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1. The U.S., at this time, does not have an adequate health care workforce to deliver excellent universal coverage no matter how much money is spent.
a) The nursing shortage in the United States is acute and getting worse! If one looks at the workforce as a pyramid with nurses at the base, physician assistants/ nurse practitioners as a next layer and physicians at the top, we have a grossly inadequate base. We have to dramatically increase the number of our citizens pursuing a career in nursing.
b) The physician workforce in the United States is woefully lacking in primary care, with now only 1/3 of physicians practicing primary care and 2/3 functioning as specialists. This is an inverse ratio from other developed nations which have much better health care results. Without adequate primary care, chronic conditions cannot be adequately cared for and preventative medicine cannot be delivered. Medicare and its payment system have emphasized procedural and technological medicine which has decimated primary care. Changing economic factors can increase the number of medical students going into primary care but it will take decades by this alone to reverse the aberrant ratio of primary care to specialist doctors. Thus a system is needed at this time so that many of our specialists also practice primary care.
2. We need to change our views about medical care in this country a) Commercialization – Medicine is not a commercial product. Rather, medicine is a personal experience between an individual patient, each with her/his uniqueness, and a knowledgeable, empathetic, caring physician who has the judgment to be able to meet each patient’s individual needs. Specialists, computerization, modern drugs, devices 103
and procedures are useful when appropriate, but harmful when overused. The overuse of medical facilities, documented by the variability in the cost of care from one area of the nation to another, is in part an unfortunate result of commercialization. Direct to the consumer drug, device and hospital advertising adds to this problem.
The influence medical device and drug companies have on our system is pervasive and in many instances abusive. We will have to control the excess commercialization of health care that is now present in our system to be able to provide affordable universal coverage for all our citizens.
b) Consumerism - Many experts have voiced that we, as a nation, must learn that more is not necessarily better in medicine. Yes, the newest may be the correct treatment in some circumstances, but in others the best treatment may be no treatment or an old tried-and-true therapy.
The Congress, in its desire to protect the consumer, has passed laws -
The Patient Self Determination Act, The Americans with Disabilities Act and The Emergency Medical Treatment & Labor Act, all written without a key phrase, for example, within the boundaries of acceptable medical standards. Unfortunately this oversight has hampered our legal system and promoted consumerism.
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The Electronic Medical Record: Must it Cost Billions to the Tax Payer?
According to a Dow Jones article the U.S. government plans to spend 20 billion dollars in five years to achieve a 12.6 billion dollar savings in ten. It is just me, or is there something bizarre about these numbers? The expenditure estimate is from an interpretation of the latest U.S. government spending plans, the savings estimate from the Congressional Budget Office. These numbers are quite approximate and may vary, but the main point is clear: electronic medical records are a good idea for coordinating patient care, but are not a tool for significant cost savings.
Is there an alternative that will provide the benefits of the electronic medical record and not require spending billions of our government’s dollars? Yes there is, with a little imagination and Congressional action. This plan calls for Congress to create a Federal Health Care Clearing House and Bank. The Bank’s first function would be to create a computer based national clearing house for patients’ billing and medical records. Many large information technology corporations (i.e.
Google, Microsoft and others) have created comprehensive computer programs that can interact with various other hospital and outpatient data systems. The
“Bank” would use standard federal government procedures for bidding and selecting the program/s and site/s for maintaining this medical record and billing system. This medical information would be kept in a central location/s with other sites for backup. The key aspect of this proposal is the centralization for maintaining electronic medical records, thus greatly lowering costs.
The central computer would receive billing and patient records from every hospital and medical entity in the land. All hospitals have most if not all their patient records on computer at this time. The “Bank” would charge the hospital, insurance companies and other medical entities a fee for each transaction. These fees would be calculated to support the computer system and would be quite modest for each entry. Keep in mind that there are millions of hospital-patient interactions and many millions of other medical transactions each year. Doctors would access the central computer, enter their information and would also be charged a much smaller fee. Pharmacy and other services would do the same.
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Patients would be able to access their own medical record free of charge.
There would be multiple levels of computer security, but with an additional caveat. As access to computer records can be traced more accurately than with paper systems, violators can be determined with greater ease. Congress when creating the “Bank” would also mandate heavy fines for unauthorized access, thus helping to ensure confidentiality.
I believe this is a workable and cost saving idea. I welcome your comments about this concept.
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The Problems with Advance Directives, Inappropriate Care and A Solution Only about 20% of Americans have executed an advance directive and only about half of these have discussed their wishes with their physician. (1) Without one, most hospitals and nursing homes assume that the patient wishes every conceivable means of medical therapy, even if inappropriate for that particular patient. Another problem with advance directives is that it asks the person to make a decision about what type of care would be wanted at some time in the future. However, one could not possibly know what the clinical situation will be at that time.
