Healing America's Ailing Health Care System
2006; Elsevier BV; Volume: 81; Issue: 4 Linguagem: Inglês
10.4065/81.4.492
ISSN1942-5546
AutoresDenis A. Cortese, Robert K. Smoldt,
Tópico(s)Primary Care and Health Outcomes
ResumoAs health care professionals, we marvel at the complexity of the human body—extraordinary when its systems perform in concert, devastating when disease or disorder invades. One malfunction within the body—not making insulin, for example—may lead to serious problems such as blindness, peripheral nerve damage, and heart disease. Our job is to bring the entire human body back into balance so the patient can lead a full, productive life. A similar holistic approach should be used to examine the way we provide health care in the United States. Like a person suffering from a debilitating disease, health care in the United States is ailing. There are many signs that it is in serious trouble. Lack of Quality and Safety. Nearly one half of physician care is not based on best practices.1McGlynn EA Asch SM Adams J et al.The quality of health care delivered to adults in the United States.N Engl J Med. 2003; 348: 2635-2645Crossref PubMed Scopus (3935) Google Scholar Also, at least 98,000 Americans die of a medical error each year.2Kohn LT Corrigan JM Donaldson MS To Err Is Human: Building A Safer Health System. National Academies Press, Washington, DC1999Google Scholar The Uninsured. The number of uninsured or under-insured people in America is rising. In 2004, nearly 46 million people were uninsured, according to the US Census Bureau (www.census.gov/hhes/www/hlthins/hlthin04/hlth04asc.html). Public Unease. Surveys have increasingly found that more Americans are worried about their health care costs than about losing their jobs, paying their mortgages, losing money in the stock market, or being victims of a terrorist attack. Among those who currently have insurance, more than one third report that they are very worried that their health plan will be more concerned about money than about what is best for them.3Kaiser Family Foundation Health care worries in context with other worries. Kaiser HealthPoll Report, March/April 2005.Available at: www.kff.org/healthpollreport/apr_2005/security/1.cfmGoogle Scholar Rising Costs. With the exception of the mid-1990s, health insurance premium increases have generally exceeded the rate of increase in the Consumer Price Index, as well as worker earnings.4Kaiser Permanente/Health Research and Educational Trust.Available at: www.kff.org/insurance/7164.cfm#backgroundDate: 2005Google Scholar An October 2005 study from the Kaiser Family Foundation reported that the percentage of employers offering health coverage decreased from 69% to 60% in just 5 years.5Kaiser Family Foundation Employer Health Benefits: 2005 Summary of Findings.Available at: www.kff.org/insurance/7315/sections/upload/7316.pdfGoogle Scholar Some companies, such as General Motors, are finding it difficult to compete globally when faced with paying billions of dollars to insure employees, retirees, and dependents. General Motors chairman and chief executive G. Richard Wagoner, Jr, notes that $1500 is added to the price of each General Motors vehicle to cover health care costs.6Connolly C U.S. firms losing health care battle, GM chairman says. Washington Post. February 11, 2005.Available at: www.washingtonpost.com/wp-dyn/articles/A15828-2005Feb10.htmlGoogle Scholar Misaligned Payment Incentives. In the current outpatient Medicare payment model, there is a built-in financial incentive for medical centers to provide more services, even though recent studies have found no evidence to suggest that doing more always improves outcomes for patients with chronic disease.7Wenneberg DE Wennberg JE Addressing variations: is there hope for the future?. Health Aff (Millwood), December 2003 (Web exclusive).Available at: http://content.healthaffairs.org/cgi/content/full/hlthaff.w3.614v1/DC1Google Scholar In addition, private insurers for people younger than age 65 manage financial risk, not health. Insurers currently have incentives to pass on risk to Medicare once a member becomes eligible for the federal program. Baby Boomer Retirement. In 2011, the first baby boomers, those born during the United States' mid-20th century population explosion, will qualify for Medicare. This will prompt a significant increase in the number of enrollees and put a considerable strain on the program's budget. This confluence of issues requires our immediate attention and action. Something needs to be done to fix—not patch—the system. In reality, there is no health care system in the United States today. System, according to Merriam-Webster's Collegiate Dictionary,8Merriam-Webster's Collegiate Dictionary. 