Note: I first published this op ed for physicians in the Winter 2008-09 as a newsletter column during my term as Connecticut Governor of the American College of Physicians. I received so much positive feedback that it was republished in minimally revised form by Connecticut Medicine (the peer-reviewed journal of the Connecticut State Medical Society) in 2009 [Conn Med 73(6):355-358, 2009]. While some of this content is dated in light of Heath Care Reform (Obamacare) and the “meaningful use” IT subsidies contained within the 2008 economic stimulus package, much still remains relevant today. -EMM
Five Basic Tenets for Health Care Reform
As this is my final column as your Governor, I thought that I would invoke your forbearance and exploit the “bully pulpit” of both my position and this newsletter to present you with my personal thoughts about health care reform. I do not pretend to know how to pragmatically solve the health care crisis nor do I feel that I have discovered a new blueprint for the future. Rather, after many years involved in medical leadership and political advocacy, both at my hospital and through the American College of Physicians, I have developed some ideas, hopefully informed, about the fundamental principles upon which I believe an efficient, high quality and functional health care system should be structured. Unfortunately, I have to concede at the outset that from a political perspective and taken together, these principles are completely impractical. Given the positions of the two major political parties in the United States, I do not see a realistic, politically pragmatic path to reach the goals that I am about to enunciate. Nevertheless, I cannot help but articulate the principles, however politically naive, with the hope that the political landscape will change at some time in the future and that which is politically impossible today becomes feasible in the future.
Firstly, with health care expenditures currently totaling 16% of the United States GDP, I believe that it is safe to assume that there are sufficient dollars currently being devoted to health care in the United States to create and sustain a truly excellent universal health care system. Japan, with the longest average life expectancy in the world (83 years) and the second lowest infant mortality (2.8 per 1,000 live births) spends only 7.9% of its GDP on health care, only half of the U.S. rate. In absolute dollars, Japan’s annual per capita health care spending is only 38% ($2,690) of that in the United States ($7,026). The United States leads the entire world both in the percentage of GDP and the annual per capita dollars spent on health care and yet our overall health outcomes rank in the middle. While it is also true that the United States leads the world in medical research and technology, research costs consume only 2% of the health care dollar. Therefore, I do not think that it is necessary to add more money to the “pot” to achieve a quality, universal system. I would suggest that if we restructure our health care system on the following five pillars, that system would be capable of providing excellent care to all of our citizens and yet still maintain our leadership in research and technology and require no increase in the level of funding. These fundamental principles are:
Universal Access: We simply must provide (and appropriately fund) universal access to health care for all of our citizens. Since I believe that we have agreed as a society that health care is an inherent right and not a privilege, the principle of universal access is the simplest and most basic. In our current system, all patients ultimately do receive care, but the care that they receive is neither high quality nor timely nor efficient. We have evolved a hodgepodge of disparate mechanisms to provide care for the underserved, mechanisms that actually serve them quite poorly and cost us substantially more than a universal system. Our dysfunctional and piecemeal approach forces us to provide care during the most expensive, acute exacerbations and end stages of disease, disease that often could and should have been managed chronically or even prevented. Also, currently hospitals must charge their commercial payers substantially more than their costs in order to cross subsidize the care of their uninsured and the Medicaid poor (who are not even covered at a break-even point by Medicaid payments). Private physicians eschew Medicaid patients (for which payments also generally do not cover office costs) and reluctantly care for many of them on a pro bono basis in under funded, poorly organized hospital-based clinics. In order to maintain their bottom lines, hospitals are forced to develop and aggressively promote high margin clinical programs and services, chosen primarily on profit potential rather than social good. It should not be the responsibility of hospitals and physicians alone to figure out how to take care of the poor. The current reality results in parochial, ad hoc, inefficient and incomplete solutions. It is the responsibility of all of us, as a society and as a country, to shoulder this responsibility. This means developing a health insurance system that provides universal access (and adequate funding) for every member of our society. The problem of the uninsured has been “pushed down” onto the health care providers, exploiting our professional ethics and using the tools of unfunded legislative mandates and regulatory requirements. However, access cannot be solved by providers at the front lines; we must address this issue together, as an informed and progressive society, at the highest level of our government.
