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Podcast Transcript - January 1, 2008

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Hello, and welcome to a New Year and to this weeks Annals of Internal Medicine Audio Summary for our January 1, 2008 issue. I’m Michael Berkwits, Deputy Editor at Annals.

The issue this week is another good one, with articles on the cost-effectiveness of digital mammography; the effect of drug concentration expressions on dosing errors; and a detailed analysis of what the United States can learn from other Western countries about developing a better health care system.

That’s our featured article this week, and we’ll launch right in to a detailed summary of it.

What The U.S. Can Learn From Other Countries About Developing A Better Health Care System (Time: 00:32)

The paper, authored by the ACP’s Health and Public Policy Committee, notes that spending on health care in the US is 16% of the entire United States economy, and to put that in perspective, US government spending on the entire US military is estimated at about 4% of GDP, or a quarter of what’s spent by the public and private sectors on health care. And as many listeners may already know, these massive amounts of money haven’t bought the country better health; many key ratings of US health and of health care system performance is far less than that of other countries who spend a lot less. Just as one example, World Health Organization 2007 World Health statistics suggest that healthy life expectancy for men in the US is 67 years, compared to 69 years in France and 70 years in Germany. And, using a performance ranking system developed by the Commonwealth Fund -- a private foundation that promotes improvement of health care systems -- the US ranked last or tied for last compared to other Western countries on 27 key indicators of performance, including measures of patient safety, patient-centeredness, efficiency, and equity, despite per capita spending on health care about twice that of those countries.

Using data and rankings like these across multiple cross-country comparisons, the article makes the case that the quality of health care in the US could be much better than it currently is at far less cost, and it draws six lessons that could help the US achieve a higher-performing health care system.

First, high-functioning health systems provide universal coverage, meaning that they guarantee all citizens access to affordable health coverage for a defined set of benefits through single-payer systems or a mix of public and private sources of funding. Single payer systems can restrain costs and spending but they can also lead to shortages of services and delays in obtaining those services, and they don’t always provide incentives for improving efficiency. Multiple-payer systems may avoid those problems, but they are more likely to result in inequities in coverage and higher administrative costs.

Second, high-functioning health care systems require sharing of information, and cost-sharing between patients and providers that is tied to income, so that higher income patients have the information they need to make good choices without overspending or avoiding care, and lower income patients can afford or obtain for free the health services they need.

Third, high-functioning health care systems require substantial government or societal investment in provider training, and a national workforce policy that guides that training of proper proportions of primary care and specialty providers to meet the country’s health care needs. Because primary and preventive care results in better outcomes and lower costs, countries that want a high-performing system in general need many more primary care providers than they do specialty providers.

Fourth, high-functioning health care systems financially reward the provision of primary care services, or at least they do not penalize providers who make their careers providing those services, and they should provide incentives for coordinating care; for reporting and improving health care quality and meeting performance standards; and for providing care by e-mail or telephone.

Fifth, high-functioning health care systems support interoperable electronic information systems that help doctors take better care of patients through the use of decision support tools; standardize the transfer of information between providers and health facilities; and reduce the paperwork involved in billing and credentialing, so doctors have more time to spend with patients.

And finally, high-functioning health care systems require substantial government or societal investment in all kinds of medical research, including research on the comparative safety, cost, and efficacy of available treatment options, and research on the functioning of the health care system, sometimes called health services research or health evaluation science.

This podcast is being released on New Year’s eve, and the Iowa caucases are two days away. In an editorial accompanying this review, Dr. Harold Sox, editor-in-chief of Annals, calls for readers to demand change from the candidates running for office. He acknowledges that American exceptionalism – the belief that the United States is unique among nations because of its history and beliefs and unique institutions – could stand in the way of American leaders’ willingness to learn from other countries. But he makes the point that things will change one way or the other given the rising costs of health care, the growing number of uninsured patients, and the impending demise of primary care in the US at a time when the population is aging. Neither he nor the authors of this week’s review acknowledge that at 16% of the US economy, the US health care enterprise is a massive ship that can’t easily be turned around. None of this week’s authors make use of lessons learned from the failed attempt to reform health care in the US in 1994, and these papers don’t cite any evidence of that adoption of these key systems features lead to any changes in key indices of health care quality.

