Creating Fair, Effective, Efficient Care

BY RAYMOND FEIERABEND

Our nation’s health care system is in need of serious reform.

We’re capable of providing the most sophisticated medical care in the world. However, in a study of 19 industrialized countries released last month by the Commonwealth Fund, the U.S. ranked last in preventable mortality – deaths that might not have occurred with timely and effective medical care.

In 2007, 75 million adult Americans (42 percent of those under age 65) were either uninsured or underinsured. Thirty-one percent of adults reported that they went without or delayed medical care because of costs. We spend well over $2 trillion (16 percent of our gross domestic product) on health care, yet satisfaction with our health care system is lower than in almost every other industrialized country.

Thirty-four percent of Americans believe it needs to be rebuilt completely; 12 percent of Canadians and 15 percent in Great Britain feel the same way about their own systems.

There is no ideal solution to our health care crisis. Regardless of the details of what a rebuilt American health care system might look like, I believe the following are necessary to create one that is fair, effective and efficient.

* Universal coverage: We are the only modern industrialized nation that does not guarantee some basic level of health care to all citizens. Everyone living in this country should have access to health care. This makes sense from a moral standpoint and from a financial standpoint. Universal coverage does not necessarily mean a single-payer, governmentally administered program. Many countries achieve universal coverage through mandatory participation in private health insurance programs. However, these countries guarantee affordable premiums for basic levels of insurance, with publicly financed support for those who are unable to pay.

* Limitation of basic coverage: We do not have the resources to provide a premium level of care to everyone. There must be agreement on the services available to all, including mental health services. Beyond that, individuals who have the ability to pay for additional or more expedient care should be allowed to obtain those services by paying extra.

* Limitation or elimination of profits: Health insurance providers, hospitals and health maintenance organizations should not be in the business of earning money for shareholders. Numerous studies have shown that the profit motive in health care does not lead to greater efficiency, and that the quality of care suffers in those systems where profits are a driving force. Other countries have demonstrated that removal of the profit motive does not necessarily result in loss of competition.

* Elimination of “cherry-picking”: Insurers, hospitals and health maintenance organizations cannot be allowed to accept only young and relatively healthy individuals. They must be required to accept all who apply for coverage or services.

* Limitation of salaries: Those involved in the health care industry should be allowed to earn reasonable salaries. However, individuals should not be allowed to garner multi-million dollar incomes when we are faced with seriously limited resources.

* Focus on quality, cost effectiveness and administrative efficiency: The health care provided to all must be scientifically based, yet tailored to the individual patient. Electronic health records, standardized protocols for common health problems and medical audits to ensure quality of care all have been shown to improve the quality and efficiency of care. Primary medical and mental health care services should be integrated more effectively. Standardized reimbursement rules and paperwork would reduce administrative costs tremendously.

* Tort reform: Most errors resulting in patient harm are due to systemic flaws rather than gross individual negligence. Those injured should be fairly compensated when appropriate. All errors must be evaluated and changes implemented when necessary to avoid similar problems in the future. When systems do not respond appropriately, or when individuals are at fault due to gross negligence or incompetence, administrative or financial sanctions must be imposed. Litigation should be available only as a last resort.

* Emphasis on prevention: An increasing percentage of the health care burden is due to illnesses directly related to poor lifestyle choices (e.g. obesity, tobacco-related diseases, abuse of alcohol and other addictive substances.) There must be expanded emphasis on public health measures including health education, cost-effective screening and lifestyle counseling, and the development of healthy, walkable communities. Incentives should be provided to physicians for keeping patients healthy. Effective treatment of addictive disorders must be readily available to all who need it.

* Reduction of fraud and abuse: Fraud and abuse of the system are not likely to disappear. Patients will overutilize services or divert resources for personal gain; providers will engage in questionable practices to enhance income; administrators and CEOs will attempt to defraud the public. Identification of the minority who abuse the system is easier with unified, computerized medical and financial information systems. Those who abuse the system must be held accountable; those committing fraud must be dealt with appropriately via strict law enforcement.

Implementation of all of these changes will require enormous political will and great compromise. There is something for everyone to dislike; many who profit from our current system stand to lose financially. But piecemeal implementation of only some of the changes will not be sufficient.

Without fundamental change, we will continue to have a system that provides the most expensive yet least fair and least efficient care in the modern industrialized world.

Dr. Raymond H. Feierabend, of Bristol, Tenn., is a professor in the Department of Family Medicine at East Tennessee State University.