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ACP Responds
Achieving a High-Performance Health Care System : Malpractice
Single negotiating table a good idea
What the United States can learn from other countries involves more than health
Need to include medical accountablity in solutions
The MHS and TRICARE are other models that the American College of Physicians should consider
Intitute of Medicine's 1999 report misused by medicine'critics
Re: Re: Two ships passing in the night...
High-Performance Health Care
Malpractice system a prime mover of high medical costs
Re: Two ships passing in the night...
THIS IS THE HEALTH CARE CRISIS
Great job, some comments
Physicians Have Responsibilities Also
Two ships passing in the night...
In Response
Achieving a High-Performance Health Care System with Universal Access: What the United States Can Le
Unsupported conclusions unworthy of an organization of clinician-scientists
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Jack A. Ginsburg;, MPE American College of Physicians, Robert B. Doherty; J. Fred Ralston, MD, FACP
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jginsburg{at}acponline.org Jack A. Ginsburg;, et al.
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Each of the letter writers raises important points that should be considered by public policymakers for achieving universal health insurance coverage. ACP identified two pathways for consideration: a single-payer model or a pluralistic model with legal guarantees for coverage and subsidies for those who cannot afford coverage. ACP did not recommend one pathway over the other. The paper noted the advantages and disadvantages of each approach. It examined the U.S. health care system and those of twelve other countries, determined lessons that could be learned and recommendations for consideration for ensuring that all people in the United States have equitable access to appropriate health care without unreasonable financial barriers. Although we can learn much from other health systems, ACP recognizes that our political and social culture, demographics, and form of government will shape any solution for the United States. Overhauling a health care system will be an extremely complicated matter and should involve a thorough examination of not only the many issues raised in this ACP paper, but also other issues that although important, would require separate in-depth study. Several of the ideas presented by the letter-writers have been addressed in earlier ACP position papers. Dr. Cavale and Dr. Leff raise the issue of malpractice insurance and fear of litigation, which we did not address because differences among legal systems make it extremely difficult to develop meaningful cross- national comparisons. ACP supports further research and analysis of the impact of the U.S. tort system, as well as alternative models in other health systems. Likewise, comprehensive study is needed concerning the widely differing pharmaceutical costs among countries and the impact on health care systems of differences in the organization and financing of medical education and training. Drs. Cruess raise another issue to be explored if the U.S. were to follow the pathway for a single-payer system. A structure would be needed for negotiating physician payments. As they correctly point out, there currently is no legal structure in the U.S. for collective bargaining on behalf of self-employed physicians. ACP has recommended legal reforms to allow physicians to bargain collectively with payers but the College has also cautioned that physicians may not ethically strike or withhold services from patients. ACP agrees with Dr. James that physicians need to be accountable. The Patient-Centered Medical Home is one model for improving quality and efficiency that would require that qualified practices report regularly and in a transparent manner on measures of quality, efficiency and patient satisfaction. More detailed ACP recommendations are in separate position papers on linking physician payment to quality and shifting incentives away from volume-based rewards towards ones that create incentives for care coordination, prevention, and improvements in quality. More must be done, however, to improve accountability among all who are involved in patient care. Dr. Zarren raises the issues of lack of adequate time for physicians to see and treat patients. This topic also was discussed at length in another ACP position paper. We limited our study to analysis of the U.S. health care system and systems in 12 other industrialized countries that are representative of different approaches to achieving universal coverage. We did not include the Military Healthcare System’s TRICARE plan, which has a unique mission in providing care to military personnel and their families, but. we agree that there is much to learn from the TRICARE plan. The paper that appeared in Annals was an abridged version of the full position paper approved by the ACP Board of Regents on Oct. 27, 2007. The full text is available at http://www.acponline.org/advocacy/?hp Jack A. Ginsburg, MPE Robert B. Doherty J. Fred Ralston, MD, FACP REFERENCES 1. Ginsburg JA, ACP Health and Public Policy Committee, ACP Ethics and Human Rights Committee, et al. Physicians and Joint Negotiations. Annals of Int Med. 2001:134:787-92. 2. American College of Physicians Linking Physician Payments to Quality Care, 2005. Accessible at http://www.acponline.org/advocacy/where_we_stand/policy/link_pay.pdf 3. American College of Physicians. Reform of the Dysfunctional Healthcare Payment and Delivery System. 2006. Accessible at http://www.acponline.org/advocacy/where_we_stand/policy/dysfunctional_payment.pdf 4. American College of Physicians. Ethics and Time, Time Perception, and the Patient-Physician Relationship, 2005. Accessible at http://www.acponline.org/running_practice/ethics/issues/policy/ethics_timeplace.pdf. Also Braddock CH, Snyder S. The Doctor Will See You Shortly. The Ethical Significance of Time for the Patient-Physician Relationship. Jrnl of Genl Int Med. 2005;20(11):1057–1062 Conflict of Interest:None declared |
