Portal de Periódicos da CAPES

Where Is the Wisdom in Healthcare?

2009; Lippincott Williams & Wilkins; Volume: 35; Issue: 1 Linguagem: Inglês

10.1097/brs.0b013e3181cc52ce

1528-1159

James N. Weinstein,

Healthcare Policy and Management

The United States spends $2.5 trillion a year on healthcare, more than any other nation. It is an amount nearly equal to the whole of the German economy,1 yet we rank 37th in the world2 for quality of care. According to the US Census Bureau, approximately 85% of Americans have health insurance; nearly 60% obtain it through an employer, while about 9% purchase it directly. Various government agencies provide coverage to about 28% of Americans. In 2007, there were nearly 46 million people in the United States who were without health insurance for at least part of that year.3 The percentage of the non-elderly population who are uninsured has been generally increasing since the year 2000.4 These facts make it clear that our healthcare system is neither working, nor is it healthy. It is both a logical and moral obligation to improve the health of the nation and slow the rate of growth in dollars spent. Medicare These are not new problems. US Presidents starting with Teddy Roosevelt have worked to improve the health of the United States; to provide more coverage and stop the fiscal bleeding. To that end, Medicare stands as an exemplar. In 1945, Harry Truman sent a message to Congress asking for legislation to establish a national health insurance plan. Two decades of debate ensued, with opponents warning of the dangers of “socialized medicine.” By the end of Truman's administration, he had backed off from the plan for universal coverage, but administrators from Social Security and others focused on the idea of a program aimed at insuring Social Security beneficiaries. On July 30, 1965, President Lyndon Johnson signed Medicare and its companion program Medicaid into law. Former President Truman was the first to enroll in Medicare. At that time, the Medicare Part B premium was only $3 per month. Over the ensuing decades, Medicare has seen tremendous growth with seemingly little financial restraint. In 1983, it changed from reimbursement for “reasonable cost” to a prospective payment system, based on diagnosis-related groups (DRG's) for hospital inpatient services. In 1988, a major overhaul of Medicare benefits was enacted, aimed at providing coverage for catastrophic illness and prescription drugs. And in 1989, catastrophic coverage and prescription drug coverage were repealed. In 1992, physician payments were based on a fee schedule. In 1997, Medicare plus Choice provisions proved to be so financially restrictive when regulations were unveiled that Congress was forced to revisit the issue in 1999 and relax some of its Medicare funding restrictions. In 2000, Medicare plus Choice took effect, along with prospective payment systems for outpatient services and home health agencies. Medicare Part B premiums were now $45.40 per month. In 2003, the Medicare Modernization Act (MMA)–was signed into law, adding outpatient prescription drug benefits to Medicare. Employer-Based Coverage Employer-based coverage provides yet another historic dimension of how the United States provides insurance benefits for a nation. Approximately 60% of Americans get their health insurance coverage through an employer. Employer-provided insurance has its origins in World War II. The National War Labor Board (NWLB) was reconvened by President Roosevelt in part to ensure that production of weapons and supplies would not be disrupted by labor disputes. The Board decided that it was in our country's best interests to freeze wages and establish price controls, at least for the duration of the war. Unfortunately, the wage freeze made it much more difficult for employers to attract employees from a workforce that had diminished in numbers as more and more workers were sent overseas. Then the NWLB ruled that the wage freeze and price controls did not apply to “fringe benefits” like pensions and health insurance coverage. This gave employers the means to attract and retain employees. In those days, health insurance was relatively cheap, and the fact that it was (and still is) tax deductible was an added bonus for the employer. Labor unions strongly supported the NWLB ruling and encouraged businesses to offer health insurance benefits to their employees. When the war ended, job-based health coverage did not. The workforce had grown accustomed to receiving health insurance coverage as an employee benefit, so that even after the labor shortage ended, they continued to demand it, and continue to do so today. Quality and Cost These are truly impressive governmental initiatives that represent the very underpinnings of our healthcare system today. But where is the linkage between having health insurance and having quality healthcare? What about truly value-based care, where value is measured with appropriate quality measures and cost data that suggest what we are doing actually works and what well-informed patients would want? Quality represents the numerator of the value equation: Value = Quality/Cost over time that is safe. We have instruments to provide pilots with constant information that allows them to fly our planes and land them safely. And yet in healthcare, we are flying blind. Why is it that we have more information about cameras, toasters, automobiles and many other consumer goods than we do about healthcare and its related outcomes of treatment? Consumer Reports has been a trusted source for objective, research-based information since 1933. Only recently have they begun to apply the same methods and measurements to healthcare, most recently in collaboration with The Dartmouth Institute for Health Policy and Clinical Practice. Another trusted source is the Foundation for Informed Medical Decision Making, a nonprofit organization dedicated to assuring that people understand their choices and have the information they need to make sound decisions affecting their health and wellbeing.5 Considering the current debate and the need for reform, we can no longer ignore the evidence or patient preferences and values in considering