Health Care Rationing or Just Common Sense?

The media continues to produce bombastic reports regarding health care reform full of scare tactics from both sides. One of the buzz words used to scare people is the word – RATIONING.  This word has been used to describe negative aspects of the UK National Health System (NHS) system (or the proposed “public” system in the US); and the word implies the perils of such a system–as if a health care czar sits in the coliseum giving a thumbs up or a thumbs down on medical procedures based on what side of the bed he got out of.  I have a one word retort which the British might use to refute such allegations: BOLLOCKS.

You might call it rationing, but I call it common sense and logical decision making based on costs and benefits for health care procedures.  And I have a perfect example of a person who has experienced rationing in the UK and lived to tell about it – Me.

My Personal Health Care Story

As I have noted in my four previous articles at Demockracy.com, my view on this subject is based on my direct experience with the health systems both in the US and Europe. Unlike most pundits on this subject, I have worked and lived in the UK and the US and experienced both health care systems first hand, as an employee, as an executive,  as a corporate board member, as an owner, and, most importantly, as a patient.  Four years ago, I was diagnosed with cancer while living in the UK and received treatment and advice from both the US and UK systems.  The differences in the way these two systems treated my disease were telling – and at the end of the day the UK’s “rationing” system appeared to do everything the US plan offered at a fraction of the cost. Let me explain the detail.

In 2005, I was diagnosed with tonsil cancer while living in the UK. After my initial diagnoses and shock, I sat down with my UK doctors and discussed the treatment plan offered by the NHS. The proposed plan essentially consisted of the following:

1. A surgery procedure to cut the from my tonsil area and  a major neck dissection that would cut tumor surrounding tissue from the tumor and lymph nodes from my neck and shoulder area.

2.  Four weeks of rest to recuperate from the surgery.

3. Then, I would undergo seven weeks of focused radiotherapy to further eradicate pesky cancer cells in my neck and throat region.

4. And finally, in concert with the radiotherapy, I would receive several doses of chemotherapy over the same seven-week period to further blast away any cancer cells that had invaded my body.

All of that seemed perfectly reasonable to me; but to make doubly sure I was getting the correct treatment, I flew to the US to get a second opinion from a highly respected leading specialty hospital in New York. I was somewhat intrigued that this second opinion and treatment of the cancer were essentially the same as the NHS program.  Intrigued, because I was still under the impression that US health care was better–different, and that I would be offered a different option, perhaps more expensive, but perhaps with better outcomes.  But, no, the diagnosis and treatment plan were almost identical.

I followed the treatment plan in the UK – surgery, chemo, radio, all provided free of charge by the NHS. I have dual citizenship in the UK and the US and had lived in the UK for six years, so this was all perfectly within the rules of the NHS. And after 12 weeks of treatment, I was weakened and tired but satisfied that my doctors and I had done all that I could do to combat the cancer. So up to this point, there was essentially zero difference in the way a US or UK doctor would have treated me.

Now came the aftercare plan. I was told by both US and UK doctors that the tumor had a 50% chance of reappearing – a percentage high enough to cause me and my family many, many sleepless nights. Doctors on both sides of the Atlantic agreed that vigorous aftercare monitoring was needed to check to see if the cancer was to reappear. In the US, the doctors suggested that the best way to monitor a reappearance of the cancer was a series of PET /CT scans; they would use the latest and greatest technology to peer inside my body to see if the cancer had returned. They suggested a PET/CT scan once every six months for two years and then perhaps once per year until year 5.  In all, this would mean 7-8 PET/CT scans, which at about $4,000 per scan would mean a total cost of about $30,000.  That sounded like a lot of money, but, hey, – it was my life we are talking about, and there was a 50% chance of the tumor coming back so it sounded like a no-brainer to spend the money and get my ticket out of Camp Cancer.

