4 Chief Components of Health Care Reform
There are 4 chief components to health care: health care payment, health care charges, health care quality and safety, and patient issues (compliance, self-initiative, and medicolegal action). When the term health care reform is used in the lay press what is really being talked about is health care payment. What worries doctors the most in health care is the patient issue of medicolegal action. The reality though is that to truly achieve health care reform in toto requires that all components be addressed in lock-step with each-other. Attempting to address one (or even 3 of 4) will not accomplish the desired goal of comprehensive improvement in health care. I will address each of these topics independently then summarize them together at the end. Health Care Payment After the second world war almost all developed nations (except the USA) created a form of universal health care for their citizens. The great majority of them devised a government-based national system. Only two developed a private insurance, multiple payer strategy (the Netherlands and Switzerland). Most developed nations created a dual system with a national system that covers all citizens and a private system that individuals can buy into to acquire premium service (generally faster care and probably better care with more options available). A combined public/private health care payment system is probably the best strategy and would make the most sense for the USA. Generally one's strengths are also one's weaknesses. For the USA as a country, american know-how, american can-do, and american exceptionalism, have been glorified as outstanding strengths, but at the same time have often ideologically prevented the US from adopting from other nations other approaches for national policy, that americans have not developed themselves. Clearly with an expensive, all encompassing, and citizen-benefiting institution such as health care, the most intelligent approach is to study what other countries have done for the last 70 years and derive a strategy based on what has worked well. The simplest approach would be to emulate the Australian health care payment system which is a public/private blend. Australia is an ideal comparator country as it is also an Anglo Saxon culture- based, multi-ethnic, multi-racial immigrant country - hence virtually identical to the USA. Also since they speak the same language there would be no problem with mis-translation, which may occur if the US was to base their system on France or Germany. So copying Australia would be the most straight-forward approach, and with just that would make our system vastly superior, as all citizens would get health care. My suggestion though would be to use the Australian system as a framework but to improve upon it by using evolved strategies from other countries. In this case, to incorporate approaches that the UK has implemented would be of value. Two critical developments in the UK is their creation of centers of excellence and of panels of experts in their national system to assess new technologies and new drugs and to weigh if introduction into the national system will achieve an affordable cost-benefit addition. The importance of centers of excellence is that modern treatment of complex diseases, such as pancreatic cancer, gallbladder cancer, and peritoneal carcinomatosis, requires that treating physicians (teams of physicians, nurses and dedicated hospitals) have a lot of experience with the disease to achieve optimal patient success as measured by increased longevity. Many studies from countries such as Japan, have shown that physician teams with expertize in treating entities such as gallbladder cancer have resulted in vastly improved survival, compared to other centers without this dedicated approach. Cost-benefit for new treatments and new drugs is a subject fraught with considerable public reaction, conjuring up the subject of death panels. The unfortunate reality is though, that with many new treatments, the costs are so exorbitant, that to simply employ them across the board in a national system, would bankrupt the system in one year. It is not sustainable. Hence decisions need to be made. Some expensive treatments, such as Hepatitis C drugs, cost $100,000 for a course of treatment. However following that treatment there may be complete cure for a disease that can be very lethal, and also creates tremendous costs to the health care system if the complications are allowed to develop, such as hepatocellular carcinoma (liver cancer). So this may be an approach that should be incorporated. On the other hand, some of the cancer drugs can be equally, or more expensive, but here, the cost-benefit analysis may come to a different answer. A decision would have to be made, what extension of life and what benefit to quality of life, merits offering these drugs to all sufferers nation-wide. My personal view is that clear evidence of one year life extension, with associated high life quality would merit an expensive drug or approach, but less than that, maybe not. Many expensive cancer drugs have improvement of survival of perhaps a couple of months, and on top of that the quality of life may be poor. Should the nation pay for drugs like that for everyone - probably not. That is where private insurance would come in. Decisions like these, that are life and death, I believe should be made by experts, looking at data of larger numbers of patients published in large patients studies (relying primarily on independent studies and not manufacturer-sponsored studies). As it stands right now in the US, most expensive strategies are denied to poor indigent people, unless some form of miracle has intervened like an NIH-sponsored study. So much cost savings in the US are achieved by denial of services to some individuals, generally the poor. The US has by far the most expensive health care system in the world per capita, almost twice as much as the next most expensive, and yet rates as the 16th best health care system. So clearly the approach currently in operation is not exceptional, it is only moderate at best. Emulating the Australian Health Care system, and incorporating advances used in the UK health care system would result in the