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Marcus Bassett, M.D. Stormont Vail HealthCare
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mbassett2{at}cox.net Marcus Bassett
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To the Editor: The position paper by the American College of Physicians is insightful and clearly outlines what should be new goals for the United States health care system.(1) Medical malpractice is an additional factor that must be addressed to achieve these goals. Our current system of compensating patients for injuries sustained from medical care is far too costly to incorporate into a system of universal health coverage. The countries cited as having universal health care coverage have vastly different methods of compensating patients for medical injuries.(2) Our current system of compensating patients is not compatible with universal health care for two major reasons. First, the cost of medical malpractice insurance is extremely high compared to other countries.(3) Second, the cost of “defensive medicine,” although difficult to quantify, clearly costs American health care consumers dearly without contributing to better outcomes.(4) As an Emergency Physician I have first hand knowledge of the toll defensive medicine exacts on the American public and consumers of health care in the US. Our malpractice system does a very poor job of compensating those who are injured. There is strong evidence that very few patients in the US who sustain injuries are ever compensated, and those who are receive a miniscule amount of what health care providers pay for malpractice premiums. (5,6) Reforming medical malpractice in the US is a misnomer because what is needed is a different system of identifying and compensating patients with medical injuries. There are systems for compensating these patients that have been effective in other countries. To accomplish universal health care in the US without changing our medical malpractice system is an impossible dream. Marcus Bassett M.D. Department of Emergency Medicine Stormont-Vail HealthCare Topeka, Kansas 1. American College of Physicians. Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries. Annals of Internal Medicine. 2008; 148 (1) : 55-75 2. The Organization for Economic Cooperation and Development. Policy Issues in Insurance. Medical Malpractice. Prevention, Insurance and Coverage Options. No. 11 2006. 3. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Confronting the new healthcare crisis: improving health care quality and lowering costs by fixing our liability system. Washington, D.C. July 24, 2002 4. Studdert D, Mello M, Sage W, DesRoches C, Peugh J, Zapert K, Brennan T. Defensive Medicine Among High-Risk Specialist Physicians in a Volatile Malpractice Environment. JAMA. 2005;293: 2609-2617. 5 Brennan T, Sox C, Burstin H, Relation between Negligent Adverse Events and the Outcomes of Medical-Malpractice Litigation. NEJM. 1996; 335 (26): 1963-1967. 6. Ransom S, Dombrowski S, Shephard R, Leonardi M. The economic cost of the medical-legal tort system .American Journal of Obstetrics & Gynecology. 1996; 174 (6): 1903-1909 Conflict of Interest:None declared |
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Edward J. Volpintesta, md
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evolpintesta{at}snet.net Edward J. Volpintesta
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March 2, 2008 Annals Internal Medicine (Rapid Response) to “What the United States can learn from other countries involves more than health” Creuss and Creuss, Feb. 25, 2008. Having a single negotiating table for physicians and payers makes good sense. Regrettably, there are too many regulatory agencies including, HMOs, Medicare, Medicaid, hospitals that physicians have to deal with. Not only does this diminish physicians’ peace of mind it also diminishes any solidarity which they would like to achieve. As the authors pointed out accurately, most physicians’ allegiance is with their specialty organizations, each of which has its own agenda for its members, which may conflict with other specialty societies; when their representatives speak with legislators or other policy makers, the result is not a coherent unified voice but a cacophony of diverse interests and concerns that makes progress for the profession difficult. Also, without a single negotiating venue it is easy for lawmakers to pass the buck somewhere else. The result is a health system for which no one has responsibility, exposing it to exploitation by health insurers, since they control the purse strings. Conflict of Interest:None declared |
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Richard L. Cruess, MD McGill University, Sylvia R. Cruess MD
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richard.cruess{at}mcgill.ca Richard L. Cruess, et al.