I then met with my UK doctor and explained the proposed US treatment plan for aftercare. I still remember my doctor giving a wry smile that suggested there was a simpler way – (the smile also of someone who does not have a bottomless pit of money and funding).  She agreed with the need for close monitoring to see if the cancer reappeared, but then explained her treatment plan to me, which was decidedly low tech.  For the first year, she would have me back in her office every 60 days to perform a thorough physical examination. She explained that if indeed the tumor did recur, that 99 times out of 100 the tumor would reappear in the neck or throat area.  Since this area is relatively exposed and easy to see (down the throat with a scope) or feel (through touching and feeling the neck area), she would be able to see or feel the tumor before it gets to the size of one centimeter (maybe even a bit less, depending on its location) – which is about the same size by which a PET/CT scan can detect a tumor.  Furthermore, she explained, that although the PET/CT scans can be a very useful tool, they often can show false positives (white spots on the scan that turn out not to be malignant tumors), and these false positives will just lead to more aggravation and stress for both the patient and the doctor (and also more costs as the health system has to perform more tests to determine that a false positive is indeed false). Not totally convinced, I asked more questions about PET/CT scans and their use; my UK doctor then told me that if the initial tumor had been on an internal organ (the lung or pancreas for example), then the PET /CT scan would be a very useful tool, because if the tumor reappeared, it would be internal and not be in a place where a doctor’s visual or tactile examination could reveal its presence.

Upon further questioning regarding the benefits of the PET/CT scan, the UK doctor did accept that if in the 1 out of 100 chance that the tumor did reappear in another part of the body (not the neck or throat, but an organ such as the liver, the lung, or the pancreas), her physical inspection of the neck and throat area would not likely find the tumor and the PET / CT would give the patient an earlier indication that trouble had returned.  However, she also noted that if the tumor reappeared via PET/CT scan in the liver or the pancreas, that this early detection does not usually lead to a better outcome for the patient. Unfortunately, if the cancer is found in another organ in the body, this would probably mean the cancer had metastasized and was spreading throughout the body. The sad reality of this situation is that one can run all the tests and scans in the world, but in all probability the patient has terminal cancer, and now the question becomes not if but when – a sad conclusion, but medicine and health care do not always have happy endings.

Now I am generally a skeptic on such matters; and I was still operating under the mindset that the US health care is better than UK health care. But I listened to what the UK doctor said, and I believed her. After all, the UK’s public system had not skimped one bit when it came to the surgery, chemo, and radiotherapy – these are expensive procedures, but the benefit they provide is very demonstrable and intuitive.  But intuitively, the expensive aftercare offered by the US seemed to be a lot of work, effort, and technology for little result.  Indeed, I had “found” the initial tumor when I felt a “lump” on my neck about the size of a pea and it was relatively easy to feel once you knew what you were looking for.

The Costs of Health Care

And, being the accountant that I am, I did the math on the treatment plans.  The US and UK aftercare plans were similar in terms of trips to the doctors. However, to recap,the US plan included 7-8 PET/CT scans which would cost about $30,000. My UK doctor said that 99 times out of 100 a doctor’s visual/physical inspection would find the tumor as soon as the PET/CT scan.  But one time out of 100 the scan would find the tumor that had reappeared at some different part of the body – but even then, in most cases, the likely outcome for the patient was terminal cancer, and the doctors could prolong life for a bit, but the patient would be left with a similar outcome – terminal cancer and death. So for our sample of 100 patients in the US who opt for regular PET/CT scans in their aftercare treatment plan, they and their doctors will certainly feel better about all the money and technology that is being spent to combat the disease. However, these 100 patients in the US will cost the system about $3 million ($30,000 times the 100 patient sample = $3 million); and this extra $3 million will provide little or no benefit when compared with the low tech, low cost approach.

Now let’s go back to the US doctor who is presented with this argument; let’s say he or she agrees with the argument and uses the British, low-tech and low-cost method. Two years later, 50 of his or her 100 patients have cancer (50% recurrence rate in both populations) – of those 50 maybe 2 or 3 or 4 think they have been treated wrongly and decide to sue for malpractice. They engage a lawyer and spend a lot of money on courts and legal proceedings.  And ultimately the doctor has to stand in front of 12 jurors while a litigation lawyer – highly practiced in creating courtroom drama – will try to make the doctor look like a villain.  Undoubtedly, during testimony, the lawyer will pointedly ask the doctor this question: “So you decided not to use the PET/CT, a technologically advanced procedure designed to identify cancer at early stages, and you chose not to perform this test to save the company $3,000 – and because of your penny pinching treatment plan, the patient did not get all the tests available to medical science, and now my client is dying of cancer because you would not allow the PET/CT scan?” These words may not be exactly true, but the lawyer is very good at bending and stating the facts in such a way to garner sympathy for his client. (And who really can blame him; he is simply doing his job.)

So the US doctor contemplates the legal scenario above … and guess what – he or she decides to order the PET/CT scan, and by the way, when he/she orders the scan he/she also gets to charge $500 to the patient to read and interpret the scan report – just another little incentive to do more not less. But who can blame him/her: he/she correctly justifies decisions as helping to save lives, reducing threats of litigation, making patients happier, and making a bit more money.