optimal health care system for american citizens. There are multiple benefits for a national health care system. One important benefit, that is never discussed is that it decreases the cost of labor in the US since companies would not have to shoulder the expense of health care coverage for their workers, which may add on atleast 20% on top of their salary. This then makes manufacture in the US more competitive on the world stage. The indirect benefit of a national system would therefore increase greatly the competitiveness of american businesses, likely translating into millions of new jobs. Health Care Charges The major components of health care charges are physician charges, allied health care worker charges, nursing charges, hospital charges, costs of drugs, and cost of medical devices. The simplest of these costs to target, and what makes the most sense is cost of pharmaceuticals. It has been known for decades that pharmaceutical companies have relied on making profits by charging more for drugs in the USA than in all other countries in the world. Generally the costs in the USA may be twice as much as other countries, but for some drugs it may be ten times or more. Why has this happened? Drugs are extremely expensive to develop and most countries cannot afford expensive drugs for their populations, so pharmaceutical companies charge less in these countries, maybe even below cost for some. In order to survive and to be profitable, these companies have used the charges in the US system to make up the shortfall in other countries. We have allowed this to occur, perhaps because a number of these companies are US-based. Chief politicians have realized this is unfair and have targeted pharma companies: that they charge too much. The reality is though that drugs in the modern era are extra-ordinarily expensive to develop from the concept phase, through animal studies, through FDA-required human testing to the market. Estimates for the cost of this is in the billion dollar range for most drugs. Many drugs also fail to get approval so the costs are truly unbelievable. Simply telling pharma companies to charge less is not a well thought out strategy. My opinion is that as the development phase has become so expensive critical trade-offs have to be given to companies in order that they continue to develop drugs that have the potential to benefit all of us. The most straight-forward and best approaches likely start with increasing the length of time of patent protection for drugs. Generally from the time the drug hits market to when it comes off patent protection may be as short as 4-6 years. If we expect pharma companies to charge less for drugs the patent protection period must be increased dramatically. At least 10 years patent protection once a drug has received FDA approval and is marketed seems appropriate. Already the government has allowed biologic drugs to enjoy a longer period of patent protection. All drugs should get this, and biologics also experience further prolongation of protection. Another approach, that can be used in addition to prolonging patent protection, is that government should fund in part the testing of agents through FDA phases of investigation. This would cost the tax payer more, however should also translate into more job creation. In my opinion, one explanation of why it seems pharma companies do not acknowledge early enough when their FDA-approved drugs are shown to have significant adverse events is that they have invested so much money in their drug already, they are wishful that these adverse events may simply be a figment of physician and patient imagination. It may be just that simple, and not a nefarious plot of cover-up, that some physicians and many patients may believe is occuring. A number of drugs and a number of companies come to mind. If the entire process of approval is no longer $1 billion, but $100 million, companies may be more willing to believe in the existence of certain adverse events, earlier in the drug lifetime. An additional strategy is to incentivize early recognition of adverse events, while at the same time increase punitive measures for ignoring or covering them up seems appropriate. Physician charges. Physician charges in the US are often double what they are in other countries, and may be up to ten times or more for the same procedures.This forms the basis for health care tourism. Some of the reasons for higher charges are good: more quality assurance of entities, such as physician-training, greater overall hygeine; some not good but modifiable by reforming the health care system, such as offsetting the risk of medicolegal action; and some not good but human nature, wanting to make a good living. One could argue that a great physician should make as much as a great sports player or great fashion model (in large part by the latters making less money) but no better argument though can be made for teachers and what they earn. Hospital charges fall in line with the same explanations as physician charges. Hospitals should though be mandated to post what standard charges are for standard procedures (laparascopic cholecystectomy, coronary artery stenting, etc for example), so patients can compare, and also to drive charges down through competition. Nurses make considerably less, which also explains why a lot more health care has been shifted to nurse-practitioners. As with everything, this is a mixed picture - however to achieve meaningful patient compliance more health care delivery has to be done in the community and at home, and there may be no better health care professionals to do this than nurses and nurse practitioners. Decrease the likelihood of crippling medicolegal settlements against physicians and hospitals will go a long way to reducing charges made by these groups (see below). Critical though is that the government should mandate and ensure that physician and hospital charges are reduced as a reflection of the lesser medicolegal losses. The human tendency is despite experiencing less costs, the same charges are maintained. This must not be allowed to occur. Health Care Quality and Safety A recent study, published in a British journal, described that health care errors was the third most common cause of death in the USA. Debating