11th ed. Merriam-Webster, Inc, Springfield, Mass2003: 1269Google Scholar means "a regularly interacting or interdependent group of items forming a unified whole." Currently, a myriad of professionals and organizations provide health care, but no vision has ever been articulated for these disparate parts to function together and learn from each other. This article describes a vision for all health care to function as a dynamic learning organizational system. In his book, The Fifth Discipline, Peter Senge9Senge PM The Fifth Discipline: The Art and Practice of a Learning Organization. Doubleday, New York, NY1990Google Scholar describes the art and practice of learning organizations, places "where people continually expand their capacity to create the results they truly desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning to see the whole together." It is time to create a learning system for health care in the United States. The aim is to provide medical care that is safe, effective, efficient, timely, equitable, and patient centered, goals articulated in the Institute of Medicine's book, Crossing the Quality Chasm: A New Health System for the 21st Century.10Committee on Quality Health Care in America, Institute of Medicine Crossing The Quality Chasm: A New Health System For The 21st Century. National Academies Press, Washington, DC2001Google Scholar Every element of such an organizational system already exists somewhere in the United States today. However, without consistent application, we are not able to reap the benefits of a well-functioning system that brings its component parts into balance. As leaders in health care, we need to create an environment within and among our organizations in which it is second nature to share our successes and failures and what we have learned from them. Although it is true that hospitals currently have incentives to retain—not share—knowledge for competitive advantage, competition at this level hurts our patients. It impedes optimal improvements that lead to a patient-centered medical system. We must always remember that our common aim is to heal the sick. For instance, when a hospital in one area of the United States finds a way to reduce the risks of administering a medication or eliminate a complication of surgery, would it not be appropriate for every other hospital to learn of this quickly? If we are concerned about the well-being of all patients, the answer is "yes." However, even if we agree to strive for this ideal, it could not happen today for lack of a strategic, deliberate attempt to design the systematic infrastructure necessary to foster this type of learning for health care. The legal environment also should be structured to encourage the sharing of information, perhaps through increased transparency and creation of a "safe harbor" to report poor outcomes or errors. Together, we can change the current environment and begin building a new framework for health care. Shared Vision. Shared vision helps us focus on a health care system that is patient centered, safe, effective, efficient, timely, and equitable. It helps us move beyond misdirected forms of competition and instead focus on what is best for all patients. Professionalism. Professionals in a learning organization must meet expectations beyond mastering a basic body of knowledge, completing an apprenticeship, and practicing. They should expand their knowledge through perpetual education, pass on knowledge through teaching or mentoring, and add to the body of knowledge through basic, clinical, or health sciences research. Information Technology. Information is key to providing safe and effective ongoing care for all patients, and it is mandatory if we are to generate knowledge. New information and knowledge will develop at ever-increasing speed during the next several years: biotechnological discoveries in genomics, proteomics, immunology, pharmacogenomics, vaccines, micromonitoring, and electrical stimulation are a few examples. These discoveries will have major implications for the profession's ability to improve performance in several domains of medicine: prediction, prevention, precise diagnosis, prognosis, personalized care, and palliation. During the past 10 years, Kaiser Permanente, which provides health care coverage and medical care to more than 8.3 million members throughout the United States, has invested $3.2 billion in a comprehensive electronic health information system (George C. Halvorson, written communication, December 2, 2005). The overriding goal is to improve the quality of care. Once fully implemented, patient medical information and clinical-decision support will be available all the time, more than 1 clinician will be able to use a single patient's information simultaneously, and patients can more easily participate in their own care. Unfortunately, only 15% to 20% of US physicians' offices and 20% to 25% of hospitals are using electronic medical records.11Hillestad R Bigelow J Bower A et al.Can electronic medical record systems transform health care? potential health benefits, savings, and costs.Health Aff (Millwood). 