Back in the UK, the doctor has little or no liability from litigation, for a whole series of reasons. The most relevant is that the NHS has done the cost/benefit analysis and clearly sets treatment protocol based on this logical cost/benefit analysis. The doctor did it by the book, so there is little chance of liability.

And, finally, let’s look at is from the patients point of view. I imagine many may accept the logic of this argument. However, when it comes down to individual decisions on whether to do the PET/CT scans, many will still opt for doing the tests – nothing wrong with that – it’s a  free country.  But what the patient should decide is whether he or she is prepared to spend $30,000 of his or her own money to do these tests. I personally do not want to spend my tax dollars on a government run system that spends this kind of money for tests or programs with little or no benefit.  So the patient can bankroll this $30,000 option by either dipping into his or her savings or opting into a fancy, pay-all, private insurance plan with all the bells and whistles that will pay for such luxuries.  The cost of such an insurance plan will undoubtedly cost several thousand dollars more per year, but you get what you pay for.

Now back to the math and the big picture of US health care. In our little sample of 100 throat cancer patients, the US system spends approximately $3 million more than the low-tech approach. Across the country, in the US, about 30,000 people per year are diagnosed with tonsil/throat cancer. So expanding our sample from 100 to 30,000 means the US spends perhaps $900 million on PET/CT scans for throat and neck cancer patients per year, and this extra money provides little if any benefit in patient outcomes. $900 million is therefore largely unnecessarily spent in the US for this one little disease category. The American doctor often opts for the more expensive, more technical solution, not so much for the welfare of the patient, but so he or she is seen as doing as much as he/she can do when dealing with patients who are ill. This makes the patient happy, the doctor happy, the health care companies rich, and feeds into the common misperception in US medicine that more invasive care equates to better care.

$900 million – almost $1 billion spent with no recognizable benefit for one condition.  And as the saying goes, “a billion here and a billion there–pretty soon we are talking real money.” And this one economic example, repeated over and over for other disease categories is certainly one of the major reasons that the US spends twice as much per capita on health care as most other developed countries with no demonstrable benefit to the population.

Rationing of health care services – bring it on.  Let’s stop spending money on health care treatments which do not provide a real benefit.  More money does not always mean better care.

You might call it rationing, but I call it common sense–making logical , informed decisions about health care procedures is an achievable goal that can make health care affordable to all Americans.  So let’s look behind the scare tactics and buzz words and do what is right and allow for Affordable Health Care for all Americans.

The Case for the Obesity Tax

Recently, New York Governor David Paterson promoted a plan for legislation that would have levied a 15% tax on sodas and other drinks with high sugar content and containing less than 70% fruit juice. Proponents of the ‘Obesity Tax’ argued that the measure would help reduce the prevalence of obesity in New York State. The revenue generated was to be reinvested into public health programs and obesity prevention measures. Citing the success of other similar public health initiatives, including anti-smoking measures such as hefty sales taxes placed on the purchase of cigarettes, supporters were optimistic that this policy would have comparable effects in terms of reducing the consumption of soda and other high-sugar beverages, particularly in children.

Responses to the proposed ‘Obesity Tax’, however, were mostly negative and likely compounded by the Governor’s current negative approval ratings. The tax faced opposition from individuals, associations, and other organizations, including the New York State Restaurant Association and the National Restaurant Association. Disapproval took the form of the expected outrage over legislation which would dictate personal habits and beliefs that the ‘Obesity Tax’ would prove to be an ineffective public health measure. Others felt that, in contrast to successful cigarette taxes that have progressively increased the price of cigarettes by larger margins, a 15% tax on soda would fail to produce any changes in consumption. This latter criticism helped paint the Governor’s legislation as merely a disingenuous attempt to meet New York State budget shortfalls under the guise of a compassionate public health policy. And maybe that is exactly what it was, as the Governor recently performed an about face and replaced the “Obesity Tax” and other revenue measures with money from the federal stimulus package.

Yet the current political climate and unpopular governors notwithstanding, there is a larger point that can be gleaned from this debate. Public health measures that attempt to dissuade unhealthy behavior, whether through consumer tax or mandatory disclosure of nutritional information, are economically, politically, and morally justified. In addition to the promotion of healthy individual living, the basic goals of public policies like the ‘Obesity Tax’ include decreasing both the incidence of chronic illnesses and the amount spent on health care treatment for preventable diseases. In fact, as I will discuss below, reducing health care expenditures on the treatment of preventable chronic diseases should be a critical element of any plan aimed at improving the current health care system in the United States.

