Saturday, September 13, 2008

Healthcare Reform: Where to Focus?

A recent article in the Washington Post by Robert J. Samuelson presents healthcare statistics, which he interprets as meaning that:
  • Controlling cost is the central problem
  • Healthcare for the poor in our country is actually quite good
  • We cannot afford to view healthcare as a "'right' that demands universal insurance" for every American.
Following are some quotes and my comments.
The central health-care problem is not improving coverage. It's controlling costs…a quarter of the U.S. economy [will be] devoted to health care. Would we be better off? Probably not. Countless studies have shown that many tests, surgeries and medical devices are either ineffective or unneeded. Greater health-care spending forfeits any superior moral claim on our wealth by slowly crowding out other national needs…There's also a massive and undesirable income transfer from the young to the old, accomplished through taxes and the cross-subsidies of private insurance, because the old are the biggest users of medical care.
The central problem isn't cost or insurance, per se, it's increasing healthcare value to the patient/consumer. That means improving the poor quality and inefficiency of care, so that we all receive only the care we need, delivered in timely and effective manner, without waste and over-treatment, and with a focus on integrating "well-care" (prevention and self-management) with sick-care. High value implies lower cost since poor care cost more and delivering only the minimal necessary care typically results in better outcomes!

More appropriate care, delivered competently and cost-effectively (e.g., through cost-conscious, patient-centered "medical homes"), is the ONLY WAY to control costs long-term.

And there's no way to increase healthcare value without dealing with the knowledge gap. That is, our healthcare community is drowning in oceans of information, yet no one knows the best ways to prevent health problems and treat them cost-effectively, especially when you take individual differences into account. Better health information technologies are needed, as is a collaborated effort to develop, disseminate, and deliver cost-effective evidence-based care.
It is widely assumed that health care, like most aspects of American life, shamefully shortchanges the poor. This is less true than it seems…On average, annual health spending per person -- from all private and government sources -- is equal for the poorest and the richest Americans. In 2003, it was $4,477 for the poorest fifth and $4,451 for the richest.
There are many ways to interpret these numbers; for example:
  • It quite likely that the wealthy are far more healthy than the poor, e.g., due to access to better food, cleaner and safer living and working environments, better education, greater availability of the most competent doctors, access to gyms for working out, etc. That would mean the poor should be receiving much more in the way of healthcare treatments than the rich because they lack those things, but they don't according to the numbers.
  • It's likely that the poor don't go to the doctor as often because they can't afford it, it's unavailable, they don't realize they should, or they have psychological blocks (e.g., hopelessness, denial, etc.). That means they become sicker before they go, which means spending on the poor should probably be greater than on the wealthy, but it's not.
  • Since the poor receive less primary care, they tend to go to the emergency room, which is much more expensive than an office visit, thereby skewing the numbers.
  • I don't know how many working poor are in those numbers, who don't have any insurance (or have inadequate insurance), and who don't qualify for government programs (Medicare & Medicaid).
  • What about the quality of care and preventive services? It's quite likely that the wealthy receive better and more timely care, which is not reflected in the numbers.
…Government already insures more than a quarter of the population, including many poor…10 percent of patients account for two-thirds of spending. Regardless of income, people get thrust onto a conveyor belt of costly care: long hospital stays, many tests, therapies and surgeries.
I would suspect that those with good health insurance or personal wealth receive more costly care. Nevertheless, I agree spending is excessive due to inefficiencies and ineffectiveness, as well as broken economic models.
…the uninsured receive less care and, by some studies, suffer abnormally high death rates. But other studies suggest only minor disadvantages for the uninsured. One study compared the insured and uninsured after the onset of a chronic illness…20.4 percent of the insured and 20.9 percent of the uninsured judged themselves "better"; 32.2 percent of the insured and 35.2 percent of the uninsured rated themselves "worse." The rest saw no change.
Relying on patients to judge the value of care received—considering all the complexities, options, and nuances—is simply ludicrous. What we need is valid scientific outcomes research and clinical guidelines before accepting such claims!
The trouble with casting medical care as a "right" is that this ignores how open-ended the "right" should be and how fulfilling it might compromise other "rights" and needs. What makes people healthy or unhealthy are personal habits, good or bad (diet, exercise, alcohol and drug use); genetic makeup, lucky or unlucky; and age. Health care, no matter how lavishly provided, can only partly compensate for these individual differences.
So, what's being implied here? If you have bad genes; if you live in poverty—in a crime-ridden, drug-infested—and can't afford healthy food, a safe place to exercise, or become drug addicted; if you're old and have chronic conditions … then what? You don't deserve good healthcare? All prisoners do! See this link:
There is a basic dilemma that most Americans refuse to acknowledge. What we all want for ourselves and our families -- access to unlimited care paid for by someone else -- may be ruinous for us as a society. The crying need now is not to insure all the uninsured. This would be expensive…and would provide modest health gains at best. Two- fifths of the uninsured are young…and relatively healthy.
I don't think many people view universal healthcare as being unlimited care for which others pay. It should not be about getting something for nothing. Instead, it should be about assuring that everyone gets the quality care they need at an affordable price.

