The Unsustainable US Health Care System: A Blueprint for Change

Health insurance is a necessary, but not sufficient precondition to equitable access. As Massachusetts is demonstrating, providing insurance alone isn't enough. Our health insurance reform law was obviously underfunded from day 1 and unsurprisingly is running over budget. The Boston Globe runs articles about newly-insured patients who can't find a provider of primary care. Working in an FQHC, I have seen my administrative hassles increase as more of my patients who used to have state-funded "Freecare," which functioned similarly to Medicaid with one set of rules, now have many flavors of insurance, with multiple drug formularies, copays, prior authorization requirements, etc.

My FQHC is investing a large sum of money to move to an EHR - because we "have to." So are the university-affiliated hospitals and medical group. But the evidence base for improved care from EHRs is remarkably thin and the CBO recently revised its estimate to indicate there will be no monetary savings from EHRs. I am aware of only one intervention with the potential to save enough money to keep our health care system solvent - a single-payer system, as advocated by PNHP. The savings would likely exceed the 25%+ overhead directly attributable to "competing" private insurers because providers would only have to deal with 1 formulary, 1 set of prior authorization requirements, etc. Patients would not have to try to make sense of pages of incomprehensible small print and apples to aardvarks comparisons between different policies.

I am deeply saddened that none of the 3 leading presidential candidates has the courage to acknowledge that our current system has no clothes because we prefer to drape the insurance industry in furs and silks, and that the only affordable, sensible, and equitable solution is a single-payer, universal system. Then we could move on to reforming provider payment, shoring up primary care, and trying to make medical practice more evidence-based and cost-effective.

Competing interests:   None declared

I am glad to see the article by Dr. Jennifer DeVoe in this issue of The Annals of Family Medicine on "The Unsustainable U.S. Healthcare System: A Blueprint for Change." It is an articulate call for action to reform our system because of its growing problems and the increasing pain being inflicted on patients and their families. Her call for leadership by family physicians and other primary care physicians is also right on target. Primary care physicians are well placed to see every day the impacts of these problems in urban, suburban, rural and underserved settings.

While Dr. DeVoe’s blueprint for change would be a good start in strengthening primary care and expanding preventive services, we need to deal with the elephant in the living room --- the failing private insurance industry. Incremental efforts to reform health care over the last 30 years, while retaining private financing, have all failed to improve access to affordable health care. This industry has priced itself beyond the reach of ordinary Americans, offers less and less value at ever higher costs, avoids coverage of people at higher risk of illness, has a shrinking private market as it profiteers from subsidized public markets, and is not sustainable as a financing mechanism of our health care. The most important policy question now facing us is whether or not to retain private multi-payer financing. Based of its failed track record, we now need to discard this obsolete industry and rebuild U.S. health care on a single-payer public financing system, Medicare for All, coupled with a private delivery system.

Physicians wanting to become better informed on the issues and proactive toward health care reform should consider joining Physicians for a National Health Program (PNHP), now 15,000 strong. PNHP has extensive resources and educational materials on the issues. Also highly recommended is Dr. Don McCanne’s Quote of the Day, which draws on the literature, recent studies and events as they relate to health care reform; over time that becomes a graduate course in health policy (don@mccanne.org).

John Geyman, M.D., author of Do Not Resuscitate: Why The Health Insurance Industry Is Dying, and How We Must Replace It (Common Courage Press, 2008).

Competing interests:   None declared

I applaud Dr DeVoe's essay calling for change and for family physicians to lead such change. Through the tragic portraits of her patients, she brings into focus and context the problems the American people and we, as their physicians, deal with on a daily basis. The pillars of health care financing are crucial and no doubt require serious reform. However, I’d also like to suggest that even within this crumbling edifice, significant change is possible and potentially more readily attainable by getting our own ‘house’ in order.

The building metaphor is a useful one, but I resist the temptation to continue it by using the current term du jour: ‘medical home’. By our ‘house’, I’m referring not to the places in which we take care of our patients but the community of physicians to which we belong. For a building to actually function, an infrastructure must supply electricity, plumbing and climate control. We physicians are this functional soul. Structural change is necessary but insufficient. Meaningful functional (internal) change must also occur in order for larger structural (external) change to have a maximal impact.

For example, given the reality of limited resources it will be difficult to figure out AND sustain a way to cover more (or all) people as long we continue some of our resource-draining habits: our practice of defensive medicine (1), increasing reliance on expensive diagnostic modalities (2), ignorance of the costs of medical care (3), continuing collusion with those seeking financial gain from us and our patients (4) and inability to properly execute effective inexpensive interventions in favor of new, well-marketed ones (5).

