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
|$ 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)
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.