HEALTHCARE DELIVERY
U.S. healthcare: the intertwined caduceus of physicians, coverage, quality, and cost
Arthur Garson, Jr, MD, MPH*,*
* University of Virginia School of Medicine, Charlottesville, Virginia, USA
Manuscript received January 14, 2003;
revised manuscript received May 22, 2003,
accepted June 2, 2003.
* Reprint requests and correspondence: Dr. Arthur Garson, Jr., Dean, School of Medicine, University of Virginia, Box 800793, Charlottesville, Virginia 22908, USA.
garson{at}virginia.edu
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Abstract
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As cardiologists, we should increase our efforts to improve coverage, quality, and cost, both by caring for individual patients and by improving our systems. How? Coverage: by promoting a coordinated approach, beginning with state demonstrations of new safety net and individual and private insurance approaches. Quality: by adopting evidence-based practice and adapting practice guidelines for payment, beginning with non-payment for class III; by setting standards of practice below which we may not fall and paying for quality and service above this level; by involving patients as partners in their care and providing them with incentives. Cost: by challenging routine practices (why return in one year?); by beginning to address the widening gap between what is possible and what is affordable, taking part in broader discussions on what is worth the cost, supporting tort reform, and proposing alternatives; by improving our systems to reduce medical errors and addressing future physician shortages by working in teams with primary care physicians and nurses. Let's work with our patients to improve their health. Together we can make real progress.
The U.S. healthcare system is broken: no news. The system is headed for a crossroads where "the perfect storm" may occur and the system disintegrates: perhaps news. The medical profession can determine the fate of the system: that is news. As physicians, we are in a unique position to understand the complex interaction among coverage, quality, and cost; we can act as a profession to change the system; we can act as individuals to improve the care for our patients. The statistics are worrisome because they are all going in the wrong direction: we now have 41.2 million people uninsured (1); this is larger than the populations of Canada plus Australia. We think of Medicare and Medicaid as large programs, but there are more uninsured than in either of these programs, and that number may grow by another 10 million by the end of the decade (2). Our healthcare indexes, as indicated by infant mortality and life expectancy, lag behind 20 other countries. Our patients' outcomes for medical care, such as care for myocardial infarction, are somewhat better than other countries, especially as we pioneer new technology; however, we pay 50% per capita more than the next most expensive, Switzerland (3).
The American College of Cardiology (ACC) Board of Trustees has adopted principles for healthcare reform (4). These provide a vision for improvement by 2010 in coverage, quality, and cost: a vision by the end of the decade, 2010, of a healthcare system with coverage for every American in a rational way; this vision requires markedly improved processes and outcomes for our medical care and our healthcare; the vision requires the cost of a basic level of healthcare to be affordable for each of us as individuals and collectively as a nation.
We, as cardiologists, eventually will care for more than half the population. What can we do now?
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Coverage
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Framing the puzzle.
Our "system" of coverage is a fragmented puzzle with pieces missing. Increments have been proposed (5). However, we would still have an amoeba: an uncoordinated system that would provide even more administrative difficulties. With an expansion of "fill-in" programs, individuals gain and lose eligibility for specific programs in short periods of time, leading to potential duplication of health services and loss of continuity. Each program requires narrow definitions with lists of exclusions, nonetheless requiring increasing regulation and more administration for each program, ultimately funding programs that could "compete" for members of other programs.
The coordinated picture.
What is needed is the development of a framework that will combine increments into a rational whole. We need the edges of the puzzle so that the seemingly disorganized pieces can eventually fit into a coordinated picture that covers every American. The principles for the framework are as follows: 1) Establish large-scale groups building upon the current structure of insurance companies and public "safety net" programs to achieve economies of scale in administrative costs; each American would fit into one of these groups, and there would be minimal movement among groups; 2) Define an evidence-based minimum benefits package; 3) Promote quality, cost, and efficiency through incentives and competition; 4) Provide choice in providers and type of health plan, choice in covered services (above a minimum), and choice in amount of cost-sharing; these choices require educated patients who share accountability for their health; and 5) Create mechanisms for public and private support for healthcare that is affordable for each individual and family and affordable for the nation.
I propose that by 2010 a framework of five parts be created: the first three parts of the framework are currently in existence and will require relatively little modification. - Medicare. This system of care is efficient, with only 3% administrative costs (6) and with greater patient satisfaction than is found among those under 65 years old (7).