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When comparing the state of health care in the United States with that found in countries with national health plans the lessons learned about health outcomes and health economics predominate. With no national health plan and an emphasis on market forces, the U.S. is unprepared for one of the features of national health plans: negotiations between government and physicians. A national health program alters the relationship between society and the medical profession by requiring a negotiating table around which individuals or organizations representing both physicians and society will sit and hammer out the terms of medical practice. In the United Kingdom, which has a highly centralized system, representatives of the ministry of health sit at the table with the British Medical Association, a union to which 80% of practicing physicians belong, representing the medical profession. In Canada--where constitutional responsibility for health rests with the provinces—each province has its negotiating table, although the federal government continues to play a significant role. Provincial ministers of health represent society, and the provincial medical associations negotiate on behalf of the medical profession. The provincial medical associations function as unions or quasi-unions, with all practicing physicians paying dues. The majority of issues, including working conditions and the amount and method of remuneration are negotiated at the provincial level. The Federal government, through the Canada Health Act, attempts to ensure reasonable uniformity throughout the country by imposing the conditions qualify\that the provincial programs must meet in order to be eligible for federal funding. While many stakeholders have an interest, the negotiations affecting the medical profession are primarily between the federal ministry of health and the Canadian Medical Association, to which 60% of physicians belong. This situation contrasts with the United States. As pointed out by Stevens, the U.S. lacks “concentration of responsibility for universal health insurance at national, state, or local levels, and no single government agency responsible for delegating formal power to medical organizations in relation to organized payment and service systems.”(1) With no national health program, the U.S. has not needed a negotiating table or a series of regional tables. It has not needed to decide which of the various professional organizations should represent the profession. Historically the American Medical Association has fulfilled this function and has the structure to support the role. However, the small percentage of practicing physicians who belong to the AMA weakens its claim to represent the profession. The primary allegiance of most practitioners is to their specialty or subspecialty associations who also try to represent their members’ interests to legislators and regulators. In the U.S., medicine speaks with many voices at a time when there are common issues of concern to every practicing physician. We do not claim that the system of negotiations in the United Kingdom or Canada is ideal. Physicians often do not agree with those negotiating on their behalf, the negotiations are generally asymmetrical with governments enjoying much stronger bargaining positions, and physician discontent is certainly present. However, everyone knows where the negotiations take place, who are the involved parties, and what is on the agenda. The profession itself has had to develop processes for deciding its position on a variety of issues which stand at the interface of the profession and society. One can speculate that both medicine and society in the United States have suffered from the lack of a proper forum for discussing these issues. If the U.S. develops a national health program, it will have to create a negotiating table or a series of regional tables. More than dollars and cents will be on the agenda: equity, social justice, physician autonomy, and much more. Important aspects of the social contract between medicine and society will be renegotiated. If the U.S. moves forward, medicine should clarify who represents it and develop some means of arriving at a consensus on the very fundamental issues that it will soon face. Here, as in so many other areas, the U.S. can learn from examining health care systems in other countries. 1. Stevens, R. Public roles for the medical profession in the United States: beyond theories of decline and fall. Milbank Quarterly, 2001; 79: 327-353. Conflict of Interest:None declared |
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Thomas James, MD Humana Inc.
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tjamesiii{at}aol.com Thomas James
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To the Editor: The Jan. 1st issue of the Annals of Internal Medicine contained an insightful Position Paper, Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries. (1.) I think the factual information and most of the recommendations were right on the mark. My only concern with the position paper is the absence of discussion of physician accountability in the discussion of controlling health care costs (page 67). The recommendations to "create incentive to encourage patients to be prudent" will require changes in current insurance regulations; but is an absolute necessity. But as that was the only recommendation in the section on cost control, it appears to be a one-sided solution. Patients certainly may create demand, but physicians through their actions are a major driver of health care costs. We are the ones who write the orders, prescribe the drugs, and recommend the therapies. At the recent meeting of the National Quality Forum’s National Priorities Partnership, the word "accountability" was frequently used by a number of the organizations represented. I would suggest that as physician organizations we must assume that as our responsibility. It was the failure of physician accountability that drove payers to adopt utilization management oversight. That created situations where external groups made coverage decisions that sometimes had negative health consequences. We certainly don't want to return to the days of capitation with the small practice bearing the risk. The American College of Physicians can make positive recommendations toward the development of accountability. The first opportunity is through a model described in the Position Paper of the patient centered medical home. However the concept of “accountability” is never addressed. I would suggest that the ACP include "accountability" as an attribute of the medical home that can help further garner its support among employers The ACP could also look toward the development of voluntary review boards that could work with private and governmental payers at local levels to analyze data and provide peer-level counseling or recommendations. A recent editorial in the Annals of Internal Medicine made a comparison of the state of medicine to that of the medieval guilds (2.) I would also make the comparison to labor unions at the height of their power. They had the ability to ensure consistent quality of workmanship and productivity of their members in exchange for their collective bargaining power. That gave the unions the ability to gain benefits for their members. Only when the quality of work fell and costs exceeded what could be obtained elsewhere the power of the unions abated. The ACP holds an advantage being the second largest physician organization in the country. The ACP has an academic tradition and a political influence that make it a leader. But it may appear self-serving to those outside of medicine if a very thoughtful position paper fails to include a physician solutions when it recommends changes by patients, payers, and employers. As a profession we need to work collectively to reduce the waste and inefficiencies; otherwise the pressures will continue to occur outside the profession. Thomas James III MD Louisville, Kentucky References: 1.) Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries. American College of Physicians. Ann. Intern. Med 2008 Jan 1:148(1):55-75. 2.) Sox HC: Medical professionalism and the parable of the craft guilds. Ann. Intern. Med 2007 Dec 4:147(11):809-10. Conflict of Interest:Employed by Humana, Inc. |
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S. Ward Casscells, MD Assistant Secretary of Defense (Health Affairs), Elder Granger, Major General, MC, USA, Deputy Director, TRICARE Management Activity
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Thomas.williams{at}tma.osd.mil S. Ward Casscells, et al.