these findings could occupy an entire lengthy article. Suffice to say, a lot of their findings I consider are correct. In my opinion though errors must be differentiated into: avoidable and unavoidable; resulting in significant loss of health and or longevity; injures occurring in individuals otherwise healthy; and among the avoidable: individual practitioner error or system error. A great problem that arises to avoid unaffordable medicolegal settlements, is that there is a great tendency to cover-up errors in the USA. This extent of cover-up is not seen in other countries where medicolegal action is not such a tremendous issue, such as Denmark. In Denmark, hospital panels assess whether damages have been caused by the health care system, and what a reasonable compensation should be - this may explain in part why happiness quotient is so high in Denmark (and not so high in the USA). The most egregious problems in the USA are system medical errors, where significant injury and death are being caused to many otherwise healthy individuals. An example of this would be surgeons or interventional radiologists allowed by senior hospital management to operate drunk on patients. This is truly unconscionable. The reality though is many errors result because health practitioners are humans and humans make errors (To Err is Human). Many excellent health care workers, physicians, nurses, etc, may get punished by medicolegal action that forever adversely effects their quality of life and careers. Discovering that error in health care in the US has occurred, is more or less a game of chance, it has become a 'bingo' type system, where one patient may win, but the great majority lose. Often times in my considerable experience as a medicolegal expert often the cases that are pursued have little merit, whereas cases that have tremendous merit are not pursued, because patients are not informed of the error. This reflects that hospital systems are only rewarded if there are no legal settlements, and not rewarded by showing the integrity of compensating patients who have been injured, even and especially when the patients were not aware that they had been injured in the health care system. Medicolegal reform would go a long way to rectifying this unfair imbalance. Overall there are a lot of programs in place, mandated by state medical boards to ensure that physicians maintain some form of continuing education through their career. This is an excellent solution already in place. What I believe is not as well done is to discipline or remove from practice poorly performing doctors. The reality is some doctors should not be doctors and should lose their licenses to practice, and have this information shared across all states. This type of determination must be made by independent highly qualified physicians studying the practice of the physicians and the type and rate of their errors. I can think of a few cases that have recently appeared in head-lines where in my opinion these physicians should lose their licenses- but a number have not. As with physicians, hospitals range in quality. There should be national standards that all hospitals must report their complication rates for standard procedures that are conducted at their centers, such as cholecystectomies and coronary artery stenting, so that potential patients can make informed decisions. National ratings of health care systems by newspapers or journals may not have the required detail of expertize to make these most meaningful of analyses. Most quality programs turn out to be very time-consuming but of little essential value. Metrics such as how quickly a phone is answered in a radiology reading room, or how quickly a radiologist reads a film are metrics of essentially no value, and may in infact correlate inversely with quality. I have proposed and utilized an anonymous survey, to be completed by referring physicians into the quality of individual radiologists, rating quality of reports, medical knowledge and collegiality. Meaningful metrics of true quality are necessary, and not lip-service metrics to satisfy governing boards - the latter being the most common current practice. Patient safety is of paramount importance. Health care workers should experience some form of benefit for doing what has generally been the unthinkable: reporting gross violations of patient safety. Currently the exact opposite is occurring that those reporting infractions are generally the ones who are punished. The most obvious way to rectify this pervasive problem is that risk-taking reporters must be rewarded, individuals perpetrating misconduct, especially senior management who cover it up, must experience a level of punishment, that sends a message not only to the institution but to all institutions. It may be the national reporting on the multilevel crimes that had taken place at Michigan State University and the severe punishments that have been inflicted on the perpetrators may be the start of correcting the current imbalance. One problem particular to state health care systems, is that they receive sovereign protection from a number of misconducts that private universities do not receive. This sovereign protection must cease, as it lends itself to some state universities conducting themselves as organized crime syndicates, because they feel unaccountable for most misconducts. Patient Issues Patient compliance. A current hot topic in US health care system is quality rather than quantity health care. Sounds good but what does it mean and how can it be achieved. Very complex, hence unachievable metrics have been devised. As with many things, simple solutions are really the best. The problem with metrics such as shortening in hospital stays or consistent low blood sugar levels, is that it create the environment where health care system prefer to look after well-educated, economically successful patients, and avoid looking after poorly educated and economically disadvantaged patients, as the latter will make their metrics look awful, and as a result centers that treat sick and poor patients will not obtain extra financial bonuses from government for quality care as measured by decreased length and frequency of in-house stays and decreased return visits. Hence a reward