My solution is a new style of hospital admission form. The advantages of this form and its benefit to patients, families and our society include: 1. This form would be completed at each hospital and nursing home admission and would serve as a fresh and timely advance directive. The patient/family can make a much more rational decision about which therapies are not wanted. Because admission to a hospital or nursing home is an extremely stressful time for the patient and family, the medical team can facilitate the completion of an up to date advanced directive with the patient/family at that time.
2. During the discussion about the form upon admission to the hospital or nursing home, the physician can clarify the fact that only beneficial care can be administered but that the patient/family retains the right to refuse any or all offered treatments (if of age and sound mind). This eliminates, as much as possible, the potential of delivering inappropriate care.
3. The form would be adopted by Congress to be used for all Medicare and Medicaid patients and would create a legal framework for the appropriate care committee system.
4. Using this form would eliminate cardiopulmonary resuscitation (CPR) by default – that is performing CPR whether it would benefit the patient or 107
not. CPR - the restarting of heartbeat and breathing - was first developed in the early 1960s, before Medicare, when the hospital patient population was much younger. So it was reasonable to be automatically initiated whenever there was a cardiac arrest because the patients had a more reasonable chance of survival and recovery. However, the hospital population is now much older and many are in an end-of-life situation.
Despite this change in demographics the custom still remains to automatically attempt CPR, even in patients with end-stage disease despite great discomfit to the dying patient. This occurs unless a specific order is written to avoid the procedure. My proposed admission form would correct this problem by making cardiopulmonary resuscitation an ordered event to be used only in the appropriate circumstance. This would save many thousands of patients a great deal of discomfort and preserve billions of dollars of resources.
5. I have copyrighted this form so that I could insure that it be used in a constructive manner.
6. Because of the importance of this form to the reintroduction of rationality to our medical system I am asking all of you who visit my blog to download the introductory letter and the form and fax them to your Congress Person and Senators. Download the letter and the form here.
Teno J, Lynn J, Wenger N, et al. Advance Directives for Seriously Ill Hospitalized Patients: Effectiveness with the Patient Self Determination Act and the SUPPORT
Intervention. SUPPORT Investigators Study to Understand Prognosis and Preferences for Outcomes and Risk of Treatment. Journal of the American Geriatrics Society 1997;45:500-507 (PMID 9100721)
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The Road to Universal Coverage
1. The U.S. Healthcare Workforce
The U.S., at this time, does not have an adequate healthcare workforce to deliver excellent universal coverage no matter how much money is spent.
a) The nursing shortage in the United States is acute and getting worse! If one looks at the workforce as a pyramid with nurses at the base, physician extenders as a thin next layer, and physicians at the top, we have a grossly inadequate base. We have to dramatically increase the number of young Americans pursuing a career in nursing.
b) The physician workforce in the United States is woefully lacking in primary care; today, only 1/3 of physicians practice primary care and 2/3
practice as specialists. This is an inverse ratio from other developed nations with much better health care results. Without adequate primary care, chronic conditions cannot be adequately cared for and preventative medicine cannot be delivered. Medicare and its payment system have emphasized procedural and technological medicine which has decimated primary care. Changing economic factors can increase the number of medical students going into primary care, but it will take decades by this method alone to reverse the aberrant ratio of primary care to specialists doctors. We need a system in which many of our specialists also practice primary care.
2. Beneficial Care, A New Admitting Form and Appropriate Care Committees Medical care must be of high quality and deliver value for the dollar. This means that only beneficial care can be given, using judgment on a case by case basis determined by each patient’s individual overall health situation.
This must be done in tandem with expanded coverage or excess costs will quickly bankrupt the system. We need to deal with consumerism and the commercialization of medicine that has become the American healthcare 109
system. There are many examples of excess use of technology - the Courage trial demonstrating overuse of procedures in coronary artery disease, over half a million deaths yearly in intensive care units of patients who belong in hospice, etc, etc, - that must be addressed immediately and for which ample data is presently available. If not done the percent gross domestic product (GDP) devoted to health care in the U.S. will continue to increase. The economic distortions to our economy will continue, regardless if paid for by private means or taxes. We must quickly decrease our percent GDP devoted to healthcare while providing universal coverage, which, with the proper controls (hospital admission form and appropriate care committees) can be immediately achieved, or this laudable goal will cause more economic hardship for our people.
3. A
Healthcare
Board
(synonymous
with
Health
Care
Bank)
This board would be fashioned after the Federal Reserve Bank taking the management but not the responsibility of healthcare out of the hands of Congress is an idea whose time has come.
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Towards a Rational End-of-Life Policy
We have recently witnessed an intense controversy over end-of-life counseling.
Deep inside the Congressional House Health Care Reform Bill was a section paying physicians to have end-of-life discussions with patients at least every five years.