2005; 24: 1103-1117Crossref PubMed Scopus (1260) Google Scholar If timely and appropriate information is crucial, would physicians and patients not benefit from optimal use of information technology? A vision for the role of information technology is to have all information about an individual's health care immediately available to both physician and patient—anywhere in the world—with the simple click of a computer key: •Routine information such as present and past medical histories, family history, social history, physical examination, and a list of allergies•Medication lists that are linked to pharmacy data and supported by a computer-aided search for important and potentially dangerous drug interactions•Laboratory/pathology reports and radiology images•Current treatment recommendations, disease management strategies, and links to the latest medical literature related to the patient's problem•The individual's unique genetic profile, which will be used to individualize treatment•National and international clinical trials for which the patient may be eligible All these data are available today, and a diligent physician wants all of it to help each patient. However, even with the use of current information technology, it may take hours or, more often, days or weeks to accumulate these data for a given patient. The promise of information technology is to assemble all the information in a timely way to facilitate decisions, improve physician productivity, and offer the most up-to-date treatment for the patient. Systems Engineering. Physicians should be knowledgeable about processes of care and how to improve them. Unfortunately, traditional medical education does not train physicians in process and systems engineering. A recent report by the National Academy of Engineering and the Institute of Medicine suggests that a partnership between engineers and health care professionals may help bridge this gap.12Reid PP Compton WD Grossman JH et al.Building A Better Delivery System: A New Engineering/Health Care Partnership. National Academies Press, Washington, DC2005Google Scholar Currently, medical students are exposed to a highly competitive and selective process that fosters individual knowledge, responsibility, and autonomy. However, as practicing physicians, we need additional skills to work with patients, families, nurses, physicians, administrators, regulators, insurance companies, and employers. In short, we must become team members. The team approach fosters an ongoing analysis of the outcomes and processes of care, a key step in any systematic approach to improving quality care. Mayo Clinic has been using a systems engineering approach to improve medical care for the past 100 years. A good example of this from our own organization is the innovative patient record keeping first started in 1907. Henry Plummer, the fourth physician in the Mayo practice, designed a system to keep all of a patient's records, clinic visits and hospital stays, in a single file that traveled with the patient and was stored in a central repository. His system was novel for health care, replacing notes saved in individual physician and surgeon offices.13Nelson CW Mayo Roots: Profiling the Origins of Mayo Clinic. Mayo Foundation for Medical Education and Research, Rochester, Minn1990: 242Google Scholar It transformed the way Mayo Clinic provided care to patients. Mayo Clinic used Dr Plummer's system until about 8 years ago, when we began the process of developing an electronic medical record to collect, store, and retrieve data; distribute and analyze information; and generate knowledge. A year ago, we initiated a broad collaboration with IBM (International Business Machines) to accelerate advances in patient care and research with an aggressive set of technology initiatives. We are confident that this new electronic medical record system will dramatically improve the care we give to patients, deepening the pioneering work that Dr Plummer began nearly a century ago. To achieve this vision of a new health care system for America—one that functions as a vibrant, innovative learning organization—we propose a consumer-driven, market-based model that delivers universal coverage to all Americans, a model similar to the Federal Employee Health Benefits Plan (FEHBP) or the Universal Health Voucher Plan.14Fuchs VR Emanuel EJ Health care reform: why? what? when?.Health Aff (Millwood). 2005; 24: 1399-1414Crossref PubMed Scopus (40) Google Scholar Many physicians and policy makers believe that a single payer system would be the simple solution to the complicated problems facing US health care. However, we at Mayo Clinic believe a single payer solution would create many problems of its own—specifically, the burden of bureaucracy and overregulation. Instead, a consumer-driven, market-based model allows the principles of economics to flourish. In other sectors, consumers buy items or services from suppliers, who set their own prices and design their services. Consumers assess and select services that offer the best value for them. Businesses that provide value flourish; businesses that lack value fail. Competition around value will improve health care quality and lower costs. Increased transparency, publishing outcomes and quality indicators, makes it possible for consumers and payers to make informed choices about which health care provider they select. Three years after New York providers published mortality rates for open heart surgery, hospitals and physicians with better outcomes had higher rates of growth in market share.15Mukamel D Mushlin AI Quality of care information makes a difference: an analysis of market share and price changes after publication of the New York State Cardiac Surgery Mortality Reports.Med Care. 1998; 36: 945-954Crossref PubMed Scopus (166) Google Scholar In addition to helping patients make informed decisions about where to seek care, transparency