What Should Be The Goal Of Health Care Reform?

Until a few months ago the cost of health care and the percent of gross domestic product it consumes was a major concern. Our goods were not competitive on the world market in large part because of health care costs, manufacturing jobs were leaving the country and the standard of living of the middle class was compromised, all in large part because of these costs. Despite these expenditures 47 million citizens are not insured and our outcomes are poor compared with those of other industrial countries.
The reasons for our excessive spending, approximately twice as much per person as any other country, are well known:
1)An insufficient number of primary care physicians and an excess of specialists.
2)Over-reimbursement for technology and under-reimbursement for conceptual thinking and judgment.
3)Approximately $700 billion spent each year on inappropriate non-beneficial care driven in large part by our largest hospitals.
4)Excessive administrative costs in the private sector.
Without addressing these issues as in Massachusetts any attempt at universal coverage will face financial collapse!
Now we as a society are correctly trying to provide coverage for the entire nation, but without seriously addressing our excessive costs. Even the Congressional Budget Office has recently voiced the opinion that the cost control measures being discussed are at best speculative. Now we read that Congress is considering additional taxes that will certainly increase the gross domestic product devoted to health care. Thus our goods and services will be even less competitive in the global marketplace. With an even greater decline in our global competitiveness more high paying skilled jobs leave the country. In terms of social justice, without seriously addressing the known excessive costs in our health care system, as we spend more to provide universal coverage (increased social justice) we loose high paying skilled manufacturing jobs (decreased social justice).
The health care system in our country is incredibly complex and how to fix it seems elusive. However if one uses end-of-life care as a lens to understand the various forces that have created this massive over-spending and poor care one can then address the problems and provide better care for all at significantly less cost.
That is why after forty years of practice I choose to write my book, In Defiance of Death: Exposing the Real Costs of End of Life Care, which demonstrates the many problems inherent in our current system and proposes a set of feasible solutions.
Our goal should be universal coverage with a health care system consuming about 15% of gross domestic product. By focusing on how to fix end-of-life care, establishing appropriate care committees, creating a new hospital admitting form and a Federal Health Care Bank with varied administrative functions, we can achieve this goal.

Nothing New Under the Sun: Massachusetts All Over Again

A law signed in April 2006 in Massachusetts created state funded health care for all of its citizens. There was a deliberate decision to first insure the entire population and then once this was established deal with the cost issue. The idea was to offend no one, keep every constituency happy. Then sometime in the future face the music when costs become unbearable.

False arguments were made such as, universal coverage should in of itself lower costs by preventing chronic disease. This is of course absurd; chronic disease is frequently a product of medical care, keeping people alive who years ago would have died because of their illness. As average life span increases, the chronic disease burden increases and so does the cost. Another false argument was that with insurance for all emergency room visits with their large expense would be drastically reduced. But, that has not happened because of the severe shortage in Massachusetts of primary care physicians. Thus when people become ill their only alternative is the emergency room. There was no provision in the Massachusetts law regarding inappropriate non-beneficial care. However, one only has to look at the Dartmouth Atlas of Health Care to see that a large proportion of care in the state is inappropriate and extremely expensive.

So now Massachusetts has a financial crisis that must be addressed and unlike the federal government cannot print money to cover its costs. Will universal coverage in the state survive? Only time will tell.
The news from Washington is:
1) Medicare is facing insolvency in 2017, if changes are not made.
2) Many working families and our industries are now in financial distress because of the escalating costs of health insurance.
3) There is great variation in the Medicare cost of hospitalization throughout the country without commensurate benefits.

But what of the solutions offered – pabulum disguised as reform that does not address the causes of our excessively expensive health care – Massachusetts revisited!