Computerized Health Information Integration: This is the “simplest” pillar of health care reform, one on which everyone appears to agree. The potential value of computerized health information integration is obvious to all of us who take care of patients – less duplication of testing, the availability of a complete medical history and accurate medication list across all venues of care, fewer errors, lower costs etc. However, my concern is the means by which the insurance industry and the federal government are attempting to capitalize information technology implementation within the health care system. Like the problems of the uninsured and the underserved, this issue is being “pushed down” directly onto health care providers, expecting us, in this severely resource constrained environment, to fund the creation of a $156 billion technology infrastructure and support annual operating costs of $48 billion (Kaushal et al., Ann Int Med 143: 165-173, 2005) out of the very limited positive margins we are currently achieving. Computerized health information integration will provide a social good that accrues to the entire society. It is therefore also a societal responsibility and society (i.e. government) should fund it. It has been estimated that physicians who install electronic medical records in their offices will reap only 20% of the financial benefits of such a system. However, physicians (and hospitals) are being asked to bear nearly 100% of the costs. This is not fair, it is not right and it is not economically realistic.
Rational payments to hospitals and physicians: Internists realize, perhaps better than anyone, how irrational and inequitable our current payment system is. An internist consulting on a complex elderly patient with multiple chronic, life threatening diseases will be paid, for an hour’s worth of difficult cognitive work and thoughtful patient/family interaction, only a small fraction (i.e. 10-20%) of what a radiologist or proceduralist will be paid, for the same amount of physician work and time. Hospitals receive from Medicare approximately 30 fold more reimbursement (exclusive of the equipment cost) for the placement of an intra-cardiac defibrillator than for providing a patient with comprehensive diabetes education over 10 one hour sessions with a trained diabetes nurse. It is no wonder that medical students are choosing radiology over general internal medicine for their specialty training and that hospitals are choosing to develop imaging centers, bariatric surgery programs and interventional cardiovascular centers rather than geriatrics and diabetes programs. Indeed, the free market works and we have created a medical marketplace in the United States that rewards procedures and technology while discouraging cognitive services, longitudinal disease management and face-to-face patient contact with physicians. This dysfunctional payment system, as an unintended consequence, undermines the availability of desirable and very necessary clinical services (geriatrics, psychiatry, primary care etc.) as well as threatens the future composition of the physician workforce. We must rationalize payments to hospitals and physicians to create effectively a flat “playing field” in which no one type of program or service or procedure is inherently more profitable than another, and in which an hour of physician’s time reading images or performing procedures is reimbursed at a rate comparable to an hour performing cognitive work and interacting with patients. Were we to do so, I believe that we as a society would purchase more of those elements of health care (i.e. specific services) that are really required to serve the public good (and generate positive health outcomes) and fewer of those that are largely driven by high marginal profits.
Overhaul/replacement of the medical malpractice system: I realize that politicians and the public are tired of hearing from “rich doctors” who complain about rising and/or excessive malpractice premiums. Earlier in my career, I too was a bit of a cynic, believing that “defensive medicine” was overstated as a significant driver of unnecessary health care expenditures. However, as I have matured, I have witnessed (and experienced) a fundamental transformation in the perspective through which we as physicians approach the delivery of patient care, a transformation driven by the necessity to mitigate the pervasive risk of medical malpractice. During the past 25 years, there has been an insidious change in clinical practice by physicians who have shifted from doing that which we genuinely feel is best for our patients to frequently basing our clinical decisions (i.e. testing, hospitalization and even therapy) on that which first and foremost reduces medico-legal risk. Despite unambiguous research indicating that malpractice awards are driven largely by poor clinical outcomes rather than by physician negligence, politicians and the public continue to insist that access to essentially unlimited malpractice awards is required to keep us physicians “honest, i.e. to assure physician quality and reduce the risk of medical error. While for many years I had difficulty accepting the “lottery mentality” of the excessive malpractice awards driven largely by the emotions of lay jurors, I have gradually come to accept our implicit societal decision that an adverse medical outcome should be mitigated by some sort of financial remuneration for the unfortunate victim. However, I would propose that such remuneration should be provided through a society-wide, no fault insurance system program (similar to Workmen’s Compensation) rather than a medical negligence / malpractice system that punishes the involved physician. Some would argue that without the opportunity to prove medical negligence, the individual and society lose the opportunity to control the quality of medical practice and to hold physicians accountable for their clinical decisions. I would propose that we separate the administrative system that regulates physician quality and clinical practice, from that which rewards adverse medical outcomes. Regarding the former, I would have no problem supporting a much more rigorous system for medical licensure and licensure renewal; one which requires physician-specific quality reporting and review, recurrent testing and limited licenses (for those who do not maintain the level of quality necessary for independent, full practice). It is difficult to argue that we as physicians should not be completely qualified and competent throughout our careers. However, the medical malpractice system is working neither to assure physician quality nor to reduce medical error. It is only inexorably driving up the total costs of health care to a level that some Stanford economists (Daniel P. Kessler and Mark McClellan MD, 1996) estimate to be 5 to 9% of the entire health care budget. What a waste of money!
