November 1, 2009 - On and on it goes. The nation's healthcare reform debate rages on as the primary item on the local and national agenda.
And while most conversations on healthcare generate plenty of “heat”—sadly, the discussion has yielded far less “light.”
Every single one of us is affected by healthcare—whether we are well or ill, take good care of ourselves or are careless, insured or not, well off or poor.
So, too, our national economy suffers in terms of efficiency and effectiveness with a healthcare system responsible for over 17% of our Gross National Product and growing uncontrollably.
Despite the apparent gridlock in Washington on the structure and direction of a national healthcare reform package, two relatively simple changes can make a world of difference in our nation's collective health.
And lest you think this healthcare dilemma is a new 21st century problem, it's not.
History repeats itself and today's healthcare debates are no exception. In fact, this country has been debating healthcare reform for a century.
- The movement for national health insurance and expanded coverage began in the early days of the 20th century. Theodore Roosevelt seized on the issue when campaigning on the Bull Moose Party ticket in 1912. The issue was promoted by progressives in 1914 and 1917 and in the 1920s, according to a recent article in Modern Healthcare Magazine.
· The Great Depression renewed interest in the concept with President Franklin Delano Roosevelt supporting national health insurance. But, because of intense opposition from the American Medical Association (a recurring theme through the last century), Roosevelt feared the whole Social Security bill might be defeated. So he postponed the issue. Roosevelt died in 1945 before he could resurrect the plan.
· President Harry S. Truman formally proposed national health insurance, but the proposal died because of a mix of influences, including party politics, cries of socialized medicine and even segregation.
· Thereafter, major overhauls were proposed or seriously considered by seven Presidents— John F. Kennedy, Lyndon Johnson (who managed to get Medicare enacted), Richard Nixon, Jimmy Carter, and Bill Clinton. Ronald Reagan pushed for catastrophic Medicare coverage and President Clinton made an ill-fated attempt at health coverage for all Americans. Finally, President George W. Bush endorsed tax credits as a means of expanding coverage.
Why is the situation so urgent today?
For one thing, the effects of globalization have accelerated our need to change. As U.S. health costs rise out of proportion to our international peers, American companies become are become less competitive economically. For example, health care costs American auto makers about $1,500 per vehicle produced, while international manufacturers spend only about half that amount.
Then there are the steadily-mounting costs in the form of U.S. government liabilities from contractual commitments to retired employees for healthcare. Such costs could make health care a terminal illness for America's governments and businesses, according to Clayton Christensen's The Innovator's Prescription.
Healthcare economist Victor Fuchs is even more dire, contending that we will see major reform only in the wake of a war, large scale recession, or large scale civil unrest. Our current national recession has only exacerbated the problem. We have had 13 recessions since the 1940s, and none parallel this one. The point is that dollars spent on health care come out of wages. So a doubling of healthcare costs would be catastrophic for individual incomes.
So we've got to reform our healthcare system. That's clear. The question is, “How?”
Most of the discussions so far have been partisan and polarizing, focused on payment mechanisms and protecting one's own “turf.” Most insurance companies, big pharmaceutical companies, device manufacturers (e.g. pacemaker and artificial joint manufacturers, etc.), hospitals and physicians prefer the status quo. They are mostly “change-phobic.”
But two simple changes provide a wonderful opportunity both to change the system and improve individual health at the same time. These two changes would improve quality, decrease costs and do nothing to interfere with the traditional physician-patient relationship.
Sound too good to be true? Not really. Here's what we need to do.
#1 Change care delivery by mandating “evidence-based” medicine.
Evidence-based medicine comprises guidelines for best practices that have been established by practitioners from both research and medical outcomes studies.
This approach has been supported by numerous healthcare experts, including the Dartmouth Atlas (www.dartmouthatlas.org/), National Quality Forum-NQA (www.qualityforum.org/), Institute for Healthcare Improvement (www.ihi.org/ihi) and RAND Corp (www.rand.org/research_areas/health/).
In the U.S., only 59% of Medicare patients with cancer receive best practices, according to NQA. Only 55% of all U. S. patients receive recommended care, according to RAND. Moreover, there is a 40% variation in treatment for the same diagnosis. With evidence-based medicine, this would be reduced to near zero! We could truly predict treatment results.
Evidence based medicine would also change our malpractice system, which has 1+% direct costs (awards, legal fees, administration, etc. of which the harmed patient receives only 46%) and about 9+% for the indirect costs of “defensive medicine” according to a recent Quarterly Journal of Economics study. Additionally a George Washington University study has pointed out that fraud would be easy to recognize as outliers would become obvious. This change would save an additional 10%. So these two modifications, alone, would reduce costs about 20%.
#2 Emphasize prevention.
Only 3% of Americans don't smoke, stay close to ideal body weight, exercise three times per week for at least 20 minutes, and eat fruits and vegetables regularly, according to David Nash, a respected Professor of Health Policy at Thomas Jefferson University in Philadelphia. 70% of illnesses in America today are self-induced. The remaining 30% of illnesses are genetic in origin. 90% of resources are spent on illness and not health promotion.
We simply have to change our priorities.
I'm pleased to say that's exactly what we're doing at NCH with our new Employee Health and Wellness partnership.
Our overall mission as a healthcare institution is to promote, maintain, and restore health in those we serve. Of every dollar we spend on healthcare, 75 cents goes towards patients with chronic illnesses like diabetes, heart disease, cancer and asthma—many cases of which could have been prevented entirely, detected earlier, or better managed. In Medicare and Medicaid, the numbers are even worse—we spend 83 cents and 96 cents per dollar, respectively, on chronic illnesses.
The point is that we are all in this together. America has 5% of the world's population and produces 20% of the world's gross national product. We live in a global environment and need to continue to be as efficient and effective as the best countries in the world.
America has a long and proud history of leading the world. We should continue this tradition of healthcare excellence by embracing first, evidence-based medicine and second, prevention—two changes that would have enormous impact in both reforming and improving righting our national healthcare.