as politicians in Washington sit down again for a surprising new effort at reform, they ought to listen to the voices of people who deal with health care benefits for a living.  If they don’t understand reform, then it’s the politicians that should be the ones feeling anxious.

Massachusetts Governor Deval Patrick announced this week he has had enough of rising health care costs.

So he is proposing a novel solution: make them illegal.

Well, it’s not fair to call this idea “novel.”  Governments have tried price controls for 40 centuries.  And even though they don’t work, they keep trying.  The explanation isn’t complicated.  It’s an easy way for a politician to seem to do something about rising prices.  In this case, it won’t do much about the underlying problem, but it is a terrific way for a governor to look like a man of action.

There is a small irony in the governor’s proposal.  It admits that government itself is one of the important reasons health insurance is so expensive.  How?  Mandates.  He says he wants a two-year moratorium on telling insurance companies what new benefits they have to cover in their policies.  Mandates are one of the important reasons why health insurance is so expensive.

But the problems of costs in Massachusetts are about way more than just the mandates.  It’s the market.

In the last 20 years, Massachusetts has become dominated by bigger and bigger insurance companies and bigger and bigger hospital systems.  They’ve been fighting it out with each other — or not — and the result has been that consumers and small businesses are getting a very bad deal.  What’s worse is that it’s happened as the state government leaders of both parties have stood by and watched, or even approved.

How consolidated is the market today?  One company controls about half of the health insurance market, with the rest is split up among 4 smaller insurers.  Likewise for hospitals.  In the Boston area, where most Massachusetts residents live, one hospital system dominates.  The rest is split up among a small number of other, smaller systems.

Now, Governor Patrick’s Attorney General, Martha Coakley said something surprising about all of this last week.

She said the problem isn’t really the insurance companies.  Instead, she says, health care is so expensive in Massachusetts because of the consolidation of hospitals.  She did a study and found that big hospital systems use their leverage to charge insurers more money, which they must pass on to consumers.  Coakley says these are “serious system-wide failings in the commercial health care marketplace which, if unaddressed, imperil access to affordable, quality health care.”

It’s odd that Coakley ran for Senate on a platform devoted to a reform bill that would have done nothing to address the “serious system-wide failings” she identified.  Or maybe it’s not.  The gulf between politicians’ rhetoric about the health care and the reality of how it works shouldn’t be surprising anymore.  But the extent to which the government acts in such disconnected ways explains a lot about how our system could become such a fine mess.

One economist, talking about the failure of price controls over the last 4,000 years said this about their appeal, and their peril:

With the wave of a hand, or the flash of a legislative pen, they promise to make everything cheaper. And for more than four thousand years the results have been exactly the same: shortages, sometimes of catastrophic consequence; deterioration of product quality; the proliferation of black markets on which prices are actually higher and bribery is rampant; destruction of a nation’s productive capacity in the industries where prices are controlled; gross distortions of markets; the creation of oppressive and tyrannical price control bureaucracies; and a dangerous concentration of political power in the hands of the price controllers.

In health care price controls won’t work, and they will do something worse.  They will be yet another way to keep in place the corroding system we live in today, yet another in the line of unfortunate policy choices that have brought us here.

And years from now people will look back and wonder: how did the system ever get this way?

Yesterday, I was sitting on the floor about two feet away from where I am now.  I was holding our wonderful chocolate lab, Hooper, in my arms as he died.

He had been sick, so it wasn’t a shock.  A short time ago, he was stricken with an aggressive cancer.  He hadn’t suffered much, even though he was declining.  The day before yesterday he was as happy and playful as I have seen him in months.  Maybe he knew something was going to happen.

I went to work but half way through the day my wife called to say I should come home.  I found him lying on the ground, right over there, where I had last seen him in the morning.  His breathing was labored, but he looked at me in the eye when I walked in.  As I went over to him and started to hold him and pet him and talk to him, his breathing started to change.  It was as if he was no longer trying to breathe, but it was just happening, reflexively.  It kept getting shallower and shallower, until, after maybe five minutes it faded away completely.  I couldn’t feel his heart beating anymore.  He was gone.

Dogs don’t live long enough, and so they bookend parts of your life.  In our case, when Hooper was born 12 years ago my wife and I were single lawyers who wanted to be married non-lawyers.  We did both of those things, and much more.  Hooper showed us that we had a responsibility to make these kinds of choices in our lives.  Choices that would fill our lives with the kind of joy that Hooper experienced every day, just by being alive.

Dogs are such pure beings.  Their love and spirit are uncluttered, unfettered, unconditional. They don’t do the “right” thing or the “wrong” thing, they just do the whatever involves taking care of those they love.  They are so undemanding, so selflessly caring, such….friends, that they bring some of that out of you.  I know with my family, my friends, my work – that if I can do for others even one percent of what Hooper did for us, well, I will have accomplished something meaningful with my life.

And so the truth is this.  Hooper died a few feet from here.  But what is important is not how he, or any of us, die.  What matters is how we live.  The choices we make to be sure our lives are in service of something greater, and more everlasting than our own.

Now, our home, filled as it is with three wonderful children, is strangely empty.  I know that will pass.  We will take Hooper’s ashes and spread them by the ocean near where he and I played fetch.  And I hope that as the pain of his loss fades, the memory of what Hooper means in our lives becomes even stronger.

Rest in peace, my friend.