- Employer-based insurance for large employers (approximately 1,000 employees or more). Large employers have a benefits infrastructure that provides economies of scale. These programs are popular with employees, giving them a choice of plan; employees also change jobs less frequently among large employers, making the loss of healthcare continuity by changing jobs less likely (8). Incentives will need to be developed for large employers to continue to offer health insurance.
- The Veterans Administration (VA) Medical Centers. The VA is the country's largest integrated delivery system and is demonstrating innovative programs in medical error reduction and electronic medical records. These three programs, of course, will not cover all Americans. To achieve this goal, two additional parts of the framework are needed. These build on existing programs in a new way:
- Consolidation of "safety net" programs. Medicaid, State Children’s Health Insurance Program, community hospitals, and community health centers could be combined into a federal/state program to reduce changes in coverage that accompany state budget deficits by using an enhanced "match" with the federal government increasing the level of contribution from current levels. This would expand the current Medicaid administration to cover those whose income is <150% of the federal poverty level as well as those <65 years old currently covered by Medicare, such as people with disabilities, including the blind and those with renal disease. States would need to meet or exceed certain quality parameters to be eligible for the highest level of matched federal funding. Medicare would then cover all of those over the age of 65 regardless of income status. As a result, the "dual eligibles" of Medicare and Medicaid would be covered entirely under Medicare. This would require an increase in Medicare funding with a corresponding decrease in Medicaid funding.
- Private insurance system. The remainder of the population, including all those who work for employers with <1,000 employees and are above 150% of the federal poverty level, would be covered in an insurance system. Individuals and families would receive a combination of an employer contribution (that for small business would be supplemented by a tax credit) and, depending on one's income, a tax credit for individual employees and family members. These tax credits would be advanceable and refundable; the magnitude of the tax credit would relate to the cost of a basic health insurance benefits plan; the cost to the individual or family would be based on a sliding scale, and would not exceed 2.5% to 6% of income (lower percent for lower income), with little or no out-of-pocket costs. The tax credits could be used only to buy individual/family insurance. There would be a community-rated age-adjusted premium for each adult and a single premium for each child. The "family" premium would no longer exist. Because those who make <150% of the federal poverty level would be covered by the "safety net" program, the tax credits to individuals and small businesses (a larger percentage of individuals in this income bracket) would not be necessary. Singer, Garber, and Enthoven (9) have recently proposed "insurance exchanges" that provide a pooling mechanism for private insurance (through a non-governmental process) and would offer a choice among multiple plans in a similar way as Federal Employees Health Benefits Program with community rating, guaranteed issue, and competition. Exchanges would adjust for risk among plans, require defined minimum benefits, establish standards, and provide bonuses for high quality. Because virtually all non-poor, non-elderly members of a community would be covered in an exchange, adverse selection would not occur. There would also be a stop-loss for reinsuring above a certain level of expense. As part of a transition, both businesses and individuals would access the exchanges; eventually, businesses could contribute directly to the exchanges, entirely removing themselves from the administration and liability for healthcare. Individuals could access health insurance either directly on the Internet, using web-based educational tutorials, or through specifically trained insurance agents who could provide education in a similar way as "H&R Block" tax advisors.
Estimates of the financing required to cover the currently uninsured range from $85 to $100 billion a year (6). Clearly, incremental dollars will be required, but there are likely to be savings that could be generated by an integrated system. For example, we can improve administrative efficiency. Reducing billing costs from the current 8% to 4% (still higher than Medicare's 3%) would save approximately $60 billion/year (8). If we reduce waste by only 3% by using more evidence-based practice, even this could account for another $40 billion/year. Targeted approaches to using $30 to $60 billion/year of the impending tax cuts have been proposed. Competing with the uninsured for dollars of similar magnitude are seniors who appropriately seek prescription drug coverage. The voice of Medicare beneficiaries is currently louder than the uninsured, but this may not be the case in 5 to 10 years, with increasing numbers of uninsured middle-class voters. In 2001, the largest group of newly uninsured—800,000 people—had incomes in excess of $75,000/year (10).
With further consolidation and administrative simplification, the ideal framework would consist of two parts: 1) a private insurance system for those who are employed as well as those individuals and families who buy private coverage; and 2) a "safety net" consisting of all of the support programs of Medicare, the Veterans Administration Medical Centers, and the "safety net" system developed over the previous 10 years.
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Quality
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Data: from denial to acceptance.