Still, it doesn’t take much to recognize that the health care system is fragmented, suffused with perverse incentives for testing and treatment, and it needs fixing, however incrementally, and it is always useful to keep an eye on what should be guiding principles of health care reform.

To get a little better sense of what the College was trying to do by spelling out these principles and recommendations, I called Dr. Fred Ralston. Dr. Ralston is Chair of the Health and Public Policy Committee that issued the paper, he’s a Regent on the College’s Board of Regents, and he’s a full-time general internist in private practice at Fayetteville Medical Associates, in Fayetteville, Tennessee.

Q: Dr. Ralston, thank you for joining me.

A: Thank you, it’s good to be here.

Q: Let’s start with the basics. What were you and the College trying to do with this Position Paper?

A: Since 1990, we’ve been calling for universal health insurance coverage in the U.S. ACP has emphasized that primary care is on the verge of collapse. We pointed out that very few young physicians are going into primary care, and those who are already in practice are under such stress that many are looking for an exit strategy. We see many suggestions for improvement in the healthcare system, but they aren’t always backed up with the kind of evidence that we like in the ACP. We’ve been hearing some people say they don’t want to give up what they have for a lower-quality healthcare system. So we set out to look at the good points but also the weaknesses of the American healthcare system. We then wanted to compare our system to those of twelve other industrialized countries, trying to find the best practices in achieving high performing healthcare systems.

Q: And what did you find in that review?

A: Well, most Americans wouldn’t be surprised to find that we were the most expensive, twice as much as the other nations evaluated. They might be disappointed to learn that we placed at or near the bottom in many leading indicators; last in life expectancy and infant mortality.

Q: And that’s against twelve other Western countries, is that right?

A: Right, that we should be doing better. Common themes emerged from the nations that scored well, still with costs that substantially below ours. They had universal coverage. They had more effective use of information systems in a way that has to involve government, whether the insurance is paid for by government, or a mix of public and private payers. There were lower administrative costs and they had a strong foundation in primary care.

Q: So that’s interesting. Is the College and the Committee suggesting that there needs to be universal health information infrastructure coverage for such a high performing system?

A: Yes, we really feel that that’s going to be an essential component of such a system.

Q: And will that be modeled, for example, in an ideal, against the VA system, which is a solely government-developed VISTA information system, or is that a mix of private and public technology that will provide an interoperable health information system in the U.S.?

A: Well, we of course understand that they’ll be political discussions in that regard, and there are existing systems that are in place. But the key is going to be the function involved, and if we can get a function using different kinds of systems that connect them together, that will be fine. But certainly, the end result of what occurs in the VA system would be a laudable goal.

Q: Now, the data you used to compare the U.S. to the health care systems of other countries was based on some data that was impressibly compiled by the Commonwealth Fund. What is the Commonwealth Fund? What does it do, and is it a resource that listeners should know about?

A: Well, Commonwealth Fund is a private foundation that aims to promote a high-performing healthcare system that achieves better access, improved quality, and greater efficiency with a particular focus on society’s most vulnerable. They support independent research on healthcare issues and make grants to improve healthcare practice and policy. The term “Fund” sometimes confuses people, but listeners could certainly find out more by visiting their website at www.commonwealthfund.org.

Q: Does the timing of the release of this paper have anything to do with the primaries and the general election in the U.S. in 2008?

