2015, The Hopeful View

"There is likely not one solution that solves the problems in [U.S.] health care 100%, but 50 solutions that each solve the problem 2% are just as good." paraphrased from Alan Sager

The professor of my Health planning and management class suggested that one way to conceptualize the challenges of planning an effective health care system is to think forward to 2015, and imagine a perfect system. From there, think back on what needed to have taken place to realise this goal. The perspective that there could be 50 solutions that each help a little bit is helpful in emerging from a state of inertia/paralysis, because your solution doesn't have to solve everything. At the same time, it's valuable to think about your corner of the solution in terms of the other 49-- your solution cannot cripple the solutions of others.

The key ideas in a positive and hopeful picture are full financial protection, identification and stabilization of needed numbers of institutional caregivers (hospitals, nursing homes, home health agencies, health centers) and professional caregivers (doctors, nurses technicians, and others), overcoming non-financial barriers to care, substantial improvements in efficacy, appropriateness, and quality of health services, and cost controls that stabilize health spending at 16 percent of GDP. What were the events inside or outside of health care that precipitated these changes?

The Picture I Imagine

In early 2009, when a democratic president was inaugurated, there was already momentum for change. Over 60 million Americans were uninsured, 150 million were underinsured, and few people felt that their health care addressed their most important needs. Health care spending was spiraling towards 19% of GDP.

This picture meant there was a public openness to new ways of thinking about health care, and to ideas that went beyond the usual debate about coverage and cost control. I'm going to look at 5 people in health care, and the solutions that they managed to implement fully before 2015. You can use your imagination to think through all the other stories that would have had to have been taking place simultaneously for everyone to truly be covered.

Snapshot 1: Administrative Efficiency
Christine was one of the many people in midst of this change. She lobbied for changes in business law to simplify billing and to create a clear relationship between spending and provision of care. From her perspective, this was the major source of waste in the health care system.

Together with thousands across the fifty states, she led change in medical schools, so that business studies were included as an integral part of medical school. She understood that we would only enjoy the fruits of these changes in the long term. Many doctors encouraged this change because they felt that they would like to make informed choices about health care spending. Certain medical schools felt that this curriculum encroached on already scarce time to teach future doctors clinical skills.

She also encouraged a symbiotic, rather than antagonistic, relationship between health care providers and insurance companies. That is, an agreed amount of risk was standardized and balanced between providers and insurers. This meant that responsibility for payment could not be shifted between providers and insurers. Essentially, this represented large scale capitation. It meant that doctors in this system were responsible for providing care using a finite budget. As practices under this system were fairly large, insurance companies felt that the system would not interfere with their profits, as at least a few of the patients would need expensive care, and it would be the doctors, not the insurance company's problem to think about these "problem patients". On a large scale, this greatly simplified administration and allowed doctors to earn more from relatively fewer patients. Patients received better care. Nurses were able to practice nursing and not be bogged down with coding etc.

Snapshot #2: Coverage
A collaboration between health care advocacy organizations effectively lobbied for universal coverage and genuine financial protection. Financial protection was initially unpalatable for a large portion of the population, who felt that they would have to pay for other people's health care. However, momentum came from the large portion of the population who were angry and frustrated at the increasing costs of health care as a percentage of GDP. They felt that until people were able to go to the doctor when they needed to, the ultimate cost would continue to increase. Rationing care and financial protection became intertwined: both were needed if the absolute cost of health care was to stabilize.

Compromises included strict guidelines for beginning and end of life care, where doctors were protected from lawsuits within the new framework. Guards were put in place to protect middle-class taxpayers. The Medicaid (MA) and Medicare programs were expanded. A federal free care pool was created and grown. A three year program began in which highly paid medical professionals did not receive salary increases. This money was used to build a free care pool and create financial protection for all uninsured individuals seeking care. An amnesty period was followed by coverage. This coverage did not include care that was considered futile, and in this way was a painful cost control.

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Deep change required some level of desperation. It required a sense that radical change was required. It required political will and compassion. It required difficult choices not to do certain expensive tests unless indicated. It required patients to give up their right to sue.