The elements of quality have recently been defined by the Institute of Medicine (11): safety, effectiveness, efficiency, timeliness, patient-centeredness, and equity. Many of these are now being measured and routinely reported. In New York State, results from individual cardiovascular surgeons have been featured in the newspapers, with improved surgical results; some of these improvements have been linked to public reporting (11). Nonetheless, public reporting of data has its problems, and as physicians, we need to take part in improving data collection and reporting. If our data are flawed, we must not deny the numbers, we must correct them; we need to move rapidly from denial to acceptance.
Data collection and performance improvement requires greatly improved information systems. Data standards must be created so that, with the development of improved electronic medical records and regardless of proprietary software, the data can be gathered and reported regionally and nationally for comparison. We must ultimately tie patient data to automated billing based on the electronic data, thus markedly reducing billing costs as well as decreasing the need for complex compliance programs. Such information systems will permit the existence of multiple payers in a seamless environment, where the information required and screens are similar, regardless of the payer (6). Ultimately, an "electronic clearinghouse" of data should be developed with appropriate confidentiality, perhaps at the Agency for Healthcare, Research and Quality, linking coverage, billing, and medical data and allowing for data collection, analysis, and answers to important questions on coverage, quality, and cost.
Payment guidelines.
Despite over 20 years of experience with practice guidelines, we as doctors, under-utilize them. It has been demonstrated that between 13% and 35% of certain procedures that are done have been judged not to be indicated; guidelines for clinical preventive services are followed <50% of the time (12). There is variation in practice across the country that cannot be accounted for on the basis of degree of illness, and this variation should be reduced; some communities that receive more care in general have no better outcomes than communities that receive less (13).
I believe it is time to "get with the guidelines" (14) and adopt evidence-based practice. Since it has been demonstrated that physicians respond to payment policy, I propose that our practice guidelines be rewritten and used for payment. In the ACC/AHA (American College of Cardiology/American Heart Association) guidelines, "class III" indicates what should not be done (15). Regardless of specialty, all guidelines should have class III. This class should be expanded, where assignment to class III(b) would be based on controlled studies indicating that a procedure or treatment should not be done; class III(a) would include those treatments and procedures thought clearly not to be indicated, but for which adequate controlled studies were not available. Payment policy could be created where class III(b) was not reimbursed and where class III(a) could require individual justification from the physician. It is well known that guidelines are not applicable in certain cases, and appeals mechanisms will need to be developed. These guidelines would be used for payment; therefore, more physicians from outside the involved medical specialty will need to be added to guideline committees to provide additional objectivity. The guidelines also must be updated as frequently as possible to reflect current practice.
Practice guidelines should be developed not only for physicians but also for our patients, because they are appropriately taking more interest in their healthcare. It is only in a partnership with our patients that health will truly improve. For example, physician guidelines for prevention of cardiovascular disease have been developed, but if patients do not change their lifestyle by smoking cessation and appropriate weight control, physicians will ultimately be unsuccessful.
Payment for quality.
It has been said that physicians should not be paid for higher quality, because high quality is expected of all of us: a part of professionalism. This is true, and we must set standards for practice below which we may not fall. However, as has been suggested by the Institute of Medicine (16), there should be a mechanism to pay for quality and service above that level, for example by giving incentive for performance measures (e.g., percentage of eligible patients on a beta blocker). It remains a hypothesis whether "payment of physicians for quality" in fact improves quality. It may be that patients should also be "paid" for following guidelines, either with reduced premiums or other incentives. Let us begin now to initiate pilots on physician and patient incentives.
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Cost
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Challenge "routine" practices.
We must continually challenge what we do. For example, we must begin to understand the need and timing of "routine" return outpatient visits and the tests that are performed. Many of us tell patients to "return in one year," without real basis. In 2001, 22% of patients had 11 doctor visits or more (17). We need to counsel the "worried well" without seeing them as frequently. It is not clear that these were all necessary; if telephone, television, and/or e-mail are effective means of follow-up, they should be used and reimbursed. On the other hand, we must discontinue practices of questionable value regardless of their reimbursement. It has recently been demonstrated that adherence to new guidelines for routine preoperative care reduces cost (18). We must stimulate health services research on issues of effective and efficient practice and then use the results to inform our guidelines.
Gap between possible and affordable.
However, some procedures and treatments are more effective and more expensive, and we must ask whether they are worth the cost. Here, we physicians cannot act as individuals but as public advocates and take part in broