So you want to know about health care reform

by: mooncat

Tue Aug 25, 2009 at 13:48:17 PM CDT

We all know the health reform debate is extremely acrimonious and political right now. I hoped Dr. Wyatt could cut through the he said/she said talking points and offer insight into the care side of the American health care system.  In particular, how do the millions of uninsured Americans get care, what happens if we bring them into the system -- will we all have to settle for less care -- and will cutting costs by reducing duplication and inefficiency result in lower standards of care for everyone?

Millions of Americans have no health insurance right now.  Does that mean they get no health care?

Dr. Wyatt says no, they do get treatment. "Many people that have no insurance are already in the system.  They go to urgent care."  Not-for-profit institutions are obligated to see anyone who comes through the door. He said the question is how to pay for the uninsured once they are into a health care system. Currently the cost of that care is shared with other patients and their insurers through cost-shifting or is covered by government subsidies to not-for-profit and teaching institutions. We're already paying for the cost of some care for the uninsured, albeit indirectly.

Will our health care system be swamped if millions of uninsured Americans are suddenly brought into the system, leading to less care for those who already have insurance?

Bringing uninsured Americans into the system won't cause a shortage of physicians and services -- the physician shortage already exists, particularly in the case of primary care physicians. Dr. Wyatt estimates Madison County has a shortage of 50 to 60 primary care physicians right now.  "If you bring more people into the system ... yes, you will need additional primary care physicians, but we already know that.  We know that there is a need.  The issue with supply of physicians is more of what are the incentives for medical students to do primary care medicine and that gets back to the economics of medical education ..." and what are the challenges: "paperwork, insurance company requirements that impose on your ability to practice medicine."

He also points to a shortage of physicians practicing in rural areas, noting this is also an existing problem, not something health care reform or universal coverage would bring about.  Effective health care reform needs to address both the shortage of primary care physicians and the problem of under-served areas.

Are the cost savings possible through greater efficiency overstated? Will forcing such savings on providers drive down the quality of care or the level of patient services?

Dr. Wyatt says no. "It will not drive down the level of services. There is, I would say, billions of dollars spent on repetitious ordering, on errors, that are either in hospitals or on medications. You have to factor in the amount of money that's paid for malpractice insurance, and so-called defensive medicine. In a system as ours where there's not an integrated electronic record it's easy to duplicate tests."  

"So, there's a lot of money in the system that can be taken out. And I think you look back at Atul Gawande and Elliott Fisher at Dartmouth who looked at just variation in health care and you find that the areas that have the highest amount of money being spent per capita on health care have the lowest quality. So there's a disconnect."

Dr. Wyatt is referring to an article in The New Yorker, The Cost Conundrum by Atul Gawande, exploring Medicare costs in McAllen,TX. A few weeks ago we pointed you toward that same article which found that although costs in McAllen were among the very highest in the nation -- actually higher than per capita income -- residents did not have the best quality health care in the nation.  Dr. Wyatt also referred to the Dartmouth Atlas when he spoke of the wide variation in health care cost and quality in America -- check out this interactive map. Higher cost does not always, or even usually, equal higher quality when it comes to health care.

"Variation is a real issue. And it's how do we take the variation out of health care? How do we do that and at the same time not interfere with a physician's ability to practice the way he or she sees best fit. When you have the highest cost of care in McAllen Texas and then you have a lower cost of care and better quality in San Francisco, we say there's an issue there. There's real money that can be taken out of the system and applied somewhere else." For more on variation, see Slowing the Growth of Health Care Costs -- Lessons from Regional Variation by Fisher, Bynum and Skinner in the New England Journal of Medicine.

Leadership is needed at three levels. In their practices, physicians can help patients understand when a more conservative path is likely to be as safe as a more intensive and higher-cost path. In their communities, physicians have the credibility to argue against the need for further growth - whether through hospital expansion, the construction of new imaging centers, or the recruitment of more specialists to oversupplied regions (www.dartmouthatlas.org provides spending, hospital, and workforce data for each U.S. hospital-referral region). And physicians can support changes in the health care system that will help their patients and communities get the best possible care at the lowest possible cost.

But physicians will need help from payers and policymakers. Under the current payment system, physicians cannot afford the time it takes to help patients understand why a test or procedure is not needed. Hospitals lose money when they improve care in ways that reduce admissions, and they lose market share when they don't keep pace in the local medical arms race. In this race there are no financial rewards for collaboration, coordination, or conservative practice.

