Ask Dr. Ira Williams

Most legislators are attorneys. Almost all universities, hospitals, large companies, etc. have risk management business components populated largely with lawyers. Wills, trusts, pre-nuptial agreements, and other legal contracts impact countless aspects of every day life in America.

We as a society have come to assume that attorneys must put a legal stamp of approval on most basic managerial functions. Otherwise, the threat of litigation can dominate behavior to the point that organized entities feel prevented from doing what they are expected to do.

Example: Hospital medical staffs far too often fail to take remedial action against disruptive or marginally-qualified practitioners for fear of retaliatory litigation.

The American College of Obstetricians and Gynecologists (ACOG) created a voluntary peer review system for hospital Ob/Gyn departments. A journal article reported the findings of that peer review system in 2003 after the first 100 inspections. There were 3,003 Ob/Gyn hospital departments at that time.

A disheartening number of deficiencies were noted in that report, but one specific deficiency was that 38 of the 100 Ob/Gyn hospital departments had “substandard or disruptive physicians” as members. Many, if not most, hospital medical staffs have failed to reprimand or alter staff privilege of those less-qualified staff members purely due to that threat of being sued.

IF the medical profession can NOT create a system of medical peer review acceptable to every court in the nation – that is NOT the legal system’s fault!

Such lack of proper administrative control illustrates an absence of understanding of fundamental judicial demands. There is absolute need for a system of peer review done by a hospital medical staff which:
a. provides a uniform system of patient care review in all instances
b. subjects every medical staff member, regardless of status, to the exact same review process

NO court in America, up to and including the Supreme Court, would sanction retaliatory litigation against such an unbiased, standardized system of medical peer review.

There are those both within the medical profession and within the field of non-physician medical expertise who would argue that such a system of medical peer review can never be established.

I have formed a social response that proves useful in certain occasions:
First, one should politely walk away from those persons who can tell you what they are against, but can not tell you what they are for.

Second, one should run away from those persons who state they can recognize the impossible.

The impossible is yet to be clearly established.

Much of mankind has been bred with a flawed gene. Descendents of the “flat-earth society” have done their best to impede social advancement throughout the ages. Where would civilization be if the great thinkers had succumbed to the masses of small minds with limited vision?

Everything in healthcare begins when a doctor and a patient agree upon a medical collaboration. The patient may come from any walk of life in America, including other doctors.

The doctor can only come from one of two regulated sources: federal or state.
Probably 90% of all doctors actively treating patients are in the private practice system regulated by the fifty states and the District of Columbia.

Federal healthcare, through Medicare, Medicaid, the Department of Defense, the Veterans Administration and Public Health, may account for almost one half of all healthcare costs, but those Medicare and Medicaid patients are primarily treated in private practice.

Therefore state legislatures are the principle source of medical practice regulation. And they aren’t up to the task.

The practice of medicine is the least regulated economic activity in America.

Someone, somewhere, hopefully, will test the validity of that statement, which demands to be tested.

The first clue that medical practice truly is the least regulated economic activity is that NO state government can produce one single person who has complete knowledge of:

1. Every existing statute, rule, regulation, and policy governing the practice of medicine in that state.
2. Regulatory mechanisms created by the above listed legislated requirements.
3. Evidence of effective regulatory results.

The second clue will appear when it becomes evident:
1. How many different persons are necessary to obtain the above data.
2. How long it takes to obtain the data.
3. How little regulatory mechanism truly exists.

The regulatory lines were blurred beginning with Medicare in 1965. Prior to that they were faint, if not non-existent in most, if not all the fifty states.

While most states were trying to establish some semblance of medical practice regulation, particularly at the hospital medical staff level, the federal government was establishing their immense presence.

Both houses of Congress have had numerous committees and subcommittees dealing with healthcare issues. The same can be said for the fifty state legislatures. There are also a plethora of governmental and non-governmental agencies, groups, organizations, foundations, etc., “focused” on healthcare issues, yet none of them has ever thought that a clear distinction between federal and state regulatory responsibility was necessary.

No consideration for healthcare change should take place before establishing a clear delineation between federally-controlled healthcare and state-regulated healthcare.
Precipitous Congressional healthcare change would be, “putting the cart before the horse.” Currently both Congress and all state legislatures are all asleep at the switch

The demand to change healthcare is reaching a crescendo now.
I advocate an immediate delay in all such discussions.
Why?

Simple: Never, ever attempt to change a large social system until you are able to describe (in detail) how that system is organized.

Case in point: The U.S. Defense Department is enormous, but the Pentagon could easily draw a complete organizational chart starting with the Secretary of Defense at the top and the newest recruits in all branches of the armed services at the bottom.

No one in America has ever drawn up a comparable chart detailing our present system of healthcare. If they had, it would be very clear we have two distinctly different healthcare systems operating in America: federal and private.

No one has ever done it, yet multitudes want to change a huge system they can’t describe. That is a scary thought, but actually only half of the problem. Who does everyone assume will create this anticipated marvelous make-over?

The federal healthcare system includes Medicare, Medicaid, Department of Defense, the VA and Public Health. This consumes about 45% of the total healthcare cost. The private healthcare system (1 doctor/1 patient) is regulated by 50 state legislatures and DC and consumes about 55% of the total cost.

Though over 90% of all practicing physicians are in the private sector, they also treat the Medicare/Medicaid patients. Therefore, about 90% of the total cost of direct patient care goes through the private practice sector of our healthcare system.

Congress made a monumental impact on healthcare in America in 1965 when it passed Medicare. It has periodically continued to blur the line between the state and federal regulation of the practice of medicine.

What got lost in that blurring of lines? The entire healthcare quandary begins with one doctor and one patient and over 90% of all practicing physicians are primarily regulated by the state legislatures.

If Congress, or anyone else, wants fast results, let them begin by imposing a system of medical peer review within the Defense Department and/or the VA. There is already a proven track record of positive change in federally controlled healthcare. The Defense Department did it in the mid-1980s and the VA in the 1990s. Successful use of medical peer review within the federal systems would pave the way for state legislatures to follow suit.

The practice of medicine is the least regulated economic activity in America. “Defensive medicine” is said to be the greatest cause of the constant rising cost of healthcare. To change this, there should be a dramatic shift in the regulation of doctors. When medical peer review replaces medical malpractice litigation as the primary system for questionable patient care review, costs will be lowered.