1)A White House conference including representatives of the health industry that makes vague promises to decrease the increase in administrative costs over the long term. No mention of tackling the problem causing excessive administrative costs at this time.
2)Electronic medical records, a good idea for patient care but not a cost saver (see post titled The Electronic Medical Record: Must it Cost Billions to the Tax Payer).
3)A Comparative Effectiveness Institute, a bad idea that also is not a cost saver (see post titled The Federal Urge to Spend: The Comparative Effectiveness Institute).
4)Enhanced wellness – a vague idea involving dramatic changes in life style of most of our citizens – probably not to be seen in our life time.
5)A change in incentives so that doctors will be encouraged to deliver high quality care. A vague concept that sounds good, but says little.

David Brooks in an op-ed piece in the Wall Street Journal (May 15), titled his piece, Fiscal Suicide Ahead, in essence saying the proposed health care cost savings so far considered by the Administration and Congress maybe good ideas, but will not decrease costs. Thus the funds for the entire Obama agenda will not be available with the result being gross overspending and excessive debt.

By not addressing the fundamental problems within our health care system at this time, and the culture that maintains these very excessive costs (see postings How to Change a Health Care Culture of Excess and Steps to Affordable Universal Coverage), the federal government will find itself in a predicament that makes Massachusetts look reasonable.

The Federal Urge to Spend: The Comparative Effectiveness Institute

Washington is thinking of spending tens of billions of dollars on a Comparative Effectiveness Institute, based on a concept borrowed from Great Britain (The National Institute for Health and Clinical Excellence). However Great Britain has adequate primary care. We do not. And Great Britain has put a dollar limit on a newer drug or procedure regardless of its potential for benefit for that particular individual, while the U.S. Congress has rightfully ruled that out for our citizens.

The biggest flaw in the need for the Institute is the assumption that American doctors do not know how to practice medicine that delivers value for the dollar, and that information on this subject does not now exist. This idea is categorically false! Physicians know very well from many existing studies when further critical care will not be beneficial, when cardiac catheritization and stenting is not warranted, when multiple transfers from nursing home to hospitals will not benefit the patient and so on. I am not discussing debatable situations, rather situations that are manifestly obvious.

It is not a lack of knowledge underlying the cause for all this inappropriate care. The culprits have been previously discussed on this blog, for instance: perverse financial incentives including excessive reimbursement for technology, inadequate primary care, fear of legal consequences, and lack of national medical standards. If you want to read up on it, get a copy of The Dartmouth Atlas of Health Care: Regional Disparity in Medicine.

On this blog I have proposed multiple steps to more effectively deal with these problems:
1) Through the Federal Health Care Clearing House and Bank, prospectively verify the benefit of newer therapies via funding of their confirmatory research through the National Institutes of Health before they are approved for general use. This information would be generated via well-performed excellent studies reported without bias.
2) Use of my new admitting form that clarifies that only beneficial care can be delivered.
3) Physician review through Appropriate Care Committees to guarantee as much as possible that care will be beneficial and uniform throughout the country.
4) Amendments to the Patient Self Determination Act, the Americans with Disabilities Act and the Emergency Medical and Active Labor Act to include the phrase, “within acceptable medical standards.”

We can provide universal coverage and decrease our percentage of gross domestic product devoted to health care. If other industrial nations throughout the world can it, so can we. And we can do it without spending billions to study this, that, and the other, when the information is already out there. However, the sense from Washington is that we have to spend many billions more before we can reduce spending. I completely disagree!

A congressional budget office 2008 report quoted in the April 7, 2009 Annals of Internal Medicine states that a Comparative Effectiveness Institute in the United States would reduce health care spending by less than one tenth of one percent. There is no doubt in my mind that my plan is far superior. Do you agree?

The Electronic Medical Record: Must it Cost Billions to the Tax Payer?

According to a Dow Jones article the U.S. government plans to spend 20 billion dollars in five years to achieve a 12.6 billion dollar savings in ten. It is just me, or is there something bizarre about these numbers? The expenditure estimate is from an interpretation of the latest U.S. government spending plans, the savings estimate from the Congressional Budget Office. These numbers are quite approximate and may vary, but the main point is clear: electronic medical records are a good idea for coordinating patient care, but are not a tool for significant cost savings.

