Tuesday, June 23, 2009

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.

Tuesday, June 2, 2009

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.