Thinking through US Health Care

(http://news.bbc.co.uk/2/hi/in_pictures/7144249.stm)



"We cannot live under the idea that we can give everybody all the health care they need. Rationing of health care is inevitable because society cannot or will not pay for all the services that modern medicine can provide. People in this state must search their hearts and pocketbooks and decide what level of health care can be guaranteed to the poor, the unemployed, the elderly, and others who depend on publicly funded health services" Oregon Health Decisions, 1988

Since this blog is largely about finding ways to stay healthy in a responsible way, I thought it would be good to post a snapshot of US health care. I believe that many of the readers of this blog may not be from the US-- this one's for you! Looking forward, this post sets the stage for my next two posts:

(1) What it might take to see a different picture in 2012, a picture where everyone has good, appropriate care without ever having to worry about how they will afford the care, or if they will lose insurance.

(2) What might have happened if the opposite had taken place and we're looking at a disaster in 2012: costs spiralling out of control, more people uninsured, the nursing shortage further deteriorating, etc.

The Snapshot

47-60 million without insurance and some 150 million under-insured
1.7 trillion (that is, 1.7 000 000 000 000) in yearly costs, or 16% of national spending.
"The United States spends more than twice as much on health care as the average of other developed nations, all of which have universal coverage"^ yet
Comparing Japan, Sweden, Canada, France, Australia, Spain, Finland, the Netherlands, the United Kingdom, Denmark, Belgium, the United States, and Germany, the United States ranks*:
- 13th(last) for low-birth weight percentages
- 13th for neonatal mortality and infant mortality overall
- 11th for postnatal mortality
- 13th for life expectancy at 1 year for females, 12th for males
- 10th for age-adjusted mortality.

20-30% of patients receive inappropriate care.
An estimated 44 000-98 000 people die each year as a result of medical errors.

Thoughts

Many readers will compare the US system to the South African system. I would like to do the same in a future post. I think it may be useful for thinking about health improvement in both countries. The South African system recognizes health care as a Human Right, which the US system does not. Yet people in the US generally receive much better care.

So, let's look at the "Human Rights" aspect of health care. The limitation of the "human rights" language of health care is that one can never guarantee health. We all get sick and we all die. As one professor at BU School of Public Health says, this fact means that health care has a 100% failure rate. As a result, it's really difficult to measure what is a reasonable amount of care. Some people will need far more resources than others. Yet the right to care is also one of the most fundamental-- it's a life and death issue.

In the U.S., patients and health care providers are uncomfortable with the idea of rationing. Surely everyone should get the best possible care that is available? Unfortunately, the answer is "no". Particularly when what is available is often extremely cutting-edge and therefore expensive, as in Boston, there has to be a limit. The challenge is drawing a line between one type of care and another. The challenge is saying no to some types of really expensive care. As a result, US health care spending is spiralling out of control.

As in the South Africa, socio-economic inequality is a root problem in the health care system. People are not guaranteed care. Worry becomes an intricate part of any visit to the ER, specialist, or primary care physican.

I argue that the deeply fragmented nature of health care is a major source of waste and of poor care. Health care is not a commodity like any other, so it cannot be treated as a common commodity in a free market. In a free market there are always people who lose everything, but losing money is one thing, and losing one's health is another.

^The Physicians' Working Group for Single-Payer National Health Insurance, Proposal of the Physicians' Working Group for Single-Payer National Health Insurance. JAMA August 13 2003, 290 (6)
*Starfield, Barbara. Is US Health Really the Best in the World? JAMA, July 26, 2000 26(4)

Getting back to the Concrete Gardener

(Ice in Oklahoma, From the BBC http://news.bbc.co.uk/2/hi/in_pictures/7138887.stm)

I didn't realise how long it had been until someone reminded me. I'm going to get back to posting regularly in the next few weeks, and build some good content here. My goal is to post on Mondays, Wednesdays and Fridays from January onwards. I'll be finishing my MPH in about a week, which is really exciting. Also, I wanted to point you to jabulanijo.blogspot.com, which is my personal blog, and adventuresofpiglet.blogspot.com, which is what we do for fun...

It's midwinter so the questions are different. I've decided to shift gears slightly and look at Boston in winter, and also look at social responsibility as a Christian, in general.

Coming up this week: Health Care in the US-- best and worst case scenarios.

Coming up in January:
Looking at the United States primaries in parallel with the South African ANC race to nominate a new president.
Comparing United States and South Africa Health Care (Ideology and reality)