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Physicians best suited to heal system

As momentous as the Supreme Court's health care decision on President Obama's signature achievement will be, that's not where the most important battle will occur.

Regardless of which way the court rules, the real fight over health care will be with the man or woman in the mirror.

Cutting unsustainable spending will depend less on what the high court says in June than on what some doctors said last week -- and on how patients react. It will depend on who wins as we play a health care version of the old TV game show "Who Do You Trust?"

The key this time is that it's doctors -- not insurance companies -- who came up with the list of 45 overused tests and treatments, ranging from imaging tests to antibiotics. It marked a significant step down the road toward medical sanity that we can trod voluntarily or be dragged down by the reality of billions of dollars in waste.

Doctors, especially primary care physicians, stand a much better chance than claims processors of persuading patients that evidenced-based medicine is not merely another name for profit-driven rationing.

"This is why we believe so strongly in people having a primary care physician that they can trust," said Dr. Michael Cropp, Independent Health president and CEO, who knows that insurers are not exactly the Walter Cronkites of health care.

Primary care doctors typically don't have the same financial incentive that others have for doing more tests. Conversely, they don't have any monetary motive to scrimp on care, either, as insurers might have.

"That trust that the patient can have in their primary care physician is an essential factor" in reforming the system and cutting waste rather than cutting care, Cropp said.

And the waste is rampant. The figures are as familiar as a blood pressure reading to the fat person who refuses to diet: The United States spends 17 percent of gross domestic product on health care, while no other developed nation spends more than 12 percent. A 2009 PricewaterhouseCoopers Health Research Institute analysis found that $210 billion a year of that goes for overtesting.

Yet members of Congress -- who have the best insurance you can buy, and I do mean you -- demagogue about "death panels" even as the exorbitant spending still leaves us in the middle of the pack in international comparisons, from infant mortality to life expectancy.

But all of those numbers are in the abstract.

"Statistics are for other people; they're not for you," said Dr. Mark Lema, president of the Erie County Medical Society, summing up patients' resistance when health care becomes personal.

The key, both doctors say, is whether a test result would lead to changes in treatment. Often, the answer is no. Lema cites the parent who wants an MRI every time a kid hits his head, even when the physical exam shows no need for the expensive imaging.

Short of having patients kick in for each test, how do you change such attitudes?

"You need good evidence to suggest that certain things don't need to be done," Lema said.

"It's about evidence and conversation," Cropp agreed, "and the conversation really depends on trust."

The medical societies -- ranging from family physicians to cardiologists -- have compiled the evidence. Developing the trust could be more challenging, but just as essential.

Health care already is rationed; it's just not done rationally. Patients have to be part of the effort to do it rationally because we can't afford not to. That means letting doctors take the lead because no one wants to follow an insurance company.