By Dr. David Bruton

Special to The Pilot

American health care is in big trouble for at least three reasons: - The way we pay for medical care is distorting clinical practice.

- We have a national disaster in medical manpower development, especially in primary care.

- Patients and their families are increasingly shut out of meaningful participation in their care.

Obviously, there are a myriad of other issues that we should discuss in any attempt to explain why health care in America costs too much and is failing to produce the outcomes we all desire. With unbridled audacity, this old retired pediatrician will also suggest some solutions we should try.

I want to make clear that today's physicians are much better educated and trained than my generation. At least half of what I learned in medical school 50 years ago is simply not true today! Medical practice is a wonderful profession that continues to develop new information and procedures to help patients. The problem is the system of delivery that we're all trapped in.

There is near-universal agreement that Americans collectively and individually are paying too much for health care. Double digit medical inflation for years has brought us to a state of decreased access to quality care, especially for low-income, uninsured patients.

Third-party payments, be they governmental or private insurance, pay for individual "units of activity": an office visit, a lab test or some procedure. We incentivize the system to perform and bill for an increasing number of "units of activity." Numerous studies have shown that a significant percentage of them are unnecessary, not appropriate, or bring about harmful results.

We must learn how to pay for the care of our patients with quality, cost-effective, patient-centered health care by moving away from payments for "units of activity" that may or may not contribute to their care.

Prevention and lifestyle changes take time, and they require resources that are underpaid in our "units of activity" payment system. Because we are humans, any system we develop must continue to have incentives for quality performance. There is too much work to be done to deny our health care system the effective tools of personal enterprise, reward and productivity.

America's medical manpower development has left us with a severe deficit of well-trained physicians, nurses and many other health care providers. It takes a long time and costs a lot of money to educate a physician; therefore, we must change our delivery system to use more effectively providers that cost less time and money to train and employ.

In general medical practice, physician assistants, nurse practitioners, nurses and aids can deliver basic primary care as well or better than the physician. The unsolved problem is safety and quality assurance. We also have that problem with physicians.

We must learn how to organize, manage and pay for caregiving teams. These teams must include our hospitals. Some of us for years have worked on integration in the medical community. Training physicians has become so expensive that new physicians must adapt to the payment system to pay off their education loans.

Last month, I interviewed a brilliant young woman for a slot in the UNC Preventive Medicine Residency. She has a $230,000 student debt. The average is now about $180,000.

Again, our payment system makes patient-centered clinical practice and integration difficult. We all have our little monopolies that we seek to protect. It will require a change of behavior for all concerned, including patients, to overcome this problem.

One of the major failings of our system is the appalling lack of effective use of 20th century information management technology in clinical practice.

Interconnected computers and IT systems are bringing great productivity gains to virtually every other enterprise. We have not learned how to bring to bear in clinical medicine modern information technology to organize, manage, deliver and accurately measure clinical outcomes. All of the software already exists. We just need to connect it and use it.

The bottom line is: We have a shortage of physicians, and it takes time and money to create new ones. We all must learn how to use them more effectively. Reliable research has documented several doable options.

Patient Involvement

Patients and their families are increasingly less involved in real decisions affecting their care and/or understanding of their diagnosis and treatment options. The gap of knowledge and language between physicians and patients contributes to this lack of understanding.

There are a number of factors that play into this. Our payment system encourages more "units of activity." Time and ancillary resources are limited. Thus the brief and incomplete patient-provider direct effective interface.

Our public schools have not kept pace with the rapidly changing understanding of math, science and biology. Thus we have a population that requires more time and additional education to understand and participate effectively in their medical care. Health literacy is a big problem in America.

Another driver of increased health care cost is our system for managing medical malpractice claims. A number of incidents of unfavorable outcomes, accidents and negligence are inevitable in medical care.

Some believe that fear of a malpractice claim, should there be a bad outcome, drives a number of extra tests and procedures so the physician will have them available for defense against a liability claim. I do not think this is often the case in the decision to order a test or procedure. It has simply become the usual way we practice medicine today.

My long service on the board of directors of a medical liability insurance company has taught me: It is not bad outcomes that cause a medical malpractice suit. It takes a bad outcome and patient-physician communications breakdown. Patients and physicians simply do not understand the claim incident in the same way.

Our insurance company spends a lot of money and energy trying to identify and correct destructive physician behavior and trying to improve our tort system. Society needs to spend some energy on health literacy and trust issues. Our defense cost managing claims is about equal our indemnity pay outs. The lack of direct involvement by many patients in the payment for their health services denies us one of the most powerful tools for control cost.

I think it was a Shakespearean character who said, "First kill the lawyers." In health care cost containment, it should be, "First kill the third-party payers."

Insurance is exactly the wrong way to pay for routine health care. Insurance is a system where premium payers pool their premiums to pay for an infrequent significant loss.

I have insurance in case my house burns down. I do not have insurance to mow the grass. We use health insurance to pay to mow the grass.

We lose 15 to 20 percent of our health care dollars just moving the money through the insurance system from patient to provider. We all need to have some "skin in the game."

Obviously, our Moore Free Care Clinic (MFCC) exists because our current health care system denies effective access to low-income uninsured people. But MFCC is a niche player. Our physicians and hospital provide an enormous amount of uncompensated care. The continuing Medicaid and Medicare cuts are making this problem worse.

Personal Responsibility

We, the American people, must become involved in health care reform. All of us must accept personal responsibility for our health and collectively aid our fellow Americans who are currently priced out of quality, patient-centered, cost-effective health care.

For every complex problem, there is a simple solution - and it is wrong. I apologize for the bumper-sticker nature of this conversation. Health care in America is excellent for patients with full access. We must learn how to provide cost-effective health care to all Americans regardless of age or economic status at a time when our national and individual debt is at a historic high.

Solving the health care cost problem would go a good way toward solving our national solvency problem. It has been said, "It takes a village to raise a child." It will require community to reform health care.

My belief is we can accomplish that task with the information and data available, if all of us would get involved, take personal responsibility for our health, and be a little less selfish.

H. David Bruton, M.D., is a retired pediatrician. A former member of the Moore County Board of education, he served during the 1970s as chairman of the N.C. State Board of Education. From 1997 to 2001, he was secretary of the N.C. Department of Health and Human Services. He is the founding chairman and board member of the Moore Free Care Clinic.