A: Well, we certainly would like to challenge each of the presidential candidates to look at the common sense recommendations that we have for healthcare system reform and speak to them. We think it’s very important for our members and the general public to pressure the candidates to deal with these issues. And, as a matter of fact, we’ve established a link on our www.acponline.org website to allow our members, and the general public, to look at the healthcare policies of the various presidential candidates and compare those with the recommendations that come from these papers. We’re not endorsing any one candidate, we’re a non-political organization, but we certainly want to educate our members and the general public on the difficult healthcare choices ahead.

Q: And what would you say to people who would argue that the U.S. has a historically unique position and the best medical care in the world, and that we should look for solutions to our problems from within our borders, rather than from other countries whose commitments differ from our own?

A: Elliot Fisher and others at Dartmouth have taken a look at healthcare within the United States and established what they call the “Dartmouth Atlas Project,” comparing medical costs and health outcomes in various parts of the country. They have found high-quality and lower-cost care to be associated in certain regions. There’s a strong connection between supply of primary care doctors and those positives outcomes. This data that the Dartmouth researchers have uncovered is very complementary to the information that we’ve gathered from abroad. But we also know from advances within the VA system in the U.S. how crucial good information technology is to improving quality. While other nations certainly differ from the U.S. our lessons learned from other countries complement information we already have from within our borders. Within the United States, it seems that information about patients often is difficult to communicate from one physician to another physician. And, it’s also difficult for patients to communicate with their doctors. With our tremendous resources, and effective use of technology and other aspects of American life, it’s surprising that we haven’t developed a system where we can communicate with each others as physicians as well as they can in some of the other countries that we’ve studied. Those countries also have systems that allow more effective communication between patients and doctors. IBM in particular has been a leader in pointing out how far we are behind other nations in aspects of our healthcare system. Our goal is certainly not to weaken the best areas of American healthcare, but to use them effectively and strengthen the areas that demand improvement.

Q: The paper tips its hat towards primary care suggesting that their needs to be more primary care practitioners to make the healthcare system function better. But, it doesn’t say much more about that other than that society needs to invest in the education of training of primary care doctors. But isn’t the real issue in workforce and balance [that] once students graduate, and residents are trained, most are opting for better incomes and lifestyles than are available in primary care medicine? To what extent is reimbursement reform an important component of what you’re trying to achieve here?

A: It’s a big one, and one that needs to be addressed immediately. The ACP knows this is the case and argues for improved reimbursement at every opportunity. We are, of course, a membership organization, and some may see that we have a conflict of interest in that many of our members are primary care physicians. The data, however, speaks for itself. It is more credible when other experts echo these calls. On NPR Science Friday recently, I appeared with Don Berwick and Uwe Reinhardt. They both noted that the essential element of high-performing health systems is an emphasis on primary care. They pointed out that higher pay for primary care was essential to get the proper balance in our workforce. The “perfect storm” is hitting with diminishing supplies of primary care physicians happening just as “baby boomers” come to peak years of medical need.

Q: One country seems to have gone pretty far in trying to meet the standards set in many of the recommendations, and that’s…the state of Massachusetts. They’ve mandated that all residents have insurance, and they’ve tried to establish a pluralist system in which residents can choose from private and public insurers, and they have regional projects testing the feasibility of interoperable electronic health systems. Can you tell us anything about the status of that statewide project? Does that experiment meet some of the standards in this week’s paper?

A: I haven’t personally observed the Massachusetts experiment. They’re certainly to be credited with high marks for the moral commitment to universal coverage and their understanding that government needs to lead the march toward interoperable health records. We need to make those same commitments to the nation. The real question mark will likely be the cost. Massachusetts already has a real shortage of primary care doctors, and adding to the roles of the insured without truly altering delivery of care will present some special challenges. Time will tell, but in Massachusetts and the rest of the U.S., we will be more successful if we cover everyone while applying lessons learned of high-performing healthcare systems here and abroad.

Q: Dr. Ralston, thanks for talking to me.

A: Thank you.