"If you look at the amount money being spent just on readmissions, it's in the billions.  So if you look at the amount of money being spent on admissions that are maybe not appropriate - that's billions of dollars. How do we get to a point where we can pull that money out? A large part of it has to do with making sure people have insurance, making sure that the tests we do, the orders we write, the medicines we give, have some basis in things that work. That's called comparative effectiveness. ... Comparative effectiveness research is needed, and then I think taking some of the risk out of practice in terms of liability deserves a good look. Even though the malpractice rates remain pretty stable, the malpractice premiums have gone up ..."

In short, we need to focus on what works, stop wasting money on treatments or procedures that are duplicative or don't improve patient outcomes, reduce hospital readmissions (you want the provider to get it right the first time) and inappropriate admissions, and reduce defensive medicine and malpractice costs.

What about Medicare -- a government run, taxpayer funded health insurance -- does it offer good care for patients?

Dr. Wyatt said the biggest issue with Medicare is the lack of primary care physicians to see patients. Some of that has to do with the level of reimbursements -- and low reimbursement rates are a problem most health care reform proposals do address -- some of it has to do with the complicated nature of the medical problems senior citizens have. He complimented Medicare on its very low administrative overhead in the range of 3 to 5%. That's well below the rate for private insurance companies, in part because Medicare does not have that level of upper management receiving millions of dollars in salaries and benefits.
 

Do you think we need changes or reforms to our system of health care?

"I'm interested in, not just health care reform but improving the quality of health care delivery.  I'm interested in performance improvement, process improvement.  I'm interested in measuring what doesn't work and then coming up with constructive ways to improve the system both for providers as well as patients. I'm interested in making hospitals a safe place to go, that you can get in and out and you get the right procedure, you get the right surgery, you get the right medication ...

I believe as a nation, really it's a human rights issue that every citizen has health care insurance. We're the largest, richest country in the world in terms of health care delivery. The care we provide ... is not as good as other countries. There's a reason for that.

The money is in the system, it's how do we spend the money in a better way? Insure people, make sure what we do is the right thing for the patient. ... Again, I think we face what is, to me, a human rights issue. To me it's beyond a political issue.

How do we treat US citizens?  This is us. How we treat our citizens, I think, reflects on us on the world stage. If we're saying, we're the biggest, we're the best, we spend the most money, then why aren't our outcomes as good as France, or England, or Canada or Costa Rica?  

I think we have to take a good hard look at how to fix the system so that people who need insurance will have it, so that people will have peace of mind knowing they have health insurance coverage, and at the same time control costs, improve quality, improve access and give people ... a medical home. Something that is patient centered ... something that is designed for the patient."

You've said the money is in the system.
Where does the money go? Why aren't we number one?

"We know there's a big disparity in physician salaries, we know that money goes into malpractice, we know that a lot of money goes into pharmaceuticals, we know a lot of money goes into durable medical equipment that may or may not be needed, we know that a lot of tests are done that may or may not be effective. I think we start by looking at what actually works, at the same time maintaining some measurable level of quality and looking at where the waste is."

"We're spending trillions now on health care and I think there's a disparity in where the money goes." He said patients need to do their part as well, accepting that some generics work as well as the latest medicine or the test advertised in a magazine may not be indicated in your case -- so you can't get it. "There's a lot of places to look to carve out savings and at the same time maintain good quality." Dr. Wyatt is concerned that doctors are so busy dealing with chronic conditions they are not able to spend enough time on prevention. He advocates a shift back towards preventive medicine even if the financial reward is years away.

Why are physicians today interested in health care reform in a way they were not in 1993 or even in the 1960's when Medicare was being debated? What's it like being a doctor today that makes so many physicians open to the idea of doing something different?

"At the core ... of most physicians is concern about the patients we take care of. So I'll put that number one. We have an aging population, more medical problems and we all care for people that are uninsured. ... Probably second to that, is when we hear repeatedly that we can do better. We hear that other countries are doing a better job.  ... There's something here that needs to be fixed. We have an opportunity to fix it.  Not sure what it's going to look like, but ... most of my physician friends and colleagues believe that it's time to at least have universal insurance coverage and then work on how we fix the system beyond that point."

Hopeful for the future

My conversation with Dr. Wyatt left me feeling hopeful that real health care reform is possible and that medical professionals both understand how America's health care system can be improved and want it to be improved. When I asked Dr. Wyatt the question for tonight's panel -- Can we have universal coverage, quality care and controlled cost? -- he said the answer is yes, but it will require some shared sacrifice. I hope we, particularly our elected officials, are willing to make that sacrifice, because the benefits to our society will be huge.