Rx for Success: What True Health-Care Reform Requires
The author is a cardiologist with Pinehurst Cardiology Consultants and FirstHealth/ Moore Regional Hospital. This is the second of two locally written opinion pieces on the health-care reform debate. The first, by Charles T. Frock, appeared in this space last Sunday.
How do you know if you are receiving the right medication for your condition? How do you know if a procedure your practitioner has recommended is necessary?
If you are like many Americans, you have access to well-trained and caring doctors, physician assistants, and nurse practitioners who will correctly diagnose and treat you in accordance with the current standard of care. But where does their information come from?
Even though billions of dollars are spent on drugs and drug research each year, not much is known about their effectiveness for many of the people who take them. The same is true for many widely available and often-performed procedures.
In an era when health-care costs are spiraling out of control, it is important to know that an expensive treatment is worth it -- that it delivers a better outcome than one that is less costly and possibly less risky.
The goal of health care is to provide all the following elements: the right care to the right patient at the right time in the right setting in the most cost-effective and caring manner possible every time. As it currently stands, this remains a goal -- and not what happens in the real world.
Providers recommend many medications based on studies showing their effectiveness for a particular condition -- but these studies are often funded by the drug companies motivated to sell their product. This in and of itself is not necessarily wrong, but it does create an appearance of impropriety and real potential for conflict of interest.
Even more troubling may be the fact that if a company sponsors a trial and does not like the results, it has the power to prevent release of the findings -- and can restrict any researchers involved from ever revealing those results.
As we look at ways to improve our health-care delivery system, it is clear that physicians and other providers need better information to make informed decisions about what treatment is best for what patient. Even in the most respected studies, a large percentage of screened patients, for a variety of reasons, are excluded from participating. Ironically, the results of those studies are then used to treat those very same patients.
While it is a tenet of modern medicine that nothing should interfere with the doctor-patient relationship, this relationship should be based on an understanding that the doctor has the best information on which to make a sound recommendation.
The health-care industry needs incentives to change the status quo. As things stand now, providers of medical services (including doctors, hospitals, drug companies and device manufacturers) have no economic reason to want to change the system: If a treatment is shown to be ineffective or a less costly one will work just as well, income to these groups could be reduced.
Our current system rewards volume: Payment is made for seeing a large number of patients or doing a high volume of procedures (whether they are necessary or not). Whether a patient actually gets benefit from the treatment doesn't enter into the payment equation. It is a system collapsing under its own weight.
We must align payments for health-care services, with the creation of value for both the patient and the society that ultimately pays for the services. Rewarding volume and not value is a constant source of frustration for all who are dedicated to providing the highest quality of patient care.
An unbiased third party collecting and analyzing data, then turning that data into useful information for providers, can effect needed change. Insurance companies have tried to do this, but their data is limited to their own beneficiaries, and they have a clear potential for bias in any conclusions they reach.
While government agencies can be dysfunctional and cumbersome, this undertaking can -- if developed, supported, and overseen correctly -- be properly performed on a federal level. This doesn't mean the government takes over health care -- it simply provides accurate information to allow all involved parties to make wise choices.
We already have such a system in place in the financial world: The federal government collects, analyzes and disseminates data (such as unemployment and inflation rates and the Consumer Price Index) that has become integral information for many businesses.
Comparative effectiveness research is the study of two or more treatment options for a given condition to find out which one is most clinically effective: which one works best. Once that has been determined, a second element comes into play: cost.
This is important -- not to prevent patients from receiving needed services, but rather to determine in a society with limited resources (as all societies are) where a dollar put into the public pool will do the most good. It makes no sense for us to continue to pay for treatments that are costly, risky and might not work.
Real Costs Are Hidden
Currently being contemplated by lawmakers in Washington is the creation of a comparative effectiveness research center that would provide impartial, reliable, publicly available information on the probable clinical outcome of various treatments for given medical conditions. This center would not make coverage or reimbursement decisions -- it would only provide the information necessary for the private sector to do so.
While funding such an ambitious project may be formidable, not doing so perpetuates the unconscionable waste of time, money and lives seen in our current system. This investment now will reap benefits well into the future -- and the cost savings from providing an increased quality of care will offset much of the upfront cost.
There is concern that health-care reform means that there will be less choice if there is involvement of the federal government, or that there will be rationing. How honest is the choice we currently have when, for many conditions, neither providers nor patients have a true understanding of what works and what doesn't, and what the real costs of their decisions are?
Is it rationing to decline to pay for treatments that don't work or can be performed just as effectively at less cost and possibly less risk? Effective health-care reform will lead not to rationing of care but to rational care.
Privilege or Right?
One of the fundamental issues that must be decided before restructuring any reform is whether health care is a privilege or a right. Those who believe it is a privilege and should be extended only to individuals able to obtain insurance coverage must take into account that ours is not a closed system. The emergency room is open to any individual seeking care, and that care needs to be paid for.
Similarly, if uninsured patients do not get preventive care (such as neonatal care) or care they need for chronic conditions such as diabetes, it will cost everyone more in the long run.
Proponents of a system that will extend the right of health-care coverage to everyone must address the upfront cost of such an undertaking: While this approach will likely yield long-term results (due to less future utilization with better preventive care now), it will be costly to implement. And even if the most efficient system is implemented, that efficiency alone may not cover the cost of caring for everyone in the U.S.
Ultimately, we all must recognize that a system that provides every service to every person who wants it, whether it is truly needed or not, is unsustainable.
Also left out of the discussion of many debating health-care reform is the role patients must play in developing and maintaining healthy lifestyles. A reformed system should not provide endless health-care benefits to people who continually overuse medical resources because of their unhealthy choices.
We Can Lead the World
One model currently under consideration envisions providing a basic health-care benefits package to all U.S. residents -- something that would cover the vast majority of currently available services, from primary care to open-heart surgery.
Individuals could then purchase, with after-tax dollars, additional insurance that would cover more exceptional care that is not routine -- such as newly developed but not yet generally accepted treatments for diseases that would have a low chance of success but potentially cost hundreds of thousands of dollars.
Such a system would allow all residents access to high-quality care provided through plans that would, through competition, promote innovation, clinical effectiveness and cost effectiveness.
Comparative effectiveness research would have a major role here and would make such a system much more affordable.
Reforming health care clearly will not be an easy task. Our goal should be to meet the objectives outlined by the Institute of Medicine in 2002: to have a system that provides care that is effective (achieves the desired result), safe (does no harm to anyone), timely (done at the right time), efficient (delivered with minimal waste -- both in human capital and physical as well as financial resources), patient-centered (takes into account the needs of patients as individuals) and equitable (does not discriminate against any patient).
To do this, there will have to be a change in expectations on the part of all involved -- including patients. Inaction will lead to continued economic decline (at 16 percent of GDP and climbing unnecessary health-care costs are a burden we can no longer bear) and ultimately decreased life expectancy and quality of life for many Americans.
Health-care reform done correctly will allow the U.S. to be a worldwide leader in providing health for its citizens. We can, and must, create a system we can be proud of for generations to come.
Dr. Peter Duffy is a cardiologist with Pinehurst Cardiology Consultants and FirstHealth/Moore Regional Hospital. He is board-certified to practice internal medicine, cardiovascular disease, and interventional cardiology.
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