Independent of political, geographic, or economic backgrounds, many will agree that one of the tenets of improving the quality of and access to health care in United States is a decrease in rising health care costs. Health care spending has been trending upward and now makes up 17% of US GDP. This rise in spending is not necessarily problematic, particularly if it coincides with an increase in the total number of people receiving health care coverage. However, the percentage of individuals receiving health care benefits in the United States has been moving in the opposite direction. There are many contributing factors to this rise in health care spending, including, medical liability costs and superfluous medical procedures, an aging population, and an increase in the incidences of (and, hence, resources allocated to) chronic disease.

The rise in health care spending for chronic illness is staggering and can be attributed to just a handful of conditions. Although the scientific data varies, one study by Kenneth Thorpe, PhD, Chair of the Department of Health Policy and Management at Emory University and former Deputy Assistant Secretary for Health Policy in the Clinton Administration, found that just five medical conditions accounted for a 31% increase in health care spending in a period spanning from 1987 to 2000. All five of these – heart disease, pulmonary disorders, mental disorders, cancer, and hypertension – are conditions associated with obesity. Furthermore, a related study found that an increase in the prevalence of obesity accounted for a 12% growth in health care spending during a similar time period. It stands, then, that any public health policy attempting to reduce the prevalence of a chronic health condition – especially obesity – should be granted serious consideration. The policies’ potential benefit of reduced spending on preventable conditions is economically and morally compelling since resources could be redistributed to efforts such as improving access, quality improvement, and patient safety. Bearing these potential benefits in mind, critics of the ‘Obesity Tax’ should shy away from criticism based on futility and aimed at legislative defeat and instead focus on removing potential roadblocks, pitfalls, or imperfections within the policy in order to facilitate the policy’s desired outcomes.

Overall, despite the political realities surrounded Governor Paterson’s proposed tax, decreasing the amount of health care spending on preventable chronic conditions is required if current efforts at health care reform are to achieve goals such as raising the number individuals with affordable access to health care and improving the overall quality of care. Ideally, a measure such as the “Obesity tax” would reduce the cases of preventable chronic disease and contribute to the diversion of limited resources away from the treatment of preventable chronic disease to other critical areas, thereby making health care more cost effective and efficient. While Governor Paterson’s “Obesity Tax” as written may or may not effectively achieve these goals, as long as public health measures such as this one have reasonable and shared objectives – in this case, a decrease in health care spending through a reduction in overall obesity – criticism should be more constructive and aimed at improving a specific policy’s effectiveness rather than merely defeating it in the name of narrowly defined interests. We should not be satisfied with defeating a public health policy that has a laudable goal, but rather in ensuring that a public health policy effectively works to achieve that goal.

A Health Care Letter to the President

Mr. Barack Obama
President of the United States of America
1600 Pennsylvania Avenue
Washington, DC  20001

Dear Mr. President:

I have a little problem.  My little problem, however, is part of a big problem – Health Care in America. It is a problem for all Americans.   I want to help you fix this problem. My individual experiences make me both passionate and uniquely qualified to help change health care in America to make our country a better place to live and work.

First, a short history of my little problem: I am a 49 year old American who moved to the UK ten years ago. I was a Chief Financial Officer (CFO) of an international health care company, and I accepted an assignment in Glasgow, Scotland for a 6-months stint that somehow turned into ten years. While staying true to my American roots, I have enjoyed my stay in the UK and enjoyed a successful career – except for one little glitch when in 2005, I was diagnosed with tonsil cancer. Six months of intensive treatment (surgery, chemotherapy, and radiotherapy) has been followed by three years of aftercare.  All of my care was provided efficiently and effectively by the wonderful, capable doctors and nurses working for the National Health Service (NHS) here in Scotland. In some ways, I consider myself fortunate that I was diagnosed with this terrible disease while in the UK where I had access to the NHS to provide care.

But, now my little problem: I would like to move back to the U.S., but cannot – because no insurance company will come near a cancer survivor like me.  So, every summer, I visit my family for two weeks, and every April 15th, I send the IRS a check for my U.S. taxes for the privilege of being a U.S. citizen. And I now wait until I am 65, when I will be covered by Medicare, to return to my home  – this, of course,  is fifteen years away.   This, Mr. President, is no way to run a country.