allows hospitals to continuously improve internal practices. In 2003, Minnesota's Adverse Health Event Reporting Law took effect. It requires hospitals to disclose when any 1 of the 27 serious events defined by law (wrong site surgery, for example) occurs. Each year, the Minnesota Department of Health publishes reports of the events by facility, along with a summary of the corrections implemented by hospitals. Eliminating errors improves patient care through better systems and processes. Relying on market forces can help us achieve our vision for health care. It can help us improve. Within this market-based model, physicians, patients, insurers, and the government also must modify their roles. Physicians' Role. Physicians must commit to achieving a learning organization through shared vision, professionalism, systems engineering, and information technology. As noted in other sections of this article, this will require changes in medical school and graduate training to emphasize teamwork, systems engineering, process improvement, and customer focus. Patients' Role. Individuals must accept personal responsibility for their own health. Lifestyle Choices. Eating a healthy diet, practicing stress reduction techniques, exercising, and not smoking will help people stay healthier, happier, and more productive. Perhaps benefit programs could be structured to provide financial incentives that encourage these healthy behaviors. Involvement With Their Care. Patients are responsible for taking care of their health. That means making healthy lifestyle choices, getting preventive care, understanding their diseases and conditions, and advocating for their needs. Patients can become involved with advocacy groups such as the National Coalition for Women with Heart Disease16The National Coalition for Women with Heart Disease Available at: www.womenheart.orgGoogle Scholar and organizations such as the Center for Patient Partnerships at the University of Wisconsin-Madison.17The Center for Patient Partnerships, University of Wisconsin Available at: www.law.wisc.edu/patientadvocacy/Google Scholar These groups of concerned patients bring attention to the need for research on a disease or condition and can serve as a great source of support for people during a personal health crisis. Acceptance of More Financial Responsibility. Patients should pay for a portion of their care so they are aware of health care costs and can become better consumers. Insuring Themselves and Their Families. Everyone must have health insurance that includes a basic benefit package. This is a matter of individual responsibility and analogous to requirements for individuals to have automobile insurance. The federal government would help finance insurance for those who are in need. Private Insurers' Role. A recent study of insurance plans that measure and report performance data was performed by the National Committee for Quality Assurance, a privately funded nonprofit group, and U.S. News & World Report. It found that many insurers have improved patient care.18National Committee for Quality Assurance The State of Health Care Quality 2005: Industry Trends and Analysis.Available at: www.ncqa.org/DOCS/SOHCQ_2005.pdfGoogle Scholar The group based its results on the type of care patients received for chronic diseases (eg, hypertension and diabetes) or for prevention (immunizations, depression screenings) and on satisfaction of enrollees. All private insurers need to operate in a way that is patient centered. Insurance companies must have a financial stake in supporting prevention and treatment of chronic diseases, and they should take care of their members throughout a lifetime, not simply until they are 65 years old. In a recent New York Times article about treatment of diabetes, reporter Ian Urbina19Urbina I In the treatment of diabetes, success often does not pay. New York Times.Available at: www.nytimes.com/2006/01/11/nyregion/nyregionspecial5/11diabetes.html?ex=1142053200&en=b204d3f3ddf6e276&ei=5070Date: January 11, 2006Google Scholar writes of this common problem: Patients have trouble securing a reimbursement for a $75 visit to the nutritionist who counsels them on controlling their diabetes. Insurers do not balk, however, at paying $315 for a single session of dialysis, which treats one of the disease's serious complications. In reality, many of these serious complications occur after retirement, when Medicare is paying the bill. Currently, private insurers have financial incentives to pass this risk to Medicare. Insurers need to insure, rather than only avoid risk. Insuring throughout a person's lifetime would be a good first step toward making this happen. Federal Government's Role. Within this new system, the federal government's role will change from being an insurance company to being an enabler of innovation and a coordinator/financier of private health insurance, based on need. Innovator. The government has a central role in pulling together the disparate parts of our health care system, supporting the diffusion of knowledge, and creating mechanisms to allow medicine to function as a learning organization. As an enabler of innovation, the government can convene private standard-setting groups to develop activities designed to