Our nation is getting the healthcare overhaul process backwards, and that presages disappointing results for us all.  We are starting to make new arrangements to pay for healthcare and are investing in information technology infrastructure before deciding on which health services the new plan will buy.

In a recent Associated Press article Ricardo Alonso-Zaldivar said that "as he moves forward, Obama will follow the plan laid out in his campaign.  It calls for government, employers, families and individuals to keep sharing financial responsibility for healthcare.  The approach would overhaul the health insurance market, particularly for self-employed people and small businesses.  He would set up a national insurance purchasing exchange through which people would be guaranteed access to private health insurance or the choice of a new public plan.”  Nothing here about which health care services the financing scheme will buy, or even how to decide which health services to buy. 

It is true that we are suffering breakdowns in coverage and that more and more Americans are underinsured, or not insured at all.   We must fix that.  However, this breakdown is only a symptom of the problem afflicting the heart of American healthcare; it is the peripheral manifestation of a “disease”.  In focusing first on the symptoms instead of the ailment at the heart of American healthcare, our leadership is bailing water from a sinking boat without plugging the leaks in the hull.    

What is the disease affecting the American healthcare system?  Think back, start with the most consistent criticism of healthcare in America these past 20 or 30 years: there is no one with time to talk to us we are sick.  “I can't get time with my doctor/nurse/PA.”  “No one calls me back.”  This has been the complaint and it started before the problem of the underinsured and uninsured blossomed.

Why this complaint? Because 30 years ago the health insurance industry stopped purchasing healthcare.   Healthcare is the process of providers guiding patients through the growing maze of tests and treatments, of helping us make the right choices at the right time.  Healthcare is the provider-patient relationship that is the brains behind the brawn of thehealthcare services that providers may order - the tests, surgeries, drugs and high-tech treatments.   In the 1980s Health plans began deeply discounting payment for “evaluation and management” services, yet they continued to pay for most healthcare services (procedures, tests, hospitalizations, etc). 

Consequently, those in the primary care specialties who used to be our guides (doctors, nurses, etc) have become too busy seeing too many patients and doing too much paperwork, and their treatment options have been restricted by managed care medical directors.  Some of us can use procedural revenues to offset “pro bono” time with patients in our offices, but we are too few and primary care physicians do not have this ability – they depend primarily on revenues generated by face to face time with patients. 

Set adrift in a sea of confusing, expensive, and vigorously marketed health services options, Americans have been making the wrong health choices en masse, blowing our healthcare budget and now threatening to bankrupt Medicare. 

Healthcare may be the beating heart of a good healthcare system, yet it is not something congress can give us, nor is it something our new president can give us because it happens in doctors’ offices, nurses’ offices, physical therapy offices, mental health professionals’ offices, one patient, one disease at a time.  It follows that healthcare reform will come one patient, one disease, one decision at a time - or it will not come at all.   

 It is time to set aside the notion that we can simply legislate healthcare reform.  And let’s not delude ourselves that technology will save us in this decade.  Someday we may have enough information amassed in central data banks for the whiz-bang gadgets of health informatics to guide healthcare decision making based on readings taken from patients by machines.  That is years away.  

Our healthcare reform effort must stimulate and support good healthcare decision making at the point of service.  Regardless of how we pay for it, we must be sure to buy this – and soon.  The leaders of President Obama’s healthcare effort must understand that face to face time between provider and patient is what creates value in healthcare, they must make good decision-making the core product of American healthcare by rewarding it well enough that many smart people will again be able to spend the time to do it well.