Ironically, since I have worked as a financial executive for various health care companies for over 20 years – I understand all too well why insurance and health care companies run the other way when they see me coming. As a cancer survivor, I am a big, fat financial liability waiting to happen.  I also know that there are ways I can “sneak” into the U.S. health care system by getting a job with an employer with an insurance plan or otherwise getting into a group plan and hoping that preexisting conditions do not trip me up sometime in the future.  But then again, I know those insurance underwriters are smart and vigilant (that is what they are paid to do); they are continually finding ways to exclude the high risk patients from their insured population. And even if I do get into an insurance plan, I would imagine the fine print of the policy would find a way to exclude me if I became a major liability.  So, is this really any way to live my life?  Is this really any way for anyone to live their life?  Is this any way to run the greatest country in the world?

So for now, I will remain here in the UK. I know the UK is not perfect, and it has its own health care issues. But I know one thing is certain – if I show up at the hospital in the UK diagnosed with cancer again, I will be treated, and I will not be financially ruined.  The peace of mind this gives me is more than enough reason for me to stay here in the UK until we solve our little health care problem in America.

As I said at the beginning, my little problem is really an American problem.  The real problem is that millions of other Americans who have similar or worse tales of woe and do not have a solution.  They come in all shapes and sizes. Someone gets ill and then loses his or her job and health insurance coverage, and someone’s illness is excluded from insurance because of the fine print in the policy, for example because of preexisting conditions that were either conveniently or inconveniently forgotten at the beginning of a policy. The circumstances are wide and varied.   Far too many people in America live in fear or ignorance of a health care event which can be catastrophic to themselves and their family.  The free market system of American health care has developed in to a multi-headed hydra which is designed more for making profits than for caring for the sick – or even keeping people from getting sick in the first place.

I am passionate about helping fix the problem.  I offer my services to you as cancer survivor, as an experienced financial executive, and as an American who wants to make the country a better place in which to live.  I will consider any role in your administration (or indeed anywhere in the U.S.) which will put me in a position to help fix health care in America.  I want to come home and help, but the irony is that I can’t come home until I get my health insurance sorted.

My compensation for providing such services is simple.  My compensation will be to once again live in a country where if I (or anyone) am diagnosed with cancer (or any major disease), I will be treated and I will not be financially ruined.  The peace of mind that comes with this end result will be more than enough reward for any service that I can provide.

Thank you for your consideration.

I remain a U.S. citizen, proud of America, and missing my home.

Warren McInteer

Glasgow

United Kingdom

P.S. I have written also written a two part series for Demockracy.com on the subject that goes into more detail regarding the problems and solutions of U.S. health care.  If you are so inclined, please look at these pieces and let us begin the work to fix American health care:

Health Care in America: A Time for Change

Health Care in America: A Way Forward

Health Care in America: A Way Forward

As previously stated, the purpose of this two part series is to set forth my views on changing health care delivery in America to make it more efficient, more effective, and, most importantly, more compassionate.

In Part 1 of this series, Health Care in America: A Time for Change, I laid out my personal experiences that led me to write this series and outlined the problem. In Part 2 of this series, I will explore ways of making health care better for all citizens of the US, starting with the concept of triage.

TRIAGE – WHERE IS HAWKEYE WHEN YOU NEED HIM

In the old sitcom, MASH, Hawkeye Pierce would perform triage for his MASH unit. His job in triage was to separate the injured into three groups:

1. Those who needed care immediately to deal with a life threatening or a rapidly deteriorating situation.

2. Those who needed care, but who could wait for a time period with little or no effect on the patients’ wellbeing.

3. Those who could not be helped by health care (either they were not sick or they were so badly injured and sick that normal health care procedures could improve the situation).

Hawkeye heroically performed triage for the MASH unit, and by doing so, used the unit’s limited resources for maximum effect. And why was he a hero? Because he made tough decisions about prioritizing the needs of patients based on triage. The system was not perfect, but decisions were made, and the doctors got on with the job of caring for the sick and wounded. And through appropriate triage, care was provided most efficiently given the limited resources at hand.

In the UK, this triage function is essentially how the national health care system works. Resources are indeed limited in the UK within the NHS, and everyone knows it. Indeed, this obvious limitation of resources does cause issues (e.g., waiting lists). However, it also forces the people and the doctors in the system to focus on what is important; it forces the doctors to make the tough decisions necessary to give care to those that are in most need. The classic triage function is returned, not to insurance companies, lawyers, or accountants, but rather to medical professionals. Indeed, this is what doctors are paid to do – not just provide care, but to provide care to the sick with recognition of the limitations of resources. They are not just health care technicians, but they also perform a much more important role – TRIAGE.