system for these metrics is counterproductive to improving the health of the poor. The best method to maximize patient compliance, regardless of their status, is for care to continue outside the medical center. It is well recognized that the information patients receive within a hospital has little true impact, because that information is often delivered quickly, in complex terms, to frightened individuals. The best method to achieve meaningful retention by patients as to what they should be doing, is by visiting them in their home situation and instructing them there, in the safety of their own surroundings. The best type of health care worker to achieve this in home training is likely a nurse or nurse practitioner, who often, based through their training, are more patient and empathetic with individuals, and can explain to them better what they should be doing to modify their lifestyle inside their own homes. They have also the patience to assessing how they are performing their daily life activities. This by far is the most impactful method of improving patient compliance. A number of pilot projects in various states have been performed confirming this. A more long term approach for wellness is achieved in many countries where healthy living in emphasized (the Netherlands and Germany come to mind). Starting in school, and for every year of schooling healthy living should be a mandatory course. Children should learn healthy food choices, importance of exercise, and do these things in class: cooking and physical education. This way it is ingrained in them as adults. The importance of mental health must also be an integral part of the program: techniques to avoid depression (meditation, yoga, exercise), spurning bullying both as the deliverer and as the recipient, speaking out for themselves, are all examples. This lifestyle training focuses on the important subject of prevention of disease, the importance of which is too often minimized in the US. Medicolegal action. Numerous studies have been published in all areas of medicine, and certainly in Radiology, that have shown that anywhere from 30% - 50%, maybe of all heath care, is unnecessary. By far the most important driver for this overutilization is the fear that physicians experience of medicolegal action. How can this be addressed. Universal health care. One of the underappreciated benefits of universal health care is that it will also result in a drop in the number of cases of medicolegal actions. We have previously reported on this in the US health care system. Since there is no universal health care, patients have to find a way to pay for health care. If patients experience a significant health care misadventure, especially at a young age - who is going to pay for their health care, especially if it runs int the millions of dollars over a lifetime? The answer is no one but themselves, and they face the real prospect of the family going bankrupt. In essence they have no option but to sue the physicians and hospital hoping to get money that will cover their future health care expenses. An awful predicament they have been put in. Perhaps all of us have reflected on the horrible situation that the Boston marathon bombing victims were put in, losing a leg or worse, and then having somehow to come up with money to pay for their health care, resorting quite often to more-or-less begging on line for individuals to help them out. No one should have to experience that. From the physician perspective of unwarranted legal action there are a number of obvious solutions. What may not be generally understood is that for a case to move forward a physician has to declare that the physician(s) involved have not met the standard of care. Then in the adversarial legal system, opposing attorneys hire medical experts, who by virtue of being paid by one set of attorneys, adjust their opinions to align with who is paying for their service. In my experience the great majority of medical experts who have been on the opposite side of the cases I have represented have frankly lied. At times I have led myself to believe it is because they simply do not know that much about the type of case they are representing... but the reality is most often they are not biting the hand that feeds them. The obvious simple solution is all medical experts should be agents of the court and not of the adversarial legal parties. Also, what also many may find amazing, medical experts are not held accountable for their opinions. I believe they all should be, and if their opinion is too far afield, they should be subject to legal action. This would serve to dramatically decrease the extent of lying by experts, if an adversarial system is maintained. Lock-step modifications of components of the health care system It should be clear from the text above that all the components of the health care system form an interlocking web that have to be evolved in unison to achieve meaningful health care reform. There are many side-benefits outside the health care system by achieving this reform, such as an economically more competitive manufacturing work-force. Most of the reforms proposed by others and by institutions are a complex patch-work of ideas that probably will result in increased complexity, but likely will not achieve any true benefit. The ideal system is a payment model of combined government-based public insurance with private insurance. Costs of drugs must be decreased and charges of physicians and hospitals as well, to make health care, whether public or private, affordable and sustainable. Medicolegal reform will serve a tremendous role in decreasing physician and hospital charges, while public universal health care will remove the desperate need of patients to sue in order that they can avoid bankruptcy. All of these changes must occur in lock-step for meaningful health care reform to occur. Note by Dr Semelka. I have written on the subject of health care reform in my text-book: Health Care Reform in Radiology. Richard C Semelka, Jorge Elias, Jr. Wiley Blackwell 2013. This perspective article takes an updated and more broad view on the subject.This gives a brief over-view of a complex subject. In the future I will expand on this subject, including the addition of references.