By John Maa, MD

The uniquely complex American construct of healthcare evolved over decades. As such, the most important lesson from my career in surgery that I share with my “patients” on a daily basis is to have “patience” and not rush to overdiagnosis and premature treatment.

Therefore, as we seek to optimize access to safe and high quality healthcare, it would be wise to patiently spend several months analyzing the problems in an open, unbiased, and thoughtful manner.

We are only at the beginning of an endeavor that will require decades to complete. Before attempting to propose reforms, we need to develop a common language to communicate, and to answer simple questions such as:

• What defines quality of care?
• If access to basic healthcare is a right, then what are the attendant responsibilities and expectations for patients?
• What should be done for cases of medical futility?
• What is a reasonable waiting period to receive elective medical care?

The difficult task ahead is to perform the careful analysis to define improvements and proper solutions for (our existing emergency care) system, which serves as the foundation for healthcare delivery across our country.

We should openly acknowledge the many ways that money and profit drive not only the healthcare delivery system, but also the debate regarding healthcare reform. The millions of Americans employed in the pharmaceutical, device, and insurance industries, the physicians, nurses, allied health professionals, hospital administrators, medical malpractice attorneys, and healthcare economists, each have careers and livelihoods at stake, and are inclined to protect their own interests, often by deflecting public attention elsewhere.

We should also acknowledge that some elected officials who champion healthcare reform are motivated by the desire to either win votes for election, or to define their legacy as an architect (or stopper) of landmark healthcare legislation.

But what those elected officials often don’t mention in their speeches is the key role that patient responsibility must play in redefining the healthcare system: in combating obesity through exercise; in tobacco control; and in imparting realistic expectations. These important points don’t win votes, but they will play an important role in controlling healthcare costs.

We should remember the valuable lessons of past experience. While the introduction of Medicare as a single payer system for Americans older than age 65 did reduce administrative costs, it was simultaneously also a catalyst to an unintended overall increase in healthcare expenditures, and a rise in physician salaries.

This government-based reimbursement system disconnected direct payment from the patient to the physician, relegating it to a third party who “is not in the room” when the care is delivered. This led to an expansion of the fee-for-service industry, with an unintended incentive for physicians to perform more procedures and tests, and ushered in the period when patients began to regard healthcare as an entitlement, and to expect more in services. Ultimately, we will need to address this central disconnection between the recipient, provider, and payer of healthcare.

Many Americans are quite satisfied with the care they receive, and are concerned about changes that may compromise their access to healthcare, particularly if they perceive that a sense of urgency is being created to adopt solutions for incompletely characterized problems. The solution to such a complex situation will require a balanced perspective, and the patience to thoughtfully reflect upon critiques of proposals under consideration.

Fundamentally, we may come to realize that too much is spent on healthcare already. If so, the central task is not to search for extra sources of funding to pay for coverage for the uninsured, but to be more intelligent about how and where our healthcare dollars are spent. Ultimately, regardless of whether one is a patient, provider, supplier, or payer of healthcare, we likely can all make valuable contributions to promote greater efficiency in the American delivery system. Perhaps the key principle that will transform the existing money driven medical system is to consider healthcare as a public good. In the end, we will likely identify ways to reform our society as a whole.

John Maa, MD, is an Assistant Professor in the Department of Surgery, at the University of California, San Francisco. Dr. Maa is also the Assistant Clerkship Director for Surgical Education at the UCSF School of Medicine, and Assistant Chair of the UCSF Department of Surgery Quality Improvement Program.

The opinions expressed are those of the author, not of the Healthcare Journal of Northern California, its publisher, or its sponsors. We look forward to your comments. Dr. Maa has also written for UCSF's news publication.