Indeed, in the case of my son’s broken arm and my cancer treatment, the triage system worked just as it is supposed to work. In both of these situations, the doctors recognized a problem that needed to be addressed quickly, and even though their resources were limited, we were cared for quickly and efficiently with the resources at hand.

In America, this triage system has been distorted by the market system – a market system which has less to do with medical priorities than it does with economics, litigation, and profit. The market system ensures that the ones with the most money get the best health care in a timely fashion. The ones without money get what they can get. The market system also ensures that those with access to lawyers will receive health care, often unnecessary health care. Large sums of money in America are spent on defensive health care, where diagnostic procedures or tests are performed for the sole purpose of defending against potential lawsuits. Finally, the market system, through the prospective payment system, ensures that many wasteful procedures, tests, and office visits will occur, not necessarily for the benefit of the patient, but for the benefit of the provider who will earn more money by performing more procedures and tests.

The table below is a simple demonstration of the inefficiencies of the US health care system

Country	$ Spent Per Capita on Health Care(USD)	Health Care as % of GDP	CT Units per 1 million persons	MRI Units per 1 million persons	Infant Mortality per 1,000 births	Life Expectancy (years)
USA	6,347	15.2	33.9	26.5	6.9	77.8
Canada	3,460	9.9	12.0	6.2	5.4	80.4
Denmark	3,179	9.5	15.8	10.2	4.4	78.3
France	3,306	11.1	10.0	5.3	3.8	80.2
Netherlands	3,156	9.5	8.2	6.6	4.9	79.4
Spain	2,260	8.3	13.9	8.8	3.8	80.4
UK	2,580	8.2	7.6	5.6	5.1	79.4

Source: OECD Health Data 2005

The first two columns of the table show how the US spends approximately twice as much on health care as comparable Western countries. The third and fourth columns are an indication on how that money is spent. The money is spent on fancy machines and diagnostic tools (CT and MRI); these columns show the US usage of MRIs is 3-6 times higher than other countries in Europe. Although these types of tests are a useful tool in diagnosing certain diseases, there use in the USA is certainly out of proportion when compared to other countries. Indeed, I believe the high use of such technology is not driven by patient need, but rather by profit motivation and the fear of litigation.

Finally, the last two columns show that for all the money spent and the technological advances (such as MRI and CT), the US lags behind other countries when it comes to two objective measurements of health care – infant mortality and life expectancy.

In summary, the market system of US health care forces costs to rise and rise and rise again with no objective benefit to the population. These costs are driven by all the players in the system:

1. Lawyers – who through the threat of litigation lead many doctors to perform unnecessary and non-cost effective treatments.

2. Managers (motivated by profit) – who want to provide more care (as long as it is covered by insurance, Medicare or Medicaid programs) because more care leads to more procedures leads to more revenue, which in turn leads to more profits.

3. Insurance Companies (and HMOs) – who tend to provide more care (more coverage) and increase premiums incrementally across its insurance pool. This is especially true since the costs of increased premiums are often negotiated with employers, and the costs are invisible to the employee (the actual customer). Ultimately, more care means more revenue, which usually leads to more profits for the insurance company or the HMO.

4. Doctors – who (bless them) want to provide more care because that is what keeps their patients healthy; but we also must remember that sometimes, doctors also have a financial motivation whereby more health care and more procedures will lead to more money in their pocket. In addition, the current system gives no financial incentive for doctors to coordinate care with other providers.

These four players in the system are all motivated to provide more health care and more expensive health care. The system is fixed to continually increase because there is no one in the system who is manning the brakes!

THE WAY FORWARD

The solution to these issues is simple in theory and more complicated in practice. This solution is a return to triage. Provide health care to the ones who need it, when they need it. The solution, however, given the ensconced positions of each of the players, will not be a quick fix. The US health care system has evolved and been shaped by the market, culture, and technology for over 100 years. A miracle cure will not happen overnight; any new law or system will need to be assimilated into the culture and have its own evolutionary process. However, change needs to happen, and that change must address the incentives and motivations of each of the constituent parties (the doctors, the managers, the insurance companies, and the lawyers).

However, the strategy for health care reform is simple: a return to triage – this entails three steps.