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Dear Editor: The recent position paper, “Achieving a high-performance health care system with universal access: what the United States can learn from other countries” (Ann Intern Med. 2008 Jan 1;148 (1): 55-75), by the American College of Physicians drew a number of lessons from international health care systems and the Veterans Administration, and established several recommendations. In pointing out success stories, the article overlooked one of the largest health care systems in the United States, which covers greater than 9 million men, women, and children, the Department of Defense’s Military Healthcare System (MHS) TRICARE health plan. The MHS is vigorously addressing the problems identified in caring for wounded warriors at Walter Reed Army Medical Center and across the system. Looking beyond those challenges, observers will find a large and complex health care program worthy of further examination. The MHS is an integrated system of care that covers the health care needs of a diverse population of all ages, including children and dependents of Active Duty Service Members. No person within the MHS is denied coverage due to preexisting conditions. In fact, the military provides health care services that many Service members and dependents never had access to before enlistment because they were uninsured, underinsured, or lived in rural areas with few providers. For many, the MHS fills a gap in the fragmented U.S. health care system. TRICARE offers multiple insurance options ranging from a comprehensive, low and no fee HMO-type plan to a traditional, more expensive fee-for service plan. TRICARE and the MHS currently meet several ACP recommendations: 1 (universal coverage), 3 (cost savings), 5 (no financial barriers), 6 (personal responsibility), 10 (performance), and 11 (electronic records). These items have been implemented or expanded during the past decade as the number of beneficiaries and the budget required to support them has grown in support of current armed conflicts. The mission of military medicine goes beyond what is expected of most health systems: our Service members must maintain excellent health to reduce death, injuries and disease during and after military operations. To be successful and achieve excellence, the MHS must care for Service members and their families while also efficiently managing DoD health care costs. As evidence of successfully meeting our mission, a recent study conducted by RTI International showed TRICARE Prime, our HMO insurance plan, outperforming the overall U.S. population (insured and uninsured) on six clinical preventive measures (Morbidity, mortality, and use of preventive measures among Prime beneficiaries of the Military Health System compared to national and international populations; final report, RTI International, 2007). We continue to search for ways to improve the quality of our care and to strengthen the health of the nation’s military families. To accomplish this, we will continue to review the ACP recommendations as well our internal strategic plans. Sincerely, S. Ward Casscells, MD Assistant Secretary of Defense (Health Affairs) Elder Granger Major General, MC, USA Deputy Director TRICARE Management Activity Conflict of Interest:None declared |
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Edward J. Volpintesta, MD none
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evolpintesta{at}snet.net Edward J. Volpintesta
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This position paper mentioned the Institute of Medicine’s influential report, To Err is Human: Building a Safer Health System published in 1999. The report declared that between 44,000 and 96,000 deaths occurred yearly in hospitals because of medical errors. As well –intentioned as the report may have been, this particular fact was used against medicine by its critics. Some malpractice lawyers used it to defend their actions, and policy makers used it to further regulate medical practice. nfortunately the good that doctors do every day was overshadowed by the implications of the hospital death rate due to error. Worse, when the statistic was mentioned in the media, only the high end of the range was used stating that 98,000 deaths occurred yearly because of ignorance. This is an example of how statistics are misused and what medicine is up against when facing its critics. One wonders why the leadership of the Institute of Medicine did not make a public statement controverting the misleading conclusions to be drawn from the way their statistics were being misused. There is danger that medical organizations including boards of health, hospital staffs, and certifying boards may have responded to the Institute of Medicine’s report by increasing sanctions against hospitals, revoking of physicians’ licenses, and censures against them and anyone of many other possible reactions. Doctors are struggling to maintain their professional integrity while being pressured from all sides. The last thing they need is more regulations and more skepticism thrown their way. Why didn’t organized medicine pick up on the negative impact of the Institute of Medicine’s report and clarify this issue and the potential harm it carried? There is still time. Conflict of Interest:None declared |
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Samuel Chew, MB BCh BAO MRCP City Hospital, Birmingham, UK
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Samuel.Chew{at}swbh.nhs.uk Samuel Chew
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Thank you for your comments. I agree with your point that the patient demographics then is very much different as compared to now. However, patient demographics was not the reason that made the National Health Service a reality that continues to serve over 6o million people from birth till old age today. That, by any measure, is still a real achievement. Taking a step back, the NHS only came into being simply because the prior private-based health care system, supported by workhouses run by nuns and charity, did not meet the health care needs of the majority of the people. I would recommend the reading of the book "In place of fear" by Aneurin Bevan. In it, he detailed the many challenges that were faced in the efforts to create a health system that attended to all the needs of the people. You may not be surprised that he had a very hard time convincing the British Medical Association and all the British doctors back then that it was a good idea to even start with. Although we have more elderly patients with multiple health care needs, we are also spending a lot more money now, compared to when the NHS was first started, even after adjusting for inflation. In fact, Mr Bevan was expecting an overrun of the budget allocated to the health service in the first year as it had been predicted that everyone would