Rational rationing: Finally, we get to the “R” word – rationing. Rationing is the “third rail” of health care reform – no one wants to touch it. Nevertheless, rationing is a necessary and inevitable component of any universal health care system for which there are finite resources available and in which the demand for services is functionally unlimited. For most products and services, rationing is not required because demand is constrained by an individual’s personal capacity to purchase those products and services. However, we as a society have agreed that health care is a “right” and that everyone should have access to all necessary health care services regardless of their personal economic circumstances. In our society, there is effectively no personal economic consequence for choosing to purchase health care services. While a lot of free market economists believe that creating personal accountability for the purchase of health care services will effectively limit the demand for health care, I do not agree. I believe that the “average” individual has neither the knowledge nor the temperament to routinely make the best (and most cost effective) health care decisions on their own behalf. The health care marketplace will never be rational and consumers are not capable of judging either quality or effectiveness. Rather, I believe that we as a society, aided by physicians, health care analysts and politicians, can and must address health care rationing publicly and make overt allocation decisions – prospectively, transparently, scientifically and effectively, on the basis of social “good”. We have to recognize that rationing is already taking place in the United States and among the other developed countries around the world. In the United States we ration passively, invisibly, and irrationally, allowing services to be allocated to our citizens based upon a mishmash of insurance products and an individual’s age, employment and economic situations. In Canada, health care is rationed by limiting access and centrally budgeting health care resources, producing long queues that reduce the utilization of many high demand and expensive services. Neither of these approaches allocates health care services rationally and thus neither serves its public well. Given the vast amount that we are already spending on health care in the United States, I do not believe that the rational rationing of health care will reduce anyone’s access to necessary and effective procedures and services. But, we have to critically evaluate that for which we do and do not provide funding, investing in only those procedures and services that truly improve meaningful health outcomes. We as physicians observe the squandering of health care resources every day – hundreds of thousands of dollars of ICU care for the tenth and terminal pneumonia of an elderly, malnourished COPD patient; demented, wizened patients sustained on dialysis because their families cannot make the decision to let them die; third line complex chemotherapy or extraordinarily expensive biologic therapy for the patient with metastatic cancer of the lung and essentially no prospect for incremental quality survival; complex back and disc surgery for pain that otherwise would have resolved with time and, countless other examples. Our society, focused intensely on the “rights” of the individual, is loath to make decisions that overtly restrict an individual’s right to choose anything on the health care smorgasboard, regardless of how expensive or ineffective. I believe that we cannot allow our cultural orientation towards the “rights” of the individual to undermine our capacity to create an affordable (and equally effective) health care system that serves our entire society. The right to effective health care should not be translated into the right to all possible health care nor the right to cost ineffective and futile health care. The alternatives to rational rationing are our current approach of de facto irrational rationing and/or financial insolvency of the health care system. We must accept that rationing is an inevitable, necessary and inherent part of all universal health care systems. Let’s ration deliberately and overtly, so that the choices we make are active and evidence-based, not passive. Let’s ration rationally, such that the rationing optimally benefits every one of us and results in universal access with quality, meaningful and effective health care for everyone.
So, there you have it – my personal prescription for the principles on which health care reform should be based. Pie in the sky? You “betcha”! Politically impracticable? Absolutely! But, sensible and reasonable? I think so. Creating a universal system of health care at realistically achievable costs that provides quality outcomes for all is definitely within our reach and clearly within our budget. However, it will require major concessions from both sides of the political aisle and a change in how we as individuals view the balance between our personal “rights” and social benefit. We are at the beginning of a new political era – let us hope that our leaders have the courage to think “out of the box” and are willing break new ground in leading the United States to our shared (and elusive) goal of the best health care system in the world.