As I See It

Capitol Punishment

Dr. Koch, like Longfellow, encounters an audience baffled by "the accents of that unknown tongue."

By Paul S. Koch, M.D., Editor Emeritus

There are a number of hereditary diseases, but perhaps none so rampant or distressing as hereditary government employment. In our egalitarian nation, where all men are created equal and George Washington declined to be king, we have successfully fought off all attempts at familial dynasty, excepting, of course, the Kennedys and inherited government jobs. One finds no need for special qualification for a position if one carries the famous Irish surname or if your cousin knows a guy who knows a guy.

That's how it works in my little state and perhaps yours, too. I have, however, the benefit of being in a place where everybody knows everybody and most are related to one another, so a government job is mine for the asking. I think I'll ask around and see if there is an opening on the Health Care Management Commission.

Make Way for Excelsior

Now that we have thrown gazillions at the banks, the companies that insure the banks, and the companies that make the cars bankers don't want to drive, it appears that health care is next. Certainly they will need some experts to help them, won't they? They wouldn't try to change the system with as much thought and care as they did the financial sector, would they?

Yikes, I better rush down there and apply. If asked how I could improve health care, I would charge forward carrying a banner with the strange device. "Stop busting capsules!" it would read. The bureaucrats would stare at my flag, curious in its simplicity. "Stop busting capsules!" I would shout.

I would be ushered aside by charismatic young men, quite possibly entry-level Kennedy cousins. They would politely offer a modest compromise. Instead of imploring surgeons to stop busting capsules, perhaps (they urge) we could let them continue to bust capsules, but when they do, have them type or dictate the description into an electronic medical record. The Kennedettes would explain that quality medical care is not preserving capsules, but preserving the information in perpetuity in electronic format.

"No, it's the work, not the record," I argue. "If we stop busting capsules, people will see better. That's where you should focus your attention."

They smile indulgently, and explain that their plan would pay us for quality care, not just the number of work units performed. And, they continue, the one who pays the piper gets to write the rules. Quality will be defined by the format of the note — better if electronic and poorer if written, even if perfectly typed and completely legible. (Digital so Big B can look over our shoulders easier? Paranoid, moi?)

I do not give up. Look, if we can't agree to get people to stop busting capsules, at least grade us on how vigorously we treat the after-effects, OK?

Of course, the sycophants encourage, just as long as the patient is not given a prescription for the medication. That would be so appalling they would have no choice but to financially penalize the surgeon for the script. It matters nothing to them what medicine is used to treat the problem — it matters only if the prescription is sent electronically to the drug house. Whether or not the selection was wise or otherwise will be irrelevant; what will matter is the method of delivery.

Beware the Awful Avalanche

I will stand my ground but I will lose. The piper's payer processes the payment, so the doctors will have to dance to their decrees. There is already widespread consensus that quality equals digital. You can't fight city hall, especially when the best and brightest in residence believe in their hearts that we are not. OM