make use of the free service immediately, whether they actually need to or not. Unexpectedly, the reverse happened. People only used the health service if they really needed to, hence leading to a surplus in the end of the first financial year for the NHS. Alas, this is definitely not the case now. They had also looked at a means-tested way of financing the NHS. However, the conclusion was that it would be an inefficient system as a lot of resources would be needed to administrate this system. Further more, it would also not be an all-inclusive system. I suspect the current American system would be affected by similar issues. Many more thoughts and challenges are detailed in the book and I will not elaborate any further here. Last but not least, I agree wholeheartedly with you that there is an urgent need in how we structure and deliver health care. Instead of the "One-pill or One-procedure for every ill" mentality, we need to focus on primary prevention and address simple but significant public health issues like obesity, smoking, alcoholism, etc. Unfortunately, this change of mindset is unlikely to happen anytime soon as the public would prefer to live with the illusion that we doctors can cure every ill and prescribe immortality with our great knowledge and technological advances. This belief frees the public to be reckless with their health and contribute tremendously to our consumerism societies on both sides of the Atlantic. What would happen to the myriad of fast food companies, soft-drink companies, alcoholic beverages companies, snack-food companies, tobacco companies, hydrogenated fat producers, etc, if suddenly, people made sensible decisions and stop literally "killing" themselves? Furthermore, chronic illnesses guarantee a constant stream of "customers" for private healthcare services, drug companies and doctors. Why would anyone in their right mind want to do anything to change this state of affairs and deprive ourselves of own livelihood? The answer is because chronic illnesses cause much suffering for our patients in addition to the burgeoning costs of care, despite our ever increasing ability to prolong this suffering. I see it everyday as a geriatrician. Unfortunately, the damage done is usually irreversible by this stage. If we as doctors really do care about our patients, then it is my opinion that that alone is enough reason for us to try to make a change for the better for the future now. Thank you. Conflict of Interest:None declared |
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Harvey S. Zarren, M.D. North Shore Medical Center, Tufts University school of Medicine, The Integrative Medicine Alliance,
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hzarren{at}cove.com Harvey S. Zarren
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Dear People, The single biggest issue in the quality of health care currently is the failure to provide adequate time for caregivers to spend with patients (and even with colleagues). Time for quality history assessment, good examinations and formulation of diagnosis and treatment plans is not being reimbursed adequately. Single-payer health insurance makes great sense and there must also be a shift in reimbursement away from testing and procedures towards adequate time for physicians and nurses to form the relationships with patients that are the essence of healing health care. The Pew-Fetzer Task Force Report in 1994 clearly articulated the need for healing relationships as the foundation for quality health care. Healing relationships require conscious focus on adequate time, not just on standards, rules and regulations. We must address the issue of time directly as a necessary component of healing relationships and we must foster time spent between colleagues sharing knowledge, expertise, intuition and support for the difficult precious work of health care. Thank you for your efforts, Harvey Zarren, M.D. Conflict of Interest:None declared |
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Edward J. Volpintesta, MD none
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evolpintesta{at}snet.net Edward J. Volpintesta
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January 2, 2008 Annals of Internal Medicine (Rapid Response) It is particularly important that the threat of medical malpractice be looked at and how it affects costs. It is hard to estimate just how much defensive medicine affects the costs of healthcare; most doctors, however, will admit that the worry over missing something in a diagnosis enters into every decision they make. To some degree, this is good because it makes them more thorough. But, the malpractice system is too punitive and has contaminated physicians’ ability to think as true healers with patients' best interests at heart. The result is endless testing and ever-increasing costs. I suspect that medical technology companies that develop new technology, base part of their sales strategies on the fact that doctors feel a “technological imperative” to use every new piece of technology that comes along, regardless of how little an improvement it represents. Until a system is in place that allows doctors to make unpreventable, and even in some cases, preventable errors, and not have their professional lives destroyed by litigation, any plans for a more affordable health system will be incomplete. If health costs are to be controlled, medical liability has to be taken out of the courts. Perhaps special panels presided over by judges with training in medical liability should be given a try. This has been proposed by Common Good a tort reform group. Another alternative would be treating medical liability like workers compensation. This works in Scandinavia and should be considered as well. There are many factors at work in healthcare that raise costs. Defensive medicine, which is a direct result of the threat of malpractice is one of the most dangerous. Edward J. Volpintesta MD Conflict of Interest:None declared |
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Cleaves M. Bennett, MD Harbor-UCLA Medical Center
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doc{at}nomoremedicines.com Cleaves M. Bennett
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The founder of the National Health System, Aneurin Bevan did not have to deal with millions of baby boomers turning 60. In England as in most of the rest of the world they were slowly emerging from decades of scarcity, especially food. No one was obese. Everyone was very physically active just to survive. Predominant transportation was walking or bikes. Rebuilding England was a massive under-taking in which everyone participated. Medical care was for infection, malnutrition, accidents, some cancers, inherited problems. Children were not coming down with type 2 diabetes. Probably few adults were either. The world is a very different place now. The solutions of the past will not work for the present. If society does not deal with and solve the pandemic of diabesity and other diseases of affluence and "too much", how we seek to pay for it matters little. The bottom line, there is not enough money in the world to pay for it, no matter what the insurance system is. CMB nomoremedicines.com Conflict of Interest:None declared |