Is there an alternative that will provide the benefits of the electronic medical record and not require spending billions of our government’s dollars? Yes there is, with a little imagination and Congressional action. This plan calls for Congress to create a Federal Health Care Clearing House and Bank (see posting The Bank). The Bank’s first function would be to create a computer based national clearing house for patients’ billing and medical records. Many large information technology corporations (i.e. Google, Microsoft and others) have created comprehensive computer programs that can interact with various other hospital and outpatient data systems. The “Bank” would use standard federal government procedures for bidding and selecting the program/s and site/s for maintaining this medical record and billing system. This medical information would be kept in a central location/s with other sites for backup. The key aspect of this proposal is the centralization for maintaining electronic medical records, thus greatly lowering costs.

The central computer would receive billing and patient records from every hospital and medical entity in the land. All hospitals have most if not all their patient records on computer at this time. The “Bank” would charge the hospital, insurance companies and other medical entities a fee for each transaction. These fees would be calculated to support the computer system and would be quite modest for each entry. Keep in mind that there are millions of hospital-patient interactions and many millions of other medical transactions each year. Doctors would access the central computer, enter their information and would also be charged a much smaller fee. Pharmacy and other services would do the same. Patients would be able to access their own medical record free of charge.

There would be multiple levels of computer security, but with an additional caveat. As access to computer records can be traced more accurately than with paper systems, violators can be determined with greater ease. Congress when creating the “Bank” would also mandate heavy fines for unauthorized access, thus helping to ensure confidentiality.

I believe this is a workable and cost saving idea. I welcome your comments about this concept.

Steps to Affordable Universal Coverage

As we pursue universal coverage there are some realities to contemplate as we try to provide affordable universal coverage.

1)The U.S., at this time, does not have an adequate health care workforce to deliver excellent universal coverage no matter how much money is spent.

a)The nursing shortage in the United States is acute and getting worse! If one looks at the workforce as a pyramid with nurses at the base, physician assistants/ nurse practitioners as a next layer and physicians at the top, we have a grossly inadequate base. We have to dramatically increase the number of our citizens pursuing a career in nursing.

b)The physician workforce in the United States is woefully lacking in primary care, with now only 1/3 of physicians practicing primary care and 2/3 functioning as specialists. This is an inverse ratio from other developed nations which have much better health care results. Without adequate primary care, chronic conditions cannot be adequately cared for and preventative medicine cannot be delivered. Medicare and its payment system have emphasized procedural and technological medicine which has decimated primary care. Changing economic factors can increase the number of medical students going into primary care but it will take decades by this alone to reverse the aberrant ratio of primary care to specialist doctors. Thus a system is needed at this time so that many of our specialists also practice primary care.

2)We need to change our views about medical care in this country

a)Commercialization – Medicine is not a commercial product. Rather, medicine is a personal experience between an individual patient, each with her/his uniqueness, and a knowledgeable, empathetic, caring physician who has the judgment to be able to meet each patient’s individual needs. Specialists, computerization, modern drugs, devices and procedures are useful when appropriate, but harmful when overused. The overuse of medical facilities, documented by the variability in the cost of care from one area of the nation to another, is in part an unfortunate result of commercialization. Direct to the consumer drug, device and hospital advertising adds to this problem. The influence medical device and drug companies have on our system is pervasive and in many instances abusive. We will have to control the excess commercialization of health care that is now present in our system to be able to provide affordable universal coverage for all our citizens.

b)Consumerism - Many experts have voiced that we, as a nation, must learn that more is not necessarily better in medicine. Yes, the newest may be the correct treatment in some circumstances, but in others the best treatment may be no treatment or an old tried-and-true therapy. The Congress, in its desire to protect the consumer, has passed laws - The Patient Self Determination Act, The Americans with Disabilities Act and The Emergency Medical Treatment & Labor Act, all written without a key phrase, for example, within the boundaries of acceptable medical standards. Unfortunately this oversight has hampered our legal system and promoted consumerism.

