By Dominique Perkins
The magic of medicine
Life can take a winding path at times, and it is interesting to look back and wonder how things would be different if you had turned left instead of right at a crossroads.
We often ask our profile physicians what they think they might have done if they had not pursued a career in medicine, and they usually make a good guess or select something based on a hobby they have come to enjoy.
But in the case of Dr. Richard Manch, the moment of decision was clear. While he was interested enough in medicine to enter college as pre-med, he focused on drama, music, and anthropology.
He played regularly in a folk music group, both on guitar and the banjo. One of his bandmates tried to convince Manch to choose a career in music over one in medicine.
“He went on to be a successful music producer,” Manch said of his friend, working with artists such as Linda Ronstadt, Boston, and The Eagles.
Manch chose a different path.
“Being a physician seemed like a magical thing, a special ability that one could work hard to achieve,” he said. “I love being a physician, and feel very privileged every day to do what I do.”
A three-phase career
After completing an internship at Buffalo General Hospital in New York, Manch became enamored with the desert southwest. He completed his residency at Maricopa Medical Center in Phoenix, and then a gastroenterology fellowship at the University of New Mexico.
He returned to Phoenix to practice, joining a group based at Good Samaritan in 1976. This began what Manch would call phase one of his medical career, and he would continue to practice gastroenterology for 12 years.
He then went back to school, obtaining a master’s degree in health administration. He worked in management for about three years at Samaritan Health Services (which has since become Banner Health).
After leaving his managing role, he began working full time with Good Samaritan. His role was initially an academic one, but when Good Samaritan restarted liver transplants in 2000, Manch’s role quickly morphed into full hepatology, launching phase three of his medical career.
Manch has remained a full-time hepatologist for the past 16 years and is board-certified in transplant hepatology. He moved to Dignity St. Joseph’s over four years ago to start a new liver program there.
Government involvement in care
Given the dynamic nature of his career, Manch is no stranger to changing roles, and he’s had the opportunity to view the involvement of Government agencies in the healthcare arena from several different positions.
Since the development and introduction of Medicare, the government has played a major role in healthcare in America, Manch said. However, since then, he doesn’t feel that role has changed a great deal.
This is despite several attempts, beginning with President Clinton’s plan, which Manch said failed mainly because it was too complex and too expensive, and through to the Obama administration and its renewed attempts to accomplish expanded access to care.
“The Accountable Care Act (ACA) is also flawed, in part because of compromises dictated by political circumstances,” he said.
While it nudges us in the right direction, removing pre-existing condition restrictions, it is still greatly impaired, Manch believes. Because it depends on private insurers, unsustainable premium increases have probably doomed it, he said, and the recent election outcome will likely doom it further.
“I think that’s unfortunate: in my view, it needs to be fixed, not eliminated,” he said.
When asked specifically about the state of Arizona, Manch points out that while many consider the Arizona Healthcare Cost Containment System (AHCCCS) to be one of the better healthcare entitlement programs in the nation, initially it failed miserably because the health plans developed to provide the coverage were not operated with the appropriate expertise.
“Simple insurance concepts such as tracking the ‘incurred but unreported liabilities’ were not managed properly, or at all,” he said, by way of example.
“But eventually, the various difficulties were resolved, and Arizona Medicaid (AHCCCS) became the model for many other states over the years.”
Speaking of Obamacare
The topic of Obamacare has been highly politicized and has become a divisive conversation in the national arena. Manch believes it is a step in the right direction, though hardly perfect as currently implemented.
“It needs to be simplified, and a way must be found to either cover the financial risk borne by the insurers or perhaps take the insurers out of the process and have the government bear all the risk,” he said.
While the effort to expand care and coverage is worthwhile, the ACA has currently led to fewer coverage options and higher premiums, Manch said. This provides a clear obstacle to patients.
“I also believe it further weakens the leverage and control that we as physicians and other providers still wield in the healthcare system, and tends to give too much power to the major, well-financed entities, such as the large insurance companies and health systems,” he said.
As evidence of this, Manch points to Accountable Care Organizations, stating that while the best of them are thoughtfully constructed, they require a level of cost and quality management that doesn’t really exist currently, making them unsustainable.
Much debate has risen in recent years over the Health and Human Services (HHS) and Centers for Medicare & Medicaid Services (CMS) being bound by a federal law restricting them from negotiating drug prices with the pharmaceutical industry.
Considering CMS is the largest purchaser of drugs, many believe they should be able to better control prices.
Manch describes the issue as troubling and complex. Branded drugs are expensive, and many insurance plans require a large, upfront deductible, which can often be entirely consumed by a single drug.
“Patients on Part D Medicare often fall right into the ‘doughnut hole’ and are stuck for the cost,” he said.
In an effort to obtain the drugs they need at a lower price, an elaborate infrastructure has developed, with many patients purchasing drugs through Canadian pharmacies, which get them from developing countries.
Manch said that while this “workaround” can get patients access to the drugs they need, “It doesn’t make much sense to me if we are the country we claim to be.”
However, he has also been involved on the other end of the situation, and described drug research and development as an, “exhaustive, expensive, and lengthy process.”
This means that should the government step in to regulate drug pricing, the research, and development of new drugs could suffer.
“Still, some drug pricing is neither rational nor fair, as the media have pointed out in recent years,” Manch said. “I believe the answer lies in the establishment of some sort of drug pricing protocols, which would obligate drug companies to document in greater detail and with more transparency their pricing strategies.”
In addition to questions of cost control, government mandates are also in a debate concerning prescription monitoring, specifically of opioids.
“I believe the overprescribing of opiates is one of the major crises in medicine in the US today,” Manch said.
When he was in medical school, Manch remembers being taught never to prescribe opiates for chronic disorders. A lot has changed since then, and Manch shared his view that the medical establishment has lost total control of opiate prescribing.
“So this indeed an area in which government intervention is both needed and appropriate,” he said. “Although this smacks of government control of medicine, medicine can’t control it so government must. Isn’t that the role of government?”
Expanding technologies and treatments
As medical technology advances, and we turn more and more to high-tech methods of care, such as telemedicine, medical practice across state lines becomes more of a reality. With these advances, governance and monitoring discussions are inevitable.
Manch feels that whatever the thoughts on oversight, government in general should support the development and use of telemedicine and other technologies to expand access to providers, especially in those circumstances where specialized care is unavailable.
Manch described St. Joseph’s Project ECHO Hepatitis C program, which he said allows local providers to treat hundreds of their own Hepatitis C patients with telemonitoring supervision from their center in Phoenix. The program has received national recognition and sparked a movement in congress to provide payer support for the concept in many disease states.
“I believe the public and private payers can and must do more to support these kinds of approaches through direct and code-based reimbursement,” he said.
“I see this as an example of how technology has made the practice of medicine much better, unlike the electronic medical record, which has in my opinion greatly worsened the practice of medicine, but that is another issue entirely!”
Manch said that currently, the Federal Drug Administration does fairly well in improving access to advanced medical technologies and treatments, but that some of its policies are cumbersome and prone to cause needless delays.
“Also I have perceived that the FDA is someone inconsistent and seems to allow more latitude for some pharmaceutical manufacturers than others,” he said.
Manch strongly disapproves of such favoritism and is also strongly opposed to branded drug direct-to-consumer advertising. However, he said that disease state advertising can prove an advantage by raising awareness and advocacy for testing and treatment.