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Cleaves M. Bennett, MD Harbor-UCLA Medical Center
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doc{at}nomoremedicines.com Cleaves M. Bennett
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In the usual sense of the word, health "insurance" is not insurance, it is an entitlement. Everyone wants it, needs it and feels they are “entitled” to it. All of the politicians foster that belief. Here is the real problem: almost everybody needs to use it. That is why the system is broken. Now I have fire, flood, earthquake, auto and life insurance and I’ve never had any claims. That is how insurance works; only a few of the 1000’s of insured ever make a claim. That keeps the cost down for all the rest of us. Try to buy flood insurance in New Orleans or hurricane insurance in Jamaica and you will see what I am talking about. If we took as poor care of our automobiles as most of us do ourselves, auto insurance would be unaffordable too. Even if all the profit was taken out of the Health Care system it still goes broke. (see below) Just takes a little longer. But this is America. Do you really think we are ever going to accept socialized medicine? Do you really think Medicare is ever going to bargain for cheaper drug prices? Congress is in the deep pockets of Big Pharma and the Insurance Industry. There are many reasons why our system is so expensive. Doctors prescribe multiple meds for years to people who aren't sick. That costs a lot of money. Then those same patients (who never did take all those pills correctly) get sick anyway and end up needing expensive, life prolonging medical care with specialists in hospitals and nursing homes. That costs a lot more money! Life prolonging care can drag on for years. 78 million baby boomers are turning 60, and they are going to break the health care bank. (Bill Clinton led the pack with his heart attack.) Just ask Richard Walker, the head of the GAO. He is traveling all over the country preaching “The sky is falling, the sky is falling.” Unfortunately he is right. But Socialism is not a viable solution. Canada, England and Europe face the same crisis. The aging Baby Boomers are going to break the bank in most developed and even developing countries. Doesn’t matter how the Health Care system is financed, over the next 20 years they all go broke. What’s to be done with this mess? Well, there is one dream solution. Everybody has to take a lot better care of themselves: eat healthfully, exercise regularly, keep their weight down, moderate on the alcohol, stop smoking, fasten their seatbelts, etc. Everyone knows the routine, but too few follow it. Every doctor and every politician must tell the public, living healthfully is the only thing that can work. Else 78 million baby boomers are going to suck the US Treasury dry over the next 10-15 years. Well, at least that will end our misadventures in Iraq. Conflict of Interest:None declared |
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Bernard A Cooper, md retired
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coopersb{at}yahoo.com Bernard A Cooper
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I worked in Quebec for many years and experienced a system with tight control except when modified by resistance from organized medicine. In general it worked well except when decisions by the ministry were based on nationalistic or political considerations. The best way to keep politics out of such a scheme is to have the plan funded by premiums that are paid as a separate line item and not part of general revenues. There is much concern about how well one can plan a medical system: many government decrees to alter the output of medical schools and the type of training have had to be altered later as counterproductive and wrong. Financial incentives based on pay scale are better means of increasing the numbers of primary care physicians than is a decree from a committee. Physician evaluation-based fees, on the other hand, have seemed to me to be divisive and not effective in the UK where they were widely used. The VA system is a good benchmark. Note that a previous OECD-based reprort described salaried specialists as characteristic of the higher- scoring plans. Conflict of Interest:None declared |
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Kennth A. Fisher, M.D. Borgess & Bronson Hospitals
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momfish1{at}charter.net Kennth A. Fisher
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We are the third most populous nation, with the most diversity. Lessons learned from other nations about their health delivery systems must be adapted to the complexities of our population. We spend more per person than any other nation, yet have poor results and millions uninsured. Health care costs negatively effect business and our middle class’s standard of living. It is imperative that we fix our dysfunctional healthcare system to provide universal coverage without putting further strain on our economy. The American College of Physicians can take a leading role in fixing our system by addressing the excessive use of technology which frequently is of no benefit to the patient and consumes billions of dollars, causing under-funding of primary care.(1) As pointed out by Fisher et al. during end-of-life excessive use of technology is most flagrant in our major teaching hospitals.(2) This teaches our young physicians that inappropriate care is the norm and that judgment about what is appropriate for a patient at a particular time is irrelevant. The Patient Self-Determination Act has been misinterpreted to mean that there is the right to any care, regardless of its appropriateness, whereas its purpose was to give the right to refuse the various medically indicated options.(3) Another reason for this behavior is the financial rewards for the institution and the physicians. Individual physicians and societies such as the American College of Physicians have not as yet addressed this problem. The question to be answered in these situations is not how long the patient will live, but rather, does acute care rather than hospice have the potential of benefit in light of the patient's overall health? Inappropriate care also extends beyond end-of-life situations; for example, placing stents in coronary arteries in stable coronary disease when medications are equally efficacious.