It's the doctors, stupid.
If we really want to fix America's overpriced and under-performing health-care system, what really matters is changing the ways doctors practice medicine, individually and collectively. Everything else -- mandate or no mandate, the tax treatment of health benefits, whether there's a "public plan" to compete against private health insurers -- is just tinkering at the margin.
I was reminded of this reality by a recent article in the New Yorker by Atul Gawande, a surgeon at Brigham and Women's Hospital and the Dana Farber Cancer Institute who somehow manages to find time to turn out deeply reported and elegantly written essays on health care. Like many health reformers, Gawande says the essential problem with the American health-care system is that so much of what we spend -- as much as a third of the $2.3 trillion spent in 2007 -- goes toward care that is either unnecessary or inappropriate. Fixing that is the first step to fixing everything else.
It is tempting to lay the blame for this enormous waste of resources on greedy drug companies or incompetent insurers or misguided government policies -- and surely all of these contribute to the system's high cost and disappointing results. We consumers also share some of the blame when we demand to have all the latest treatments, whether we need them or not, or when we fail to shop around for the best value, knowing that our health insurance plan will pick up most of the tab.
At the end of the day, however, it is physicians who have the greatest impact on the cost and quality of health care we get. It is the docs who drive the decisions on what tests are ordered up, what surgeries performed and what drugs prescribed. And it is around the doctors and their practices that the medical system is organized.
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