To be generous it was meant to be helpful. To be cynical it was an attempt at cost saving. Opponents to the proposed legislation exaggerated its intent using inflammatory rhetoric which made headlines but added little to nothing constructive towards a thoughtful discussion of a very sensitive topic.
The medical advancements available to maintain bodily functions (such as heart beat) beginning in the 1970’s caught our entire society ill-prepared. Two famous cases illustrate this point.
1. In 1975, 21 y/o girl Karen Ann Quinlan suffered anoxic brain damage (not enough oxygen), causing irreversible and complete loss of her cerebral cortex. The cerebral cortex is the humanized part of the brain responsible for consciousness, thinking, awareness, speech, purposeful movement, and all other human traits. She was kept “alive” by artificial means. Karen’s father wanted to remove a breathing machine realizing she was irretrievably lost as a person. He was vigorously opposed by her physicians, the local prosecutor and the New Jersey Attorney General. This opposition was most unfortunate considering Karen’s loss of humanness. Physician opposition to removing the respirator help created the image of physicians as irrational purveyors of technology regardless of the potential for benefit.
This does not absolve agents of the state who were also complicit in this irrational use of technology. It took the New Jersey Supreme Court to give the father authority to remove the respirator.
2. A similar crisis arose in 1983 when 25 y/o Nancy Cruzan also suffered anoxic brain damage and irreversible loss of her cerebral cortex because of an automobile accident. She was kept “alive” in a state hospital via artificial nutrition although her parents, realizing recovery was impossible, wanted cessation of all therapy. The conflict which arose between the state and the 111
parents was resolved by the U.S. Supreme Court which in 1990 ruled that a competent person could refuse artificial means to sustain her/his life. A corollary to this is that a competent patient can refuse any or all therapy.
Shortly thereafter friends of Nancy testified that she would not have wished this kind of treatment. Life support was removed and she ceased to exist shortly afterwards.
Later, in 1990, Congress, as part of budget legislation, passed the Patient Self Determination Act that became the authority for states to initiate advanced directives. Missing from the act was the phrase, “Within the boundaries of good medical practice”. Thus the imperative of knowing the medical feasibility of any desired treatment was missing.
There is a voice missing from this abbreviated synopsis. What is the opinion of physicians and their medical societies on this issue? Their silence was and still is deafening! Should not the fact that complete and irreversible loss of all human functions enter into the decision process, especially when there is medical certainty that for this individual there is no chance of recovery?
Unfortunately cost considerations are mentioned by some when discussing this issue. However, many more important principles are at hand.
1. It is unethical to have a human body decompose in a hospital bed with absolutely no chance of recovery in the name of medical care.
2. The doctors, doctors-in-training and nurses become desensitized to human suffering perhaps lasting their entire careers if they participate in de-humanizing non-beneficial care!
3. Training young physicians and nurses to have the skills to provide futile care takes away from learning more important humane skills such as tolerance, kindness, empathy and physician-patient communication.
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4. Families while experiencing great stress are forced to make decisions regarding the continuation of care in situations where further care is only prolonging death.
5. Advanced directives created at any time in the past and without physician input as to what is feasible are at best problematic and at worse deceiving. I suggest that a new admitting form be routine at every hospitalization to determine patient desires and medical feasibility.
In summary, for this nation to develop a rational end-of-life policy it must be based on human need, realistic expectations and devoid of any financial considerations. It must be policy that if there is any chance of recovery there should be no consideration of cost.
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United States (U.S.) Health Care Costs versus The United Kingdom (U.K.): What We Can Do About It
The Organization for Economic Cooperation and Development (OECD) is the body that generates comparative national data regarding health care spending. This involves the compilation of massive amounts of data, thus the comparisons are about three years behind the present date. The latest data I could find is for the year 2007. In that year the U.S. devoted 16% of gross domestic product (GDP) to health care while the U.K. devoted 8.4%. In equivalent dollars per person spending was $7290 in the U.S. and $2992 in the U.K., quite a difference. Disease adjusted mortality was then and is now superior in the U.K. than in the U.S. If I had compared the U.S. to another industrialized nation, the exact figures would be different, but the lesson is the same: the U.S. spends much more than any other nation on health care without having superior results.
These differences have been the focus of many investigations and publications.
Noted experts Uwe E. Reinhardt, Gerald F. Anderson and at that time Ph.D.
candidate Peter Hussey published a paper in Health Affairs 2004 examining differences in cost from an economic prospective. They focused on a number of factors, some of which cannot be changed (1-2) and others that could be addressed (3-5).
1. As nations’ GDP increases, the fraction of spending on health care also increases.
2. Because of the many opportunities in our large economy we have an increased cost of recruiting and keeping talented people in medicine.
3. In our present system there is greater market power in the supply side versus the demand side for health care. This is because we have a greatly fragmented payment system.