(4) There is no doubt that patients should become educated about their medical condition/s and take an active part in decisions regarding their therapy, but patients will never be able to have the judgment that is accrued over many years of education and experience to determine what will be beneficial, considering their overall health situation. Thus, a therapeutic relationship with a primary care physician is crucial for preventative health and the delivery of appropriate care. Despite attempts by Medicare to adequately fund primary care, because of excessive funding for specialists and procedures, this has been a failure.(5) 1. Barnato AE, McClellen ME, Kagay CR, Garber AM. Trends in inpatient treatment intensity among Medicare beneficiaries at the end-of-life. Health Serv Res 2004;39:363-375 (PMID15032959) 2. Fisher ES, Wenngerg DE, Stukel TA, Gottlieb DJ, Lucus FL, Pinder EL. The implications of regional variations in Medicare spending, Parts I&II. Annals Intern Med 2003;138:273-298 (PMID 12585825 & 12585826) 3. Drought TS, Koenig BA. “Choice” in end-of-life decision making: Researching fact or fiction? Gerontologist 2002;42 spec No.3;114-128 (PMID 12415142) 4. Mitka M. Cardiologists get wake-up call stents. JAMA 2007;297:1967-1968 (PMID 17488954) 5. Ginsburg PB, Berenson RA. Revising Medicare’s physician fee schedule – much activity, little change. N Engl J Med 2007;356:1201-1203 (PMID 17377156) Conflict of Interest:None declared |
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Samuel Chew, MB. BCh. BAO. MRCP(Edingburgh) City Hospital, Dudley Road, Birmingham, West Midlands, B18 7QH UK
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Samuel.Chew{at}swbh.nhs.uk Samuel Chew
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I read with great fascination the proposed changes in the above article. At a time when the British government have made changes towards an American model of healthcare, it seems that the American model is looking to change towards the British system. No doubt the former was made in the hope of greater efficiency. The later for its all inclusive nature, thereby addressing the problem of millions of people without adequate health-care in the US. Both systems have evolved and have been tested in the real world setting over the last 60 years, and it would seem to me that the vision and fore-sight of the founder of the National Health System, Aneurin Bevan, have rung true. He had said “Not even the apparently enlightened principle of the greatest good for the greatest number can excuse indifference to individual suffering..." in his book, "In Place of Fear", Quartet Books; 1952.ISBN:0-7043-0122-9. In the same book, he detailed the challenges and solutions in implementing what was then unheard of before, a state-funded healthcare for all British people. Mention must also be made of the late author, Alvan R. Feinstein, who was the Professor of Medicine and Epidemiology at Yale University, in his article: "Scholars, Investigators, and Entrepreneurs: The Metamorphosis of American Medicine". In it, he describes in detail, the history and the evolution of the problems faced not just by the American physicians, but also of those faced in the managed care health system and in research as well. In particular, he laments the lost of the ethos of "caritas" and of the traditions of a caring personal physician, replaced by the demands of financial "efficiency" and the uniformity in practise, as required by guideline or protocol-driven care. He also offered probable solutions, in a way that only someone who have lived through both worlds of the American health system can, grounded in the best interests of both patients and physicians. This article can be found at: "http://muse.jhu.edu/login? uri=/journals/perspectives_in_biology_and_medicine/v046/46.2feinstein.html" I leave you with the final words of Dr Feinstein from the above article: "Neither the medical academy nor the NIH are likely to make the drastic changes needed. The new goals, therefore, probably will have to be conceived and formulated by practicing clinicians, working through their professional organizations and hoping that the organizations will develop enlightened, courageous leadership. If the aims are merely to resurrect the golden age, to retain the status quo, or to recover what existed before the managed-care takeover, the problems will remain unsolved, and the system will remain unstable. If the leaders have adequate vision, however, they can develop policies aimed at four main goals: 1. To promote not just the customary type of basic science used for explicatory research, but particularly the new type needed for clinical evaluations; 2. To reduce costs by eliminating unnecessary or unconfirmed procedures; 3. To provide universal health-care coverage; and 4. To restore a Samaritan ethos to medical care." There is much to learn from both of these works on both sides of the Atlantic, in our quest for a better future for ourselves and our patients. Thank you. Conflict of Interest:None declared |
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Nemer Dabage-Forzoli, MD Private Practice
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nemerdabage{at}hotmail.com Nemer Dabage-Forzoli
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1-We spend a significant amount of our dollars in the last 6 months of life and in futile care that could be used for future generations. There is a significant number of patients and families that are unable to cope with this and since health care in many occasions does not cost them the system is ravaged. 2-Physicians live in a state of fear that even if they use their best clinical judgment a lawsuit may occur for "negligence" when they made an honest mistake. This encourages extra use of ancillary services, technology, laboratory. You cannot detach the rising health care cost to the cost of liability in this nation and the extraordinary cost driven by it. Nemer Dabage, MD Internal Medicine Conflict of Interest:None declared |
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Arvind R Cavale, MD, FACE, FACP
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mdllcoffice{at}gmail.com Arvind R Cavale
