By Evan Falchuk

Everyone’s busy trying to figure out what the President is going to say in his big health care reform speech tonight.  I’m more interested in predicting what he won’t say.

Here is my list of three things the President won’t talk about tonight – but should.

Patients have far too little time with their doctors

Government data show that nearly 60% of doctor visits feature face-to-face contact with the doctor of less than 15 minutes.  But not because most doctors are abusing the system.  It’s because for years government and private insurers have paid less for care, forcing doctors to see more patients just to keep up.  Ironically, it probably ends up making health care more expensive.   Not letting doctors take the time they need with each patient makes care fragmented and uncoordinated.  It creates an increased likelihood that something will be missed, and a greater chance that a bad decision will be made.  It’s why almost everyone knows someone who has been lost in the system, trying to get their doctor’s attention, knowing something was wrong in their care.  Some of us are lucky and avoid tragedy, others are not.  Our system should pay for doctors to spend the time it takes to make sure care is done right.  It’s already happening at some medical centers, but it’s not the norm.  It should be.

Patients are far too uncertain about their medical care

Patients find huge amounts of information on the internet and feel more comfortable than ever taking it to their doctors for an explanation.  It makes the life of a medical professional pretty difficult.  And it makes the life of a patient vying for the doctor’s limited time that much worse.  It’s why patients report, in large numbers, that they feel uncertain about their medical care.  What’s more distressing is that they are often right to worry.  Studies show that 15% or more of patients have their diagnosis missed, delayed or wrong.  Other studies show that the biggest driver of these results are the cognitive errors that happen when you make complicated decisions with fragmented information and restricted time.  If we’re going to have a new entitlement program it ought to be this: everyone is entitled to be sure that their medical decisions are right for them.

The ways we measure quality aren’t very good

Health care quality is conventionally thought of as bringing concepts of high-quality manufacturing processes to medicine.  Just as there is a right way and a wrong way to attach a door to a car, there also is a right way and a wrong way to treat a patient.  And so, government and private quality programs have looked for ways to measure process and to ensure doctors adhere to it.  For example, the federal government has catalogued almost 1,500 “quality measures,” everything from whether your pediatrician told you about using a booster seat in your car, to whether your cardiologist took a specific set of steps before prescribing a certain medication.  But medicine isn’t an assembly line process.  Treating it that way fundamentally undervalues the thinking, processing and deciding aspects of medicine – the things that are so important to you as a patient when you are sick.  While some doctors are starting to sound the alarm, the larger point is this: quality ought to be a question of whether the patient got the right care.

These issues are at the core of the problems we face in American health care.  And while I expect the discussion tonight to be about costs and public plans and exchanges and coverage and compromise, I will be very happy to be wrong.