While most of the focus in the national healthcare debate is over whether to have a public insurance system, the real action is in a couple of other areas. One involves how the local medical community is organized and decides on treatment. The other is whether decisions on treatment will be based on science or on “local practices” and what’s most profitable for the doctors. Both of these will have far more impact on the cost of healthcare than who pays for it.
The social sciences and mental health or addiction treatment are moving to Evidence Based Practices, where a practice is independently evaluated to see whether it has positive outcomes. But doctors and medicine still make decisions on what they learned in school, maybe decades ago, and on what the local practices are when they talk shop at the country club. As a result, people are often overtreated using less effective models.
As discussed below, people are often overtreated and evidence-based practices would provide a mechanism for changing how medicine is practiced, producing better health outcomes and lowering costs. Buzzcut (a frequent commenter on this forum) calls reducing overtreatment “rationing” and argues that it would prevent medical mishaps. Whatever you call it, it’s going to be vital to both controlling medical costs and raising the quality of healthcare in the United States to the level of other industrialized countries.
There are several examples in America of low-cost, high-quality institutions – the Cleveland Clinic, the Mayo Clinic, Kaiser in the Bay Area and Portland, Geisinger in Pennsylvania, Intermountain in Utah. These institutions are organized for efficiency and effectiveness, using different models and serving different populations, but they universally provide excellent care without generating excessive costs. There are also some local communities where doctors and hospitals have organized themselves without an institution – The New Yorker article below talks about Grand Junction, Colorado.
I’ve been a Kaiser member for years and while you do need to learn to work with the bureaucracy, it’s less hassle then coping with Blue Cross. Aside from a co-pay, I never have additional charges nor receive bills or paperwork. All my health records are kept electronically – if during an appointment my doctor orders lab tests, prescribes from the pharmacy, and refers to a specialist, the information is in their records before I leave the exam room (and without the notorious doctor’s handwriting problem.)
The stimulus package dedicated $19 billion to starting to create a national electronic medical records (EMR) system. In the digital age it’s obscene that people get poor treatment because their records are scattered among file cabinets. I recently worked on a collaborative project between a large mental health/substance abuse provider and a FQHC “safety net” primary care clinic. They both have EMR systems, but the softwares aren’t compatible, so they can’t easily share patient information.
This is from the current issue of Time Magazine:
Americans tend to assume that more is better, especially when it comes to the heroic brand of try-everything medicine we’ve watched on ER and House M.D. But overtreatment is a national scandal. It’s bad for our health: with medical errors now estimated to be our eighth leading cause of death, drugs, procedures and hospital stays can be risky (as well as painful, time-consuming and wallet-straining) even when they’re necessary. It’s also bad for the economy: health costs are bankrupting small businesses and even conglomerates like General Motors as well as millions of families. And it’s awful for the country: Medicare is on track to go broke by 2017, and our long-term budget problems are primarily health-cost problems.
They’ve already stuffed $1.1 billion into the stimulus bill to jump-start “comparative effectiveness research” into which treatments work best in which situations. Now they’re pushing to overhaul the entire health-care sector by year’s end, and they’re determined to replace ignorance with evidence, to create a data-driven system, to shift one-sixth of the economy from “that’s what we do here” to “that’s what works.”
And an article in The New Yorker is what started me thinking about this issue. Here are some quotes:
McAllen, Texas is one of the most expensive health-care markets in the country. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.
El Paso County, eight hundred miles up the border, has essentially the same demographics. Both counties have a population of roughly seven hundred thousand, similar public-health statistics, and similar percentages of non-English speakers, illegal immigrants, and the unemployed. Yet in 2006 Medicare expenditures (our best approximation of over-all spending patterns) in El Paso were $7,504 per enrollee-half as much as in McAllen.
The annual reports that hospitals file with Medicare show that those in McAllen and El Paso offer comparable technologies-neonatal intensive-care units, advanced cardiac services, PET scans, and so on. Public statistics show no difference in the supply of doctors. Hidalgo County (McAllen) actually has fewer specialists than the national average. Nor does the care given in McAllen stand out for its quality. Medicare ranks hospitals on twenty-five metrics of care. On all but two of these, McAllen’s five largest hospitals performed worse, on average, than El Paso’s. McAllen costs Medicare seven thousand dollars more per person each year than does the average city in America. But not, so far as one can tell, because it’s delivering better health care.
As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future.