4. Because of the greater complexity of our medical system we have significantly greater administrative costs. These two factors, 3 & 4 could be 114
addressed by creating a series of standardized insurance plans across the country (see link to policy paper on right hand margin- look under health care bank).
5. We have a practice of medicine that lacks discipline when weighing benefit to risk ratios, leading to much non-beneficial care along with the excessive use of technology. To address this need for a cultural change in the way we practice medicine I have suggested a timely physician and nurse support system and a dialogue between patient and physician as to what constitutes beneficial care.
Additionally, superiority in physical diagnostic skills helps explain why physicians in the U.K. rely less on expensive diagnostic testing than their colleagues in the U.S. American medical students now have to demonstrate physician diagnostic skills before graduation. This is certainly progress in the right direction, but is it enough? I think not. Presently there is not an oral exam focusing on physical diagnosis after three years of an Internal Medicine residency; hence this expertise has disappeared. Dr. Abraham Verghese, Professor of the Theory and Practice of Medicine at Stanford University, comparing the physical diagnosis training of medical students in the U.S. versus that in the U.K., stated in The American Medical Association Journal of Ethics, 2009:
I have no doubt that if we attempted to put in place a standardized test using standardized and real patients, with examiners watching for technique as well as understanding of the methods of bedside examination, our students and residents would (much as they do in Canada and Britain) spend a lot more time mastering these skills…..I have great confidence in the clinical knowledge and patient management skills of our students and residents, but the area of bedside skills is in need of improvement, particularly if we are to practice cost-effective medicine and minimize a patient’s exposure to radiation. Imaging tests are valuable and often necessary, but if simple bedside skills make them unnecessary, then lack of such skills is not just costly, but dangerous.
I completely agree with Dr. Verghese. I along with most of my colleagues are 115
concerned that presently most our Internal Medicine residents are not skilled in excellent physical diagnostic techniques. Certainly challenging these residents to learn superior physical diagnostic skills will not completely solve our problem of an exorbitantly expensive style of medicine; however, it would be a step forward for making our medical system less technologically dependent, more rational, safer and less expensive.
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What Should Be The Goal Of Health Care Reform?
Until a few months ago the cost of health care and the percent of gross domestic product it consumes was a major concern. Our goods were not competitive on the world market in large part because of health care costs, manufacturing jobs were leaving the country and the standard of living of the middle class was compromised, all in large part because of these costs. Despite these expenditures 47 million citizens are not insured and our outcomes are poor compared with those of other industrial countries. The reasons for our excessive spending, approximately twice as much per person as any other country, are well known: 1. An insufficient number of primary care physicians and an excess of specialists.
2. Over-reimbursement for technology and under-reimbursement for conceptual thinking and judgment.
3. Approximately $700 billion spent each year on inappropriate non-beneficial care driven in large part by our largest hospitals.
4. Excessive administrative costs in the private sector.
Without addressing these issues as in Massachusetts any attempt at universal coverage will face financial collapse!
Now we as a society are correctly trying to provide coverage for the entire nation, but without seriously addressing our excessive costs. Even the Congressional Budget Office has recently voiced the opinion that the cost control measures being discussed are at best speculative. Now we read that Congress is considering additional taxes that will certainly increase the gross domestic product devoted to health care. Thus our goods and services will be even less competitive in the global marketplace. With an even greater decline in our global competitiveness more high paying skilled jobs leave the country. In terms of social justice, without seriously addressing the known excessive costs in our health care system, as we spend more to provide universal coverage (increased social justice) we loose high paying skilled manufacturing jobs (decreased social justice).
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The health care system in our country is incredibly complex and how to fix it seems elusive. However if one uses end-of-life care as a lens to understand the various forces that have created this massive over-spending and poor care one can then address the problems and provide better care for all at significantly less cost.
That is why after forty years of practice I choose to write my book, In Defiance of Death: Exposing the Real Costs of End of Life Care, which demonstrates the many problems inherent in our current system and proposes a set of feasible solutions.
Our goal should be universal coverage with a health care system consuming about 15% of gross domestic product. By focusing on how to fix end-of-life care, establishing appropriate care committees, creating a new hospital admitting form and a Federal Health Care Bank with varied administrative functions, we can achieve this goal.
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Overly High Healthcare Administrative Costs And A Solution Billions of healthcare dollars go to paying the salaries of the folks who have to handle healthcare claims – both from insurance companies and Medicare. There are all kinds of different insurance policies with variations in coverage. That means that healthcare providers have to employ people who are skilled in the complexities of the various plans. In a primary care practice that might be 2 or 3
people, in a large hospital, dozens of people. The insurance companies and Medicare also have many people working for them to ensure payment goes only to covered services. All of that adds up to a lot of money in administrative costs on all sides.
I have a solution. I propose the creation of a separately chartered, independent federal a