1. Define the resources (set the budgets): At a regional (manageable) level (state, county, or city) define the budget and resources which are available to each entity in any given year. Money, operating rooms, MRIs, hospitals, and all of the other resources available and the cost thereof must be defined and budgeted.

2. Define the health care needs of the population being serviced: At a regional level (state, county, or city), an actuarial study will need to define the health care needs of that particular population; any population of 50,000 persons or so can be studied from an actuarial viewpoint, and a very good estimate of health care needs of that population can be developed.

3. Allow medical professionals to make resource decisions: Doctors and medical professionals then need to make medical decisions on how to use these resources to best service the population. This will be a hard job; there is no doubt about it. However, it is the essence of triage and what doctors should be trained to do and, indeed, what they are paid to do. A limited budget means that not everyone can get an MRI; not everyone can have the expensive course of drugs that has a marginal effect. These are difficult decisions which need to be made, but without a budget limitation, the decision will not be made. These medical professionals, who should be appointed to significant staggered terms to avoid political winds, will have the flexibility to spend money on programs that provide more bang for the buck. They, in effect, will perform triage for the American health care system.

Finally, three other political decisions need to be implemented to allow this strategy to work.

First, health care must be universal and include all citizens. There needs to be an acceptance and realization that we as a country will take care of the basic health care needs of our citizenry. Patient finances should not be the determining factor when providing basic health care. This in turn will make it much easier to define the population and the health care needs of that population (because it is everyone, except those who opt out for private health care). This will also eliminate the universal problems of gaps in coverage when one changes jobs, issues relating to pre-existing conditions, and other problems caused by a private insurance system.

Second, all citizens will be allowed to opt out to a private system. If a person wants to spend his or her money for a special medical procedure, medical “gap” insurance or whatever he thinks is appropriate, he can. It is envisaged that only the relatively wealthy will opt for this type of coverage, but anyone who wants to spend his money on more health care can do so. (This would be analogous to a private school system whereby parents can opt out of the public system at their choice for a fee.)

And finally, and perhaps most importantly, we need to greatly reduce the dollars which are spent on lawyers and procedures performed only to placate the lawyers. Through major tort reform, we need to stop paying the lawyers to police the system. We must eliminate large litigation payouts and thereby eliminate most of the defensive medicine that today is necessary simply to provide an appropriate defense for many doctors. Fair reparation should be paid in certain cases where mistakes are made. However, the multimillion dollar payouts, and more importantly from a cost standpoint, all the waste which comes from defensive medicine in response to such lawsuits need to be eliminated.

These of course are only strategy statements. Work, work, and more work must be accomplished before this strategy can become reality. As such, these are no more than first steps meant to start a dialogue. I welcome discussion and debate which can lead to developing an American health care system which can be the best, the most efficient, and the most compassionate in the world.

Health Care in America: A Time for Change

The purpose of this two part series is to set forth my views on changing health care delivery in America to make it more efficient, more effective, and, most importantly, more compassionate.

In Part 1 of this series, I will explore my personal experiences that led me to write this series and outline the problem. In Part 2, I will lay out my solutions for a way forward to solve the health care problem in America.

My credentials for my views come from both my personal and professional experience. I have 20 years of experience as a financial executive and CFO in the health care industry in America and Europe. As a CFO throughout my career, it was my job to create value (i.e., make profit) through the marketing and delivery of health care to the general population. This involved understanding the rules and complexities of both private and public health care systems from a financial viewpoint. In the later stages of that career, I have founded, owned, and managed health care companies in both the US and the UK and have experienced firsthand how the corporate world prospers in both market-based and government-supported systems. In addition, while living in both Europe and America during this time, I have experienced health care as a patient on both sides of the Atlantic.

In 2005, my health care experience became more personal when I was diagnosed with cancer while residing in the UK. I was treated for the disease in both the UK and the US and directly experienced how each of these countries dealt with the diagnosis, treatment, and aftercare of a person with a major health issue. As a patient with a major illness, I suddenly had a very different perspective on what constitutes best practice when it comes to delivering health care. After one year of treatment and three years of aftercare, I am now a cancer survivor and am on a mission to bring about affordable, efficient health care to all citizens of the US.

Overall, I believe that my 20 years of business/health care experience gives me the expertise to help make a difference in health care delivery in America. My experience as a cancer survivor in America and Europe makes me want to make a difference

My Vision or (How I Learned How to Stop Worrying and Embrace National Health Care)

First, let me state my bias; I believe the UK health care system is better than the US system in many ways:

1. It is more efficient than the US system in terms of costs per capita.

2. It provides better outcomes than the US system (based on measures such as life expectancy and infant mortality rates).