That was Dr. Fred Ralston, Chair of the Health and Public Policy Committee of the American College of Physicians and coauthor of this week’s Position Paper on What The US Can Learn From Other Countries About Achieving A High-Performance Health Care System With Universal Access. Listeners can learn more about how Democratic and Republican presidential candidates’ health care plans match up the 6 ideals I detailed in this summary by going to www.acponline.org/advocacy/election08.

Other Articles In This Week’s Issue (Time: 16:30)

Other articles in this week’s issue include a cost-effectiveness study of digital mammography. Digital mammography allows image contrast to be manipulated so that it can be increased in denser breast areas which have lower contrast. A large trial published in the New England Journal in 2005 suggested that digital mammography is indeed more accurate than standard film mammography in younger women and those with denser breasts, but it is also much more expensive. This week’s analysis uses data from the trial to determine if the extra cost is worth it, and reports that it’s not worth it to screen all women or women with denser breasts, but that it is if it’s targeted for use in women younger than age 50.

Now here’s a pop quiz: you’ve got a patient in your office or clinic who seems to be going into anaphylactic shock. You reach into your resuscitation cart or med cabinet and pull out a vial of epinephrine labeled as 1:1000. How much do you give?

OK, so you may still remember the dose from some resuscitation protocol you memorized, but in a trial we’re publishing this week, providers were asked to treat a case of anaphylaxis in a simulated pediatric patient; the use of a kid meant the providers couldn’t just remember the dose they always give for adults. But here’s the interesting part: they were randomized to epinephrine ampoules labeled with the dose of the drug in milligrams-per-milliliter, or ampoules labeled with the dose of the drug in the ratio of 1:1000. Providers randomized to the ratio had to do the arithmetic to give the proper dose, and you can guess the result: they consistently overdosed the patient and they took a mean 90 seconds longer to give the drug. The authors conclude that epinephrine labeling and drug concentration expression could be a source of harmful drug errors, and that

This issue also has the print version of two systematic reviews of ACE inhibitors and ARBs and an accompanying editorial by Dr. Patrick Parfrey of Memorial University in Newfoundland Canada, which were summarized in detail in my November 6 podcast. If you missed that or want to hear my interview with Dr. Parfrey again, go to the podcast homepage, at www.annals.org/podcast.

We have an Update in Nephrology, the 10th and final update we’re publishing based on presentations given at the American College of Physicians annual Internal Medicine 2007 session held in April in San Diego

If you’re having trouble sleeping, put on your nightcap, curl up under the sheets with this month’s In The Clinic on insomnia, and with a little reading and much respect for the hard work of In The Clinic editor Dr. Christine Laine, you should be asleep in no time.

And Shing Nien Kwai La. That’s Mandarin Chinese for Happy New Year. With this issue Annals is launching a trial of audio summaries in Chinese for our colleagues in China, Taiwan, and the Chinese Diaspora. Go to our home page at www.annals.org to hear what the Annals content sounds like in another language, and if you have Chinese-speaking colleagues here or internationally, help us spread the word.

Well, that’s it for today.

At the time of this recording, we’re still awaiting word of whether Congress and the White House will approve postponement of scheduled Medicare pay cuts. It’s not strictly an Annals issue but we’ll keep an eye on that in the next weeks and months if things look threatening I’ll get someone from the College to come and talk about what the organization is trying to do about it.

We’ve got some great issues coming up, so tell all your colleagues to subscribe to Annals, and the podcast.

Send comments and feedback about this project and the journal, to podcast{at}annals.org.

Technical support for this summary was provided by Andrew Langman, Neil Kohl, and Beth Jenkinson.

Special thanks to Kevin Stahl and all our friends at WHYY, public radio and television of Philadelphia, who helped produce these podcasts.

We’ll go out this week with a track from Dust-To-Digital’s 2004 release “Where Will You Be Christmas Day?”; here’s Mary Harris’ 1935 recording of Happy New Year Blues.

Check back in two weeks for our regularly scheduled January 15, 2008 issue.

I’m Michael Berkwits, and thanks for listening.

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