Admittedly, some of these issues present ‘chicken-egg’ questions: Would we practice as much defensive medicine if there were more reasonable limits on medical liability? Would we seek more efficient ways to take care of our patients if our reimbursement accounted for services other than individual visits to our office resulting in the ordering of tests and prescribing of medications?

Nevertheless, we as a physician community cannot avoid taking some responsibility for the rising costs of care which ultimately contribute to our collective ruin in the form of poor health outcomes and access. Our conversations must not only be about changing health care and being more 'evidence-based' but also about prioritization based on cost-effectiveness and 'clinically-preventable burden' (6).

Dr DeVoe’s call to lead change strikes at the heart of family medicine’s revolutionary origins (7). But the circumstances are different--both the world AND we have changed--and will require creative ways to engage not only policy-makers but society at-large and the community of physicians. We and our patients enable each others’ fascination with things new (and usually expensive). And in some ways, medical practice has come to resemble our corporate, fast-food, ‘easy’ button culture. Fortunately, the media has given health care an unusually long hold on its short attention span but is always ready to move on to the next big thing: we risk this ‘tipping point’ passing without effecting significant change. But while we help work towards structural change, let’s not forget to also get our house in order.

References

1. Kessler D, McClellan M. Do Doctors Practice Defensive Medicine? The Quarterly Journal of Economics, Vol. 111, No. 2 (May, 1996), pp. 353-39

2. Bhargavan M, Sunshine JH. Utilization of radiology services in the United States: levels and trends in modalities, regions, and populations. Radiology. 2005 Mar;234(3):824-32.

3. Allan GM, Lexchin J, Wiebe N. Physician awareness of drug cost: a systematic review. PLoS Med. 2007 Sep;4(9):e283.

4. Campbell EG, Gruen RL, Mountford JM, Lawrence G, Cleary PD, Blumenthal D. A National Survey of Physician-Industry Relationships. N Engl J Med 2007 356: 1742-1750.

5. Woolf SH, Johnson RE. The break-even point: when medical advances are less important than improving the fidelity with which they are delivered. Ann Fam Med November/December 2005;3:545-52.

6. Maciosek MV, Coffield AB, Edwards NM, Flottemesch TJ, Goodman MJ, Solberg LI. Priorities among effective clinical preventive services: results of a systematic review and analysis. Am J Prev Med. 2006 Jul;31(1):52-61.

7. Stephens GG. Family medicine as counterculture. Fam Med 1998;30(9):629-36.

Competing interests:   None declared

Another excellent outline of what is wrong with the US healthcare system. No insurance, underinsurance, deductibles, copays, cost shifting, medical bankruptcies, overburdened ER's, fewer primary care physicians and general surgeons, politicians indebted to pharmaceutical and insurance companies, no political will, oppositon to change by organized medicine, malpractice costs... oh, sorry, I got carried away.

I would like to point out HR 676 introduced by John Conyers Jr, currently with 85 cosponsors in the US House of Representatives. This will establish a government run single payer system with PRIVATE delivery of medical care. It will abolish all health insurance as we know it now and will do away with Medicare, Medicaid, SCHIP, insurance premiums and roll all this money into a government entity with a payment system modeled on Medicare. With savings of 31%(cost of insurance overhead and dealing with them) we can afford to insure everybody... forever... no matter where they work.

We don't need to reinvent the wheel, no need or angst about how to design our new healthcare system. We now have an EVIDENCE BASED outline about how to do it. Take almost any example of any other industrialized country... say Canada or Taiwan who have a similar system with better outcomes and less cost.

More about this at www.pnhp.org

Recent polls show >50% US physicians favor single payer and ACP has already endorsed single payer. DOCTORS need to start talking about this with their patients and anyone else who will listen. We need to practice evidence based medicine.

Tom Jenkins MD

Competing interests:   None declared

Thanks reminding us of the distress of those on the periphery of our medical system with little (or no!) medical coverage.

Whether or not the “medical home” concept is just the latest buzz-word for solid primary care, we must remember that we need to care for ALL those in need, not just those who can pay or who are covered. If access and continuity are good for patients, they are good whether they are reimbursed or not, and whether the patient is "covered" or not.

Access and continuity must be extended to the 15% of our population who has no insurance, and the even greater percentage who lack adequate insurance. Development of the “medical home” concept must not be divorced from work to improve health-care access. This will take a values-based approach that affirms the importance of access and continuity for all, and your essay gives some thought-provoking ideas on first-steps in that direction.

Competing interests:   None declared