3. It is more compassionate than the US system because all citizens are cared for regardless of income or net worth.

4. It allows for rich people to “opt out” and go private.

What’s not to like – better, more compassionate care for less money, and the ability to pay more to get an even higher standard of service?

My vision for US health care is certainly affected by my experience with the National Health Service (NHS) in the UK and Europe. The UK health care system is far from perfect, and the purpose of this series is not to critique that system. I also know that individual anecdotes seldom tell the whole story. Nevertheless, my health care experiences in a foreign country are worth mentioning.

In 1999, soon after moving to the UK, my son, aged 7, fell and broke his arm. I rushed him to the emergency room and I was in a fair amount of anxiety, not just because of the injury, but because I did not know how the medical system worked. He was in obvious pain, and upon arriving, the attending nurse quickly gave my son some drugs for the pain. After a 30 minute wait, the doctor diagnosed a broken arm, an x-ray confirmed the diagnosis, and after about 2 hours, my son left the emergency room with a cast on his arm. Both he and I were tired, but relieved that everything was going to be OK. While at the ER, we did not fill out forms, and there was no mention of money or insurance. The only thing that appeared to matter was that my son was in pain and injured, and the doctors acted on his injury. A light bulb went off in my head – this might be a better way.

Five years later, while still living in the UK, I was diagnosed with tonsil cancer. Six months of intensive treatment followed including two surgeries, radiotherapy, and chemotherapy. Three years of follow-up care (still ongoing) continued afterward. Interestingly, in terms of health care administration, my bout with cancer exactly paralleled my son’s broken arm incident. There were no forms, mention of money, or insurance and what was covered and what was not. More importantly, there were no discussions of employment gaps or pre-existing conditions or how future insurance coverage would be affected. Instead, the only thing that appeared to matter was that I was ill, and the doctors acted on that illness. I imagine there was some administration and paperwork somewhere, but I didn’t see it. All I saw was a focus between doctor and patient regarding the care, well being, and options of the cancer patient – me.

The light bulb in my head was now a spotlight in my face. This had to be a better way.

The Problem – Health care in America.

American health care, as in many other facets of American life, can lay claim to being the best in the world. America arguably has the best doctors, the best equipment, the best medical schools, the best research and development, and the best hospitals in the world. Many US hospitals are known throughout the world as “The Place” to go to ensure the best health care possible. The Mayo Clinic and the Sloan Kettering Institute are two examples of organizations which lead the world in health care practices. However, from the standpoint of efficiency, effectiveness, and perhaps most importantly, compassion, the US system falls well short when compared to other countries.

For example, studies have shown that the US spends about twice the amount on health care per capita when compared to other Economic Developed Countries (EDCs). (These other EDCs generally use a socialized or government sponsored health care system.) More interestingly, of the total US expenditure, about half is actually spent by the government that generally foots a large portion of the bill for over 65’s (through Medicare) and the “non-wealthy” through the Medicaid system.  (I put non-wealthy in quotes, because nearly 40 percent of the uninsured population in the US reside in households that earn $50,000 or more, so this group is not the indigent poor.)   So, even though there is a popular opinion that the US primarily relies on private health care, the US government spends about the same as other developed countries on a minority of its population even before one factors in private expenditure.  The US already has a national health care system whether it knows it or not.

So the issue is not whether the US should or should not have a national health care system–the US already has one. The issue is how the US as a country can spend twice as much on health care as other similar countries, AND

1. Obtain medical outcomes (as measured by key health care statistics) that are no better and, indeed, worse than many other EDCs.

2. Have approximately 1/6^th of its population (approaching 50 million people) with no insurance or health care plan other than a trip to the nearest emergency room when trouble occurs. This segment of population lives either in ignorance or fear of the liabilities which could occur if their health takes a turn for the worse.

But let’s put these statistics aside and get to the real issue – the human issues of people who are sick and suffering from not only sickness or disease, but also from the anxiety caused from the personal financial repercussions of injury or illness. When you or a loved one is sick and unsure if you have the financial wherewithal to deal with the sickness, the financial/personal issues can become more important than the sickness itself.

So what is wrong with American Health care? One thing that is not wrong is money – as stated previously, twice as much is spent in America on health care when compared to other countries. So what IS wrong is that this money is being spent on the wrong things, and I will sum that problem up in one word - TRIAGE. I will explore this and much more in Part 2 of this series.