foster competition based on quality, service, and cost. These groups would recommend standards for quality, transparency, vocabulary, and connectivity through information technology. The federal government is venturing into this realm already, through the Office of National Coordinator for Health Information Technology (www.hhs.gov/healthit/). The government could also create a regulatory board that provides incentives for providers to quickly adopt safety and quality improvements. This board would be nonpolitical, with members chosen for their ability to bring the best science and management to bear on the field of health care. Coordinator and Financier. The government's role must change from insurance company to coordinator and financier of private health insurance, based on need, perhaps by providing sliding scale financial assistance to purchase private insurance. How can this be accomplished? Many aspects of this proposed approach to health care reform are based on the FEHBP, which provides private health insurance to federal employees through a market-based system of choice and promotes competition among insurance plans. As a model, FEHBP is affordable, offers choice, covers drug costs, has no state mandates, and allows people the right to purchase more options. Employers would not be required to provide health insurance but, in the interest of their business or employees, could choose to contribute to the cost. Employees could use the employer payments to cover all or part of the cost for any insurance plan on the national menu. The federal government could coordinate these insurance offerings through an organization like the Office of Personnel Management, which currently runs the FEHBP at a relatively low administrative cost. A market-based insurance model similar to the FEHBP, which functions well for government employees, would ensure fair, universal access to private insurance, with the government providing financial assistance to those who need help purchasing insurance. Reimbursement would be negotiated among plans and providers, without government price controls. This model offers several benefits. 1.The government could focus its limited financial resources on those who need help, an imperative as the baby boom generation reaches Medicare's current eligibility age.2.Everyone could choose from among multiple insurance offerings, as long as these offerings meet the minimum package requirements. Individuals could buy coverage that exceeds the minimum, if they wished.3.The patient could be more fully engaged as the purchaser and customer.4.A dynamic private market could allow more freedom to provide the innovation and increases in productivity that can reduce health care costs.5.The model provides assurance that everyone will have access to a basic level of affordable, market-based universal health insurance. With this model, the government would use tax revenue to fund its responsibilities. Health Insurance for the Needy. The federal government has an important role in helping finance insurance for those in need. The government would determine who is eligible for financial assistance to purchase health care. Assistance could be in the form of vouchers, tax credits, or direct payment. Financial assistance could be based on income, age, disability, or any other criteria the government chooses. Eventually, there would no longer be a need for a separate Medicare or Medicaid program because this new model would ensure coverage for all. A transition period may be necessary to avoid disruption for current beneficiaries. Health Services Research. To improve the quality and efficiency of health care, the government should dramatically expand funding in health services research, including patient outcomes research and process management. This research would improve quality, safety, and service as well as manage or reduce costs, thereby increasing the value of health care. Results of such government-funded studies would be widely available in a timely fashion to all participants of the health care system, so learning could occur quickly. Research and Education. The government should maintain financial support for such societal benefits as medical research and medical education. In addition, all health insurers, not just Medicare, should contribute a portion of insurance revenue to fund medical education and graduate training. Alternatively, the government could set up a central funding pool to support medical education, following the research-funding model of the National Institutes of Health. We firmly believe the principles outlined herein provide a strong foundation on which to build a learning health system for all Americans. We also realize that others have creative ideas about how to transform health care to meet the needs of patients. Together, we can define the scope of the health care crisis, acknowledging all perspectives and aspects of these complex issues. As we share, consider, debate, and refine our collective ideas, once disparate voices will form a chorus of actionable solutions that can heal our ailing health care system. We thank Roshelle (Shelly) W. Plutowski for editorial assistance with the submitted manuscript.
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