Primary care doctors are the first ones the patient should consult regarding their medical concerns. That doctor is the first to assess their problems and manage their medical care.  For primary care doctors, the patient is at the center of care. This may seem obvious, but many doctors no longer do this. They focus on the disease and its treatment, often ignoring the personal needs of the patient.

Today, many regard medical care as the applied science of statistically derived, evidence-based medicine based upon practices shown to be effective for the majority of a group. They treat the individual as a statistical integer in a group or herd, and not as a person.

Medical care should be more than individual care. It should be personal care. Individual care defines a person in terms of measureable characteristics such as age, weight, height, blood pressure, blood tests for sugar, cholesterol, hemoglobin and many others tests such as genetic makeup, to name a few.

Personal care, on the other hand, includes not only measureable characteristics, but other factors that lend themselves less readily to measurement, such as cultural background, education, training, likes, dislikes, view of health and disease, and other biases. These factors have been proven to have a significant impact upon the effectiveness of disease management. They’re mostly ignored in herd care.

I want to emphasize that personal medical care should not be confused with personal-ized medical care, a term hijacked by geneticists and deceptively used starting 10 years ago. This genome-based care focuses on genetic markers to target diseases and care methods, such as susceptibility to certain drug treatments. This alone may help provide more precise individual care, but it is no more personal than a fingerprint.

Primary care physicians are the ones who traditionally focus on personal care.   Health systems that incorporate the primary care physician as a central part of treatment have better outcomes at lower cost than those systems without them.  

Despite the obvious advantages of using primary care doctors, they are in danger of becoming obsolete. They are the victims of a medical system that now largely focuses on costly technology in the treatment of disease.

The challenge today is to return the primary care doctor to the center of patient care.

Norman Makous, M.D.

[ Excerpted from the article, “Is the Primary Care Doctor Obsolete?” by Norman Makous, M.D. Follow this link to view the complete article. ]

Among these is the provision that health care benefits will be chosen by a Health Care Commissioner and by a government committee.  This will include benefit levels for private plans. How can this be done in order to be just and equitable and not based on cost savings alone? That’s the question on which public attention should be focused.

Instead of continuing to deny that we have had and still have rationing, and that it must continue, the necessity for rationing should be admitted.  The mechanisms must be closely scrutinized to help insure that they are just and subject to the least amount of lobbying and for-profit abuse.

The rationing system must not be left to politicians, bureaucrats and insurance company executives. Public values must control our methods of rationing.

Norman Makous, M.D.

The problem that has not been touched in the current legislation relates to how we provide medical services. The main driver of increases in medical costs is our technology-based medical service system. This causes an economic squeeze in health care that has already required rationing of medical services. Even with health insurance reform, the cost of medical care will continue to rise, and the need for rationing will increase.

Having an independent primary care physician at the heart of the patient’s medical care is a proven effective and ethical method of monitoring the care process. This reduces unnecessary and expensive tests and procedures, and the quality of care is higher from the patient’s point of view. On the financial side, there is much less waste and costs are controlled.

Cost control will always require rationing of care, but the current legislation creates broad methods of rationing that are built into the payment approval process for care providers. The rationing process is hidden from the public. These methods of allocating resources and deciding who receives what services should be openly addressed and discussed. They have not been.

The new health insurance reform legislation is just a beginning. As it stands, the US healthcare system will continue its wasteful and ineffective medical care practices.

If the patient-doctor relationship is recognized as essential to our health system, however, medical care will be humanized and unnecessary spending will be greatly reduced. We will then have a society that is not only happier and healthier, but also more financially capable of affording broader coverage for a greater number of people.

Norman Makous, M.D.

Many important differences that affect disease manifestations and responses to treatment, however, are difficult to quantify. Every person has his or her personal theory regarding the maintenance of good health and the nature of illness. These result from the combination of cultural background, education, vocation, standard of living, experience, and world view. As you can imagine, they are difficult to quantify.

These personal attitudes enhance or impair the responses to drugs and other treatments. A good example would be a patient who has very little response to a severe heart attack, as compared to another patient experiencing a complete upheaval of their health and self-image from a heart attack of exactly the same severity.

Such effects are actually measurable in about one out of three people and are referred to as placebo responses. Attention to these important personal attitudes makes medical care an art based on science. Personal care is medicine that take all of these factors into consideration, and it is fundamental to effective treatment.

Medical care based upon the overall benefit for a group of individuals, rather than for each individual, falls into the category of herd care. This is the approach adopted when government is responsible for public health. Meting out the swine flu vaccine is a current example.

Herd care also results when people pool their medical purses through insurance companies. The companies dictate the amount of medical care the group as a whole is allowed. This herd care can be detrimental to individualized care, whether personalized or not. The limitation of resources is recognized, and the result is rationing.

Herd care may be fundamental to the health of our financial system, but for healthier and happier people in our society, care can and should be personalized, not just individualized. The individual’s personal experience during the health care process must prevail.

Norman Makous, M.D.

Most people have turned their medical care purse over to third parties, who now negotiate with the doctor over care.  These insurers and managed care entities pressure the doctor to act as “gate keeper” and ration the patient’s care in ways that may not be in the patient’s best interest.  Doctors have a conflict of interest and are placed in an unethical position.

Doctors still interested in doing things in the best interest of their patients are concerned about the poor quality of care. The third parties blame the doctors.

“Caveat Patiens.” Patient, beware. An increasing number of doctors have succumbed to turning medical care into a business for profit.

The third parties have wrested control of medical care from the physician community and turned medicine into a free market commodity. This is an assault on medical professionalism and independence.

Most people in the general public don’t recognize rationing when it happens, and many health professionals refuse to admit to its use or disingenuously deny that it exists.