diagnostic tests and treatment options.6,7 It is true that greater access to healthcare through Medicare, Medicaid, and employer-based insurance, along with our incredible economic prosperity since the second World War, have given us better health and a better quality of life. Significant scientific advancements such as water purification, antibiotics, and immunizations have ameliorated or prevented life-threatening diseases. These advances saved lives with monumental impact. On the other hand, the measureable impact of many new diagnostic tests, procedures, drugs and or devices is far less clear. In a free market society, with incredible capacity for innovation, the lack of measures of benefit and effectiveness for nonlife-sustaining interventions is unacceptable. Having health insurance, in and of itself, does not mean good healthcare and having an electronic health record, does not, in and of itself, improve health. These are simply tools in the toolbox, like seats on an airplane or a GPS in your car. One is for comfort and one gives directions but first, you need to know where you want to go. Healthcare Proportion of GDP As a wealthy nation we spend an ever-increasing proportion of our income on healthcare – 16.2% of GDP in 2010, projected to be 20.3% in 2013. Health insurance premiums have increased 120% between 1999 and 2008 while family coverage has gone from $130 to $330 per month in the same period.8,9 This growth rate is unsustainable, particularly given the lack of measureable effect on overall quality. Therefore, we must reconcile to a new model of Health and discontinue the current models that are based solely on a flawed healthcare delivery and reimbursement system, wholly unsupportive of Value. We must move toward a model of Health and Wellness by redesigning the whole of the “Delivery System” with value-based measurement as part of any system we create. Many new and exciting ideas are being batted around in the current attempt to solve the dilemma of fixing US healthcare. Congress is proposing a myriad of potentially effective solutions in thousands of pages of text. Unfortunately, these pages are long on ideas and short on details. It will be the task of congressional staffers, the Department of Health and Human Services, and many others to work through the details of actually implementing these changes. As part of the process, the Congressional Budget Office worked overtime to make 10-year cost projections, with an accuracy that is at best questionable, given the very nature of medicine and the rapid and ever changing landscape of new diagnostic tests and treatments. Medicare Trust Fund The Medicare Trust Fund, seemingly grossly underfunded, is estimated to be exhausted by 2017, 2 years earlier than originally projected, according to the annual report by Medicare Trustees.10 Medicare's annual costs were 3.2% of the Gross Domestic Product in 2008, equivalent to $468 billion, or about three-quarters of Social Security's. They are projected to surpass Social Security expenditures in 2028 and reach 11.4% of the GDP in 2083.10 If we are to sustain the Medicare Trust Fund, we need to begin the hard work of cutting cost in real ways, including infrastructure, technology, and treatment. Deciding how much to spend on the health of a nation is indeed challenging. As our population continues to grow – it is currently over 300 million – the “oldest old,” those 85 and over, are the most rapidly growing group. Some politicians and others suggest any changes in Medicare funding will lead to rationing of care. It is my belief that a more rational use of Medicare funds will lead to higher quality care, an overall improvement in the delivery system, and bend the cost curve. There is a big difference between rationing care versus rational care. Knowing what works allows for rational, evidence based, and appropriate use of healthcare resources.11 Where Is the Wisdom in US Healthcare: Reform 2010? Taking a Page From the “Wizard of Oz.” In the end, can history be our guide or at the very least our roadmap for our destination? The journey toward health reform has been decades in the making and there have been many mishaps along the way. But there have also been many lessons learned. I cannot help but think of Dorothy in the “Wizard of Oz.” What is our “yellow brick road” to a rational and effective healthcare system? And do we have the “heart, brains, and courage” to get there? Like Dorothy, we all just want to get home safe and sound. In our case, “home” will be where we have health coverage for all, 1) that is affordable, 2) accountable, 3) transparent 4) cost effective 5) incorporates patient self-reported outcomes, and is based on 8) best evidence? Congress and the White House might benefit from the Tin Man's heart, so they have the will to do what is needed, Mr. Scarecrow's brain, so knowledge will inform the changes they are advocating, and the Cowardly Lion's courage, to make the necessary decisions even when their local politics say otherwise. Dorothy woke up to a reality better than the fantastic dream she had. Before the President signs into law a nearly trillion dollar healthcare bill, can we wake up and realize real reform requires real change with real accountability for the waste and excesses we can no longer afford? The reality of effective healthcare demands measurement and transparency in reporting. Like the nutrition panel on a cereal box or an issue of Consumer Reports, we need information to know what's in the treatment we are buying and how it compares to others. Healthcare reform needs to focus on the delivery system at the individual level and at the population level. The wisdom in healthcare is not in Congress, it is in the American people asking for more from their elected officials and it is in the millions of us involved in this most precious of avocations of caring for mankind. Let's all “follow the yellow brick road,” toward a value based healthcare system. Like Dorothy, patients and their families want to arrive safely home. We can and must all wake up and move this process forward! Thank you and happy holidays to all of our readers, reviewers, editors, and staff. Wishing you happy 2010.