A New Style of Hospital Admission Form

There are many reasons why our American health care system is so much more expensive than those in other developed countries, and yet we have inferior results. But, by far the largest single reason is the delivery of non-beneficial care which accounts for about one third of our total health care bill and contributes to a tremendous amount of unnecessary human suffering. Perhaps the most obvious example of our inappropriate care is the prolonged anguish and cost associated with the way we practice end-of-life care. Unfortunately however, the irrationality of how we practice medicine in the United States is not isolated to end of life care. Issues that must be addressed are:
•How can we create an advance directive that is both up to date and rational considering the over-all condition of the individual?
•How can we ensure that the care being given is beneficial and not serving other masters such as cash flow, avoiding legal hassles, the prestige of the hospital, etc.?
•How can we make sure that every patient and family has the right to appeal the medical team’s decision as to what is beneficial?
•How are we to avoid doing cardiopulmonary resuscitation on patients that are far too frail to benefit and who as a result suffer a disfiguring inhumane death?

The answer to these questions is my proposed hospital admission form shown below. The form provides a realistic up-to-the-moment advanced directive while providing an opportunity for the patient/family and the medical team to agree on what will be beneficial care. It also provides the patient/family and the medical team a mechanism to resolve disagreements, the appropriate care committee. This new admission form would also make cardiopulmonary resuscitation an ordered event for those patients who could benefit from it in any way, and not done routinely for the majority of patients for which it is of no value.

The Appropriate Care Committee as a Resource for the Patient

The basic concept behind appropriate care committees is to always act in the patient’s interest. Thoughtful medicine practiced with good judgment supported by the applicable medical evidence is the goal of the appropriate care committee system. Technology, procedures and medicines that do not benefit the individual not only have the potential for complications, but also create economic havoc for our nation. In large part inappropriate care is responsible for the health care crisis we now have in this country. Appropriate care committees allow us to solve this problem while maintaining the flexibility to be able to treat all patients as individuals each with unique circumstances, for instance the case of Joe Franks.

Joe Franks is a 57-year-old gentleman temporarily in a nursing home recovering from a heart attack and moderate congestive heart failure. He has type II diabetes, poorly controlled, and is 80-100 pounds overweight. His diabetes has adversely affected his vision such that recently he lost his cab driving license and is now unemployed and has only very basic health insurance. Joe’s mental status is excellent; he is an avid chess player. His doctor in the nursing home told Joe that if his obesity was controlled and he lost the extra 80-100 pounds of weight his health situation would dramatically improve. Joe told the doctor that he has tried everything, but has been unable to lose weight.

The doctor told Joe about the stomach banding procedure, a relatively simple surgery that restricts stomach size and has been quite successful in promoting weight loss in patients just like him. Joe is excited about this idea and asks the doctor to make a referral to the closest medical center offering this procedure. Immediately after nursing home discharge Joe and his wife traveled to the medical center hoping to arrange for the banding procedure.

Unfortunately the banding clinic told Joe and his wife that he was not a good candidate for the procedure and tried to send the two of them back home. However, Joe’s wife had read about the appropriate care committee system and asked for an appeal. The appropriate care committee nurse was immediately notified about his case. The appropriate care committee nurse arranged for Joe and his wife to stay the night at a nearby hotel to wait the full committee’s (two physicians and the nurse) finding early the next morning.

The committee heard from the clinic doctors who felt Joe was not a reliable patient and was unable to pay the additional fee above that of his basic insurance. The committee also interviewed Joe and his wife before rendering a decision. The committee decided that Joe was an excellent candidate for the procedure and that the clinic must offer it to him.

One year later Joe had lost 95 pounds, his Type II diabetes was cured, his eyesight and heart failure much improved. He was able to reactivate his cab driving license and was proud to again be an active contributing member of his community. He told all the overweight customers in his cab about his experience with gastric banding and how pleased he was with the clinic. After the tenth referral to the clinic because of Joe, the physicians at the clinic put on an appreciation party for Joe and his wife which included an overnight stay in a nearby luxury hotel.