In the past six months, nearly every politician has mentioned rationing in order to deny that it will ever happen under the new healthcare system.  The fact that it already exists in the current system is unaddressed.

Rationing is a normal part of our lives.  Everyone uses it on a daily basis.  What is actually meant by the word “rationing?” When resources like money or food are in limited supply, they require sparing and prudent use – in other words, rationing.

For individuals in a group to conduct rationing on a fair and equitable basis requires what is called, “the ethics of distributive justice.” The group must create the rules of rationing, and must agree on how these rules will be applied. This principle applies in the rationing of medical care, but it has not been followed.

In the US today, the decisions about who will receive funding for medical care and who will not are made by insurance company administrators who base the decisions on the healthcare underwriting rules of the company, protecting the company stockholders. This is a proprietary rationing system with little public input.

With the introduction of Medicaid and Medicare in the 1960s, the government has also been involved in rationing a good portion of medical care.  Most of the rationing policies there, however, have not been established with much public input and comment.

Much of the onus of the rationing decision today has been shifted to physicians and to the institutions providing care.  Since the patient interest comes first for healthcare professionals, this conflict of interest has resulted in an unrelenting assault on professional ethics, and has been very counterproductive.

Coming to agreement on the rules of rationing will satisfy the same needs as universal care – everyone will feel that healthcare is being delivered in a fair and equitable way, given the limited resources today. If the healthcare reform process leads to a public debate on the rules of healthcare rationing, we will have accomplished a great deal in the process.

Norman Makous, M.D.

This requires rationing, by definition. In the US, rationing of medical care has always been with us. We are in denial, and we tend to avoid the term “rationing.” It’s perceived as un-American, so we refuse to acknowledge it.

One common method of rationing is by queue. People await their turn. Another method of rationing long in use in the US  is the limitation of  care through age discrimination. For example, organ transplants frequently are denied to those above a certain age.

Today in the US, rationing decisions are made by medical insurers based on profit motives. An individual’s healthcare needs are limited by the insurer’s financial goals. The decision-making process and its implied social values are considered part of the free-enterprise system. The methods for decision-making are hidden from the general public.

To achieve a consensus on rationing methodology, both the goals and the limitations of healthcare in the US should be recognized and thoroughly discussed. These should be debated, whether the system is called socialized medicine or universal healthcare, and whether the system remains a version of the for-profit, free-market system we now have, or becomes a fully government operated program, or is some blended version of the two.

While Medicare and Medicaid have paved the way for acceptance of comprehensive healthcare – which contains key elements of rationing – the lion’s share of the debate lies ahead. To be effective in the US, the system must be equitable, and it must be perceived as equitable. This requires a great deal of open discussion.

Norman Makous, M.D.

Within this context, there is a huge push by many people for universal care provided by the government. We are the only country in the world that is applying the capitalistic, free-market approach to the delivery of healthcare. This commercial approach has limited our access to care.

Key questions about universal care include: How much care should be guaranteed? Who will manage it? And, who will pay for it?

Many people insist that universal healthcare must be delivered by the private sector with government oversight only. Even with the private sector approach to universal care, the costs will continue to rise dramatically.

With the economic squeeze today, the only way costs can be effectively controlled is through increased rationing of care. Today, rationing occurs behind the scenes through the insurance underwriting system. Approval for coverage of tests, procedures, and the amount of care is a form of rationing. This is medicine’s “dirty little secret.” Rationing of healthcare has been with us for decades.

In the future, we need to ration with values and terms that are openly discussed and agreed upon. The decisions about who does and who does not receive care cannot continued to be made in the back offices of insurance companies.

Norman Makous, M.D.

Life is one of the inalienable rights set forth in our Declaration of Independence. But how healthy and how long a life is part of that inalienable right to life? The Constitution and Bill of Rights do not explicitly provide for health rights. Since this is not already covered as an American entitlement, maybe we need a Health Rights Amendment.

If everyone has the right to good health, this becomes a government fiscal responsibility. Our government, however, cannot possibly fund the good health to which everybody in the US may feel they are entitled today.

How should we define good health?  The World Health Organization has defined good health using personal standards. It is not simply freedom from disease. It consists of complete physical, mental, and social well-being as each individual sees it, not as others see it.

Even without a Health Rights Amendment, the current debate about health reform should address these issues. We need to determine when we consider a threat to health as a threat to the inalienable rights we know we have to life.

Is such a threat only applicable to those conditions that require immediate, life-saving intervention like CPR? How many minutes, hours, days, weeks, or years must the person be able to survive without treatment in order for such a health threat to qualify as a threat to life?

We must determine what individuals need and are entitled to under health rights so that those who hold the purse strings can follow these rules. Anything which is simply an individual’s want or preference should be a personal financial responsibility.

These debates will be critical in approaching the challenges posed by the rationing of healthcare in the US.

Norman Makous, M.D.

Are the goals to improve the population’s health, relieve pain and suffering, and prevent immediate death? Or do the goals also include satisfying everybody’s self-perceived wants to prolong meaningful life as long as possible by all available means? These are very different goals with very different implications for our healthcare system.

Prolonging meaningful life by all available means includes not only treatment with all available drugs and surgical procedures, but also replacing and mimicking all sorts of body-part functions with transplanted organs and artificial devices. That’s a very expensive proposition.

Do our goals include the prevention of all disease? Prevention includes not only immunizations but also the treatment of risk factors for disease, both genetic and lifestyle.  Obesity is just one example of a lifestyle risk factor.

What goals can we afford? And which Americans should benefit from these goals? Only the wealthy and employed – or everyone?

If everyone in this country receives all of the healthcare to which they believe they are entitled today, it could consume the entire US economy. Goal-setting for the US healthcare system should be one of the first topics in this debate about reform.

Norman Makous, M.D.