Private insurance companies don't focus on improving care quality; they're out to make profit for their shareholders by (a) minimizing payments to providers, pharmacies, and suppliers, and (b) by reducing the amount of care rendered in whatever way they can. They'd prefer to drop all members with serious (i.e., expensive to treat) illnesses because they are driven by the profit motive.

Concerning the young and healthy uninsured, it would be inexpensive to cover them via a government run single-payer system (e.g., HR 676 – "Medicare for All") since they would not require much care.
The McCain and Obama health-care proposals, either impractical or undesirable, largely ignore the existing challenge of Medicare. By some studies, 30 percent of its spending may go to unneeded services. Medicare is so large that by altering how it operates, government can reshape the entire health-care system. This would require changes to encourage more electronic record-keeping, better case management, fewer dubious tests and procedures, and a fairer sharing of costs between the young and the old.
While I interpret the numbers Mr. Samuelson presented in a different way, we actually agree, in part, about what has to be done. I offer a blueprint for comprehensive healthcare reform—the Wellness Plus Solution—available on our Wellness Wiki at
From a philosophical viewpoint, radical reform of our healthcare system in the ways I describes requires that we, the American people, take a good hard look in the mirror to examine our culture's priorities and values. Why? Well, consider the following Commonwealth Fund report:
The U.S. health system is the most expensive in the world, but comparative analyses consistently show the United States underperforms relative to other countries on most dimensions of performance...[It] fails to achieve better health outcomes than the other countries [and] is last on dimensions of access, patient safety, efficiency, and equity.
In other words, our healthcare system is broken; healthcare in America is gravely ill and we should be looking at ourselves--our cultural values, priorities, and economic/political/business models--to understand why things have gotten so bad!

To cure our healthcare system, and to begin fixing many of our other domestic and foreign problems, the American people ought to be willing and eager to look far beyond ourselves and family and focus on giving much to others in a way that makes our country and world a better world for all.

This sentiment was reflected in link above (about medical homes), which points out that the teams of doctors who hit "medical home runs" for the patients have an exceptionally compassionate nature that drives them to go that "extra mile" for their patients. I quote:
While the specific clinical innovations to prevent unplanned hospitalizations vary somewhat across the four practices, they converge in two ways. At least one primary care team member demonstrates saliently to each chronically ill patient that they care deeply and personally about them and protection of their health. This includes mobilizing family members, social services, and other resources required for successful patient self-management. In addition, as soon as a chronically ill patient senses impending health crisis, a member of the health care team familiar with their history is readily reachable and prepared "to go the extra mile" [italics added] to prevent hospitalization, including actively coordinating with ER physicians and hospitalists in exploring alternatives to hospitalization.
An attitude of "protection of your health matters to me personally" and "I'm prepared to invest special effort to spare you a health crisis" was memorably captured in Atul Gawande's 2004 New Yorker magazine portrait of Dr. Warren Warwick in The Bell Curve. It is the exception rather than the rule in American health care delivery. Because it reflects a personality characteristic of clinical team members rather than a readily teachable behavior or a structural enhancement of a primary care practice, assuring this expression of patient-centeredness requires new selection criteria for medical home team members serving the chronically ill. Given the prolonged time frames required to correct failure to integrate robust patient-centeredness into medical student selection and into graduate and postgraduate physician training, near-term improvement implies selecting for this attitude among nonphysician team members. Other organizations, such as the retail giant Nordstrom, have shown that selecting employees for high natural service orientation is feasible."

This observation is consistent with last week's post: We Ought To be willingness and eagerness to give (sacrifice) much in ways that makes this a better world for all. Unfortunately, this runs counter to the ideals of the "Me Generation" and the American consumerist way of life, which are destroying our society by rewarding and encouraging short-term self-centered hedonism (my pleasure now!), ego-based materialism (e.g., judging human worth in terms of one's bank account), and Machiavelli's "the end justifies the means" philosophy to business ("buyer beware!").