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With due respect to the extensive effort by the authors of this paper, I would like to highlight several points of disagreement/disappointment: 1) While advocating for a government-run single payer system (Federal/State) we must define whether this will resemble the current Medicare or Medicaid system. The latter will obviously lead to most enrollees losing real time/real world access to their physicians (similar to how current Medicaid HMOs while "covering" a large portion of the low income population don't have any participating physicians for their members to get care from. 2) The paper does not define whether physicians will be forced/obligated to participate in this single-payer system; and what the implications might be if a large percentage of Primary/Principle Care Physicians decide not to participate. This will obviously exacerbate access problems that exist currently. 3) The most glaring omission is not addressing the impact of a litigious society/legal environment leading to practice of defensive medicine. There is no effort to compare the medico-legal systems of the US with all the other countries mentioned in other comaprisons. 4) The issue of chronic disease management and end-of-life care is addressed only marginally. As we know, a significant portion of health care cost is in these two areas. No mechanism is suggested to help address chronic disease management more effectively; examples being the use of remote monitoring technology, e-visits, etc., and appropriate reimbursement for such management, and for involvement of employers in providing incentives for such management. 5) As a physician, I would have liked to see language which says that payment for services should be at the time of service, with insurance plans/single-payer being legally obligated to reimburse for service rendered to plan members without the option to deny payments. This comes down to simplification of billing/collection procedures using IT so that physicians are not forced to use "middlemen" such as clearinghouses for processing claims, thereby reducing the "cost" of collecting what is legitimately due to a physician. A "smart card" in this situation would be ideal. 6) Finally, legislation with clear definitions of contractual language between IT vendors and physicians with provisions for swift remedies not involving litigation, would significantly increase adoption of IT in physician practices. This discussion has been completely omitted here. I submit that the ACP issue a follow up paper that includes at least some of these points. Conflict of Interest:None declared |
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Richard S Leff, MD
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rich{at}smalldoginthecorner.com Richard S Leff
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Achieving a High-Performance Health Care System is a thought- provoking examination of many problems of the US health care system. Unfortunately, the recommendations, representing the official policy of the ACP, are alarmingly unrelated to the data presented. Certainly, we could reach a strong consensus that our current system, despite the superb quality of care available to most Americans, fails to provide the same excellent quality of care to everyone. It is also undeniable that the rapidly growing cost of our system will soon begin to tax our ability to continue to improve and innovate. Reform is necessary. The ACP recommendations for reform, however, ignore one of the key elements driving over-utilization of technology. Overuse of technology is a complex issue but fear of liability actions clearly takes a huge toll on most physicians and results in substantial use of medically unnecessary (but legally driven) diagnostic procedures. As physicians, we are partly responsible for the importance of malpractice liability actions in our system since we have not been effective in eliminating low quality practices and practitioners. Our political system, driven by special interests, is likewise responsible. The recommendations of the ACP also ignore the peculiar consumer psyche of the American consumer. All of the systems used for comparison provide less expensive health care at the cost of decreased access to and quantity of specialty care. In the single payer systems, delays in care caused by shortages, particularly in technologically advanced care, effectively ration costly therapies. Given the choice, most Americans will opt for immediate access to care, even when it is reflected in a higher price tag. (This tendency was reflected in Medicare HMO programs initially seriously underestimating the demand and subsequent cost created by new members who were unwilling to see primary care providers for their previously diagnosed problems.) I doubt seriously that Americans will have the same high level of satisfaction as their Canadian counterparts when the CT scan to investigate a new lung nodule and then subsequently the bronchoscopy or trans-thoracic needle biopsy are routinely scheduled each with a 3 or 4 week delay. The health outcome of immediate care might not differ but the level of satisfaction certainly would. Americans may not be able to afford to be "spoiled" for much longer but changing the US health care culture will take much more than legislation. The ACP position paper also makes a very risky assumption: single payer systems are less expensive because they are single payer systems. Any systems that efficiently ration expensive care will save money. Conversely, single payer systems which are not structured to limit access to care (Medicare, for instance) can be associated with accelerated growth in costs because of lack of tempering market forces. If our elected officials are responsible for setting health care spending policy, it is likely that no one will have the stomach to own the restrictions necessary to control spending. Certainly that has been our recent experience. A US single payer system is unlikely to provide redemption. Each of the problems addressed in this very important ACP position paper warrant immediate and thorough attention and reform. I am unconvinced from the evidence presented that a single payer system will lead to solution of any problem except universal access and will, due to the nature of government, lead to worsening of many of the problems cited. Although the scholarly and very respected leadership at the ACP endorsing a single payer system may be ready to place the fate of their personal health care in the hands of the same political system and government that created CMS, the TSA, the IRS, the USDA, the Social Security Administration and the Veterans Administration, I would like to have the option of using some of my resources to allow me to choose access to a different level or type of health care (without having to leave the country). Although we should guarantee access to care for all Americans, the fact that some may not be able to afford a level of care that I might choose to purchase should not be an argument for denying me this privilege. Suggesting a single-payer system to solve our health care problems is, in essence, throwing up our hands and admitting that we give up. Single payer will not solve but merely shift our problems. Obviously, our political leaders will not or can not solve the complex problems faced by our health care system. As the professionals responsible for the outcome of each of our patients and indirectly anyone who could need care, we need to do better than this. Conflict of Interest:None declared |
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