Sick To Death > Chapter 4 > Avoiding Low-Impact Reforms
In a field that is so new and so complex, and in which the need for rapid improvements is becoming apparent, an array of possible reforms has come to the fore. Legalizing physician-assisted suicide is one idea that many states have considered. And as inflation and new treatment modalities create pressure on the income stream, nearly every provider group is adjusting its payment rates. Some advocates feel that revising the content of the education of physicians and nurses would improve the quality of care; others focus on making palliative care into a specialty parallel to cardiology or vascular surgery (Butler, Meier, and Nyberg 2003).
My guess is that these may all turn out to be low-leverage changes. Even if they all were accomplished, end-of-life care would not be greatly improved. Few patients want, and in good care fewer would want, suicide. Better payment rates for current providers won't change the incentives or dysfunctions. Teaching practitioners about good care may be essential, but it does not actually implement good care. And care delivery certainly needs more fundamental change than just adding a specialty. Of course, some of these reforms might actually have substantial adverse effects. Legalizing physician-assisted suicide might blunt our commitment to care for one another; and increasing payments or granting a protected status to certified specialists might encourage them to resist more fundamental change. Mainly, though, many of these issues would precipitate quite a struggle and demand energies that probably should be applied to other agendas.
In short, while it may well be important to pursue some of these issues some of the time, efficient reform depends in part upon forging and pursuing high-leverage strategies and avoiding spending much effort on low-leverage ones. Confidence about predictions of this sort is elusive. Nevertheless, since we have rarely even tried to strategize among the broad array of concerned parties, reformers in this arena could undoubtedly do better strategic planning, looking both for promising areas for major reforms and for areas of diminished importance. One major deficiency is that potential reformers do not now meet one another or work together, because we are split among diseases, specialties, settings of care, and vocational identities. Furthermore, we do not have galvanizing aims to share.
Some possibilities that might improve on the current uncoordinated efforts include
The job of restructuring and refocusing care for the last part of life has to become a valued task. Professionals and civic leaders must see the undesirability of slowing it down with diversions or regulation and liabilities. Reformers need to establish a few venues for strategic planning that can generate loyalty and commitment among a broad array of advocates. Especially when moving from fee-for-service to a more flexible capitation or salary financing, society generally must make peace with the care system having some limits. It will not be possible to pay for all that we might want. Developing processes and trade-offs that the community supports will be challenging - and essential. The caregiver shortage and the dramatic dysfunctions in care present opportunities to build better care.