The good news is that compassionate people with awareness and understanding are bucking this tendency! THEY are the ones who Ought To be gaining financially by, for example, paying primary care physicians for taking the time to know their patients deeply and for going the extra mile to prevent illness and deliver high-value care, as well as investing in more and better clinical outcomes research.

While this is the only sane way to proceed, there are many tough challenges to enabling and rewarding healthcare providers who go the extra mile and offer high-value services. See, for example, a recent post by Josh Siedman titled Perils of Pay for Performance (P4P) at this link, which discusses the difficulty establishing fair and valid performance measures, and the consequential perverse incentives of today's P4P programs. One commentor added that we don't have the detailed information needed to understand the unique needs of each patient and thus cannot know if an individual is getting the right personalized care, even if it's right for other patients with the same diagnosis. Also see this link to our Wellness Wiki.


Anonymous said...

I find the Samuelson article to be a reaction to the AMA's proposal (AMA Proposal Overview). The AMA concept is to expand healthcare so that it is more accessible with some secondary efforts to control costs.

I see Samuelson as merely focusing on the AMA subpremise that if we just control costs we can achieve what we need to do, vis a vis, healthcare. He goes on to simply interpret facts so that they support his framing of the problem. Is Samuelson just arguing against the overly simple AMA proposal to expand healthcare availability? I'm sure the AMA proposal is good for its members; but, is it good for what truly ails the system?

I like the efficiency of the idea to increase healthcare value because this approach would seem to both control costs while making it more widely available. 'Streamlining' healthcare in this respect is in the best tradition of capitalism and efficiency of the market.

One would hope that we could zero in on and remove the societal obstacles to fair healthcare delivery, i.e. tax breaks to people with employer sponsored coverage and restricted insurance coverage access.

We don't know what the best delivery system will look like in the future so we need a dual effort to remove impediments to the delivery of healthcare while seeking answers to improve healthcare value.

Dr. Steve Beller said...

One interesting thing about the AMA proposal overview is that it is a health insurance reform proposal, not a value-enhancement proposal, per se. As such, the “three pillars”—subsidies for health insurance, choice of insurance plan, and protection for high-risk patients—do NOT focus on healthcare value because they don’t address the quality problem (i.e., the need for substantial improvement in clinical outcomes through better diagnostic and treatment guidelines and decisions).

However, a boxed comment at the end defines four broad strategies addressing areas physicians can influence, which do focus on achieving greater value: “reduce the burden of preventable disease; make health care delivery more efficient; reduce nonclinical health system costs that do not contribute to patient care; and promote value-based decision-making at all levels.” In other words, their strategies are consistent with value promotion by focusing on prevention (well-care); efficiency (minimizing waste, which includes over-treatment and delivery of costly treatments when more cost-effective one exist); eliminating ineffective treatments; and improving decision making.

I would argue that these value-enhancement strategies should be embedded in the three pillars forming the foundation of the AMA proposal.

Dr. Steve Beller said...

Note that additional comments to this post appear in The Health Care Blog at this link.

Anonymous said...

The discussions about consumer driven healthcare usually assume that we have some kind of a market driven system in place. Just the opposite!
The current situation is far from consumer/patient friendly. It is all about big corporations/insurance companies, drug companies, and huge health organizations, all in bed with the big government, and their regulations. The regulations are carefully crafted not to hurt the major players, that is, the government, and the large companies.

Instead, the major players should be the physicians and the patients!

Whenever there is talk about consumer driven health, some commentators argue against the consumer driven healthcare, based on the assumption that people do not want to take responsibility to educate themselves sufficiently to be able to make their own health decisions. This clearly is a huge assumption, based on little data. Fact is, we, (US or the world) never had consumer or market driven healthcare. Never. If you want to call high-deductible insurance plans combined with an HSA or similar attempts in dentistry like Find a local dentist market driven health care, you ain't seen nothing yet. So basically, we never had consumer really make decisions so far. So there is no data. Get seriously started with it, collect your data, and then create opinions. Otherwise its all hot air and keyboard clicking. Also, keep in mind, in a true market driven health care, an average Joe does not need to take care of the health system, just of his own health, and his own choices for healthcare. Many of us are doing that today, successfully.