Thursday, August 13, 2009

The Health Care Reform Debate

The debate over health reform has degenerated badly and has become less about improving the health delivery and health insurance systems and more about which party can "win" and paint their opponents as evil or misguided in order to win future elections. We really have to change the tone of the debate and focus on the two problems that we are trying to solve. They are the problem of access to health care, especially for the 47 million Americans who currently have no health insurance, and the problem of high costs in health care. These are separate problems that will, in all probability need separate but coordinated solutions.

Access to Care

The number of 47 million uninsured is both true and misleading at the same time. If one looks more closely at those who are uninsured, they can be subdivided into certain subgroups. In the US census data from 2006, it was found that over 9 million of those uninsured have incomes over $75,000 per year. Another 8.2 million have incomes over $50,000. Many of the uninsured are young and while they can afford the coverage, don't see the need. We probabaly have about 18 million Americans who are truly uninsured and often uninsurable. Any number of people with no access to care is too many. As I read it, the current House bill is more directed towards solving this problem than towards solving the problem of high costs.

Lowering Costs

Total health care cost is a function of the unit cost of the services and the volume of services rendered in addition to our administrative costs and our amenity costs. While those administrative and amenity costs (which includes costs such as private rooms in hospitals) increase total costs they are not major contributors to our health care inflation. In order to lower costs, you have to lower the unit price of the services, which would mean lowering doctor's incomes, lowering hospital revenues, and lowering payment for new equipment, new drugs and other services or lower the volume of services that are rendered. In the United States, high tech and invasive services, such as MRI exams, surgeries, endoscpies and the use of new drugs have very high volumes and also exhibit the most "waste" as they often are used but often do not change the patient's outcome. Numerous studies have shown that these services and products are not useful about 30% of the time they are used. The volume of these services in the US exceeds other countries by 40 - 50% or more. In order to lower costs, we would need to lower these volumes signficantly. The challenge there is that while 30% of that volume is clearly unecessary, when programs are put in place to eliminate the unecessary care, needed care often also gets eliminated.

Putting the Two Problems Together

In many ways, the health reform debate is about the difficulties of adding millions of people to the health insurance system while also lowering the volume of services in total that are delivered to the population and still maintaining all needed care. This is an extremely difficult problem which inevitably forces decisions to be made about what care should be paid for and which care should not be paid for. The legislative instrument in making these decisions is rather blunt and that is a major part of our current dilemma.

There are ways to address the cost problem. One way is to remove the fee for service system that we have and move towards other payment systems that pay salaries for physicians or pay them in more "bundled" ways for the care of an illness. Under a bundled payment system, a physician or a health system may be paid for the complete evaluation and treatment of an illness (heart disease for example) and that payment would include everything from doctor's fees, to hospital costs to medications. Right now the evaluation and treatment of that heart disease includes sepaarate payments to multiple doctors in multiple specialities. All of those people, products and services would still have to be paid for in a more bundled system however such a payment system would create incentives to keep the costs of evaluation and treatment lower. However, make no mistake about it; the American public prefers incentives to do more over incentives to do less. We tend to prefer knowing that everything possible is being done when illness strikes. Finding a solution to lowering costs is thus a cultural challenge as much as an economic or political one.

How the Current House Reform Package Attempts to Solve the Problem of High Cost

To put it succinctly, it doesn't. It does address the issue of access by bringing many people into the health insurance system however the approach to lowering cost is mainly achieved by putting into place (for the long term) more electornic interfaces in medical record keeping and medical care, and also putting into place more government involvement in payment, benefits, and the development and maintainenece of medical care standards. Currently, the government does set fees, benefits and payment systems for Medicare and Medicaid. Most physicians and hospitals believe that the Medicare fees are very low and that the Medicaid fees may not even be enough to cover overhead expenses.

The example of End of Life Care

The loud debate over the end of life care provision in HR 3200 is a very good example of all that is wrong with the tenor of the debate and some of what is problematic in the bill itself. The goal of increasing people's options for themselves and their families at the end of life is a laudable one. As a physician, I have seen people have nothing but pain in their final days and weeks of life because they have not been given all of the options as to how they want to spend those finals days. Does the health care reform bill encourage a positive and loving way to approach one's final hours or does it result in government death squads? The reality is that it does neither. One really does need to look at the exact language in the bill to determine what is really being proposed.
Section 1233 entitled Advance Care Planning Consultation describes in excrutiating legal language all that must be done in order for a physician to charge for end of life counseling. It does not mandate the service but it does regulate it very specficially even describing the quality control for that service. This specificity can actually cause more fragmentation, at least in the billing process. A good physician does these services as a matter of course and can bill for it under the current billing system. It is an office visit. The troubling aspect of the provision is the attempt to push the physician into a script rather than encourage him or her to listen to their patient in order to understand their needs and counsel them in a customized personal manner. When government mandates specific language and approaches, costs can actually increase and the personal nature of medical care can suffer. So while I believe that end of life counseling is an important part of practice, I also believe that including it in the health reform bill will not further the goal of getting more counseling preformed in a personalized way. It will only increase administrative costs and fragment billing which also leads to higher costs. It may also further a troubling trend towards a depersonalization of medicine, at the time of life when the most personal type of service is needed.

So What Do We Do?

I hope that what we do is start to speak openly about the options and not just talk about being for or against health reform. We are all for improving the access to health care and making it more affodable and at the same time we are all for maintaining and improving the quality of care that all receive. The only question is what exact provisions need to be in the bill to best encourage those goals. There is honest disagreement about those provisions and I can only hope that the debate takes the time and care to evaluate each provision so that we end up achieving the best possible solution.