Friday, November 14, 2008

Who Will Guide Us Out of Health Care Turbulence?

Writing a blog at 34,000 feet, on a flight to Dallas going through an unusual bout of turbulence, is a rather disconcerting experience. The captain advises us that there is "no good air" at any elevation except 16,000 feet, but then says flying at the lower altitude would burn fuel at twice the usual rate - so we'd never get there. (He means to be reassuring, but I don't think the words "never get there" are ones that a captain should ever utter to nervous passengers!)

This reminds me of the turbulence in the U.S. health care system. We are looking to the new captain in Washington - Barack Obama - to guide us to calmer circumstances. But the U.S. health care system is burning its fuel - the dollars that businesses, government, and individuals are paying into health care - at a rate that can't be sustained.

The airplane analogy only goes so far. Our captain knew from years of experience how to get us through the bumps.

But, no president has experience with the degree of turbulence that is now unfolding in the U.S. health care system, the U.S. economy, and world financial markets.

Instead of thinking of President-elect Obama as the steady airline captain who relies on experience to guide passengers to the calm he knows is ahead, we should instead look at him as an engineer who is trying to redesign a broken heath care system before it crashes and burns.

He can't do it alone. He will have to rely on the advice and support of many to reform a health care system that costs too much, covers too few, delivers less than optimal quality, and has too few primary care doctors.

The American College of Physicians (ACP) is providing President-elect Obama and members of Congress with our ideas on building a better health care system. Earlier this year, ACP published a position paper in the Annals of Internal Medicine that compares U.S. health care to the experiences in other countries and draws lessons to guide U.S. health care policy. One of those lessons is that all high performing health care systems are based on a strong foundation of primary care, a topic that John Iglehardt writes about in today's Health Affairs blog. We also found that all effective health care systems in other countries guarantee, by law, that all residents have access to affordable coverage.

We just recently updated ACP's own proposal, called our seven year plan, on how to create a pathway to universal coverage that builds upon our current employer-based system. Next week, we will be releasing a new white paper that summarizes over 100 studies that shows that the availability of primary care is consistently associated with better outcomes and lower costs.

We also need your ideas. In each of my blog posts, I will continue to ask you for your comments on how to improve the health care system. (Thanks to the many of you who have submitted thoughtful comments on prior postings.)

Today's question: if there was a single piece of advice that you would want to give to President-elect Obama on how to steer the U.S. health care system out of turbulent times, what would it be?


K McCabe MD said...

My advice would be to gather a group of primary care internists from across the country to offer their perspective on what occurs in the day to day operations of a private practice and what they can identify as some of the major obstacles that interfere with delivery of care to patients. Many times we can see how each step in delivery ratchets up the cost of care for eg. interference by insurance companies controlling how pts get their prescriptions and then delay in pt's receiving their meds, and pt's not having their meds to take and then back to the hospital ER all because of an administrative snafu that the doctor could not control. There are so many examples of how the day to day care of pts has obstacles placed in front of it that I wonder how do we manage at all! The adoption of EHR would save an enormous amount of money in the long run as the doctor would have available previous data on an individual pt so as not to reorder tests that were done recently but the pt/family member didn't realize or couldn't articulate it. The list goes on and I'm sure that many other physicians could give many more examples of cost savings that they see in the office. I have not heard of any individual, practicing physician being asked to sit on a panel or in front of congress and identify what they see as solutions to some of the myriad problems that up the cost of health care.

Jay Larson MD said...


In the September 10, 2008, JAMA article, "Factors Associated With Medical Students’ Career Choices Regarding Internal Medicine" there were 3 major reasons that medical students did not choose primary care internal medicine.
1) requiring more paperwork
(800, 68.0% of respondents)
2) requiring a greater breadth of knowledge(731, 62.1%)
3) having a lower income potential (760, 64.6%).

Reducing paperwork required by physicians would free up more time for patient care and increase access to physicians. The Medicare forms and documentation requirements for durable medical equipment are increasingly burdensome. Medication denials and prior authorization requires extra time to justify a treatment regiment that the physician felt was appropriate after evaluating the patient. Prior authorizations only benefit the insurance companies and can be potentially harmful.

In the October 23, 2008 NEJM article "Cardiovascular Outcome After a Change in Prescription Policy for Clopidogrel" it was shown that eliminating a prescription policy on Plavix increased Plavix use in acute myocardial infarction patients treated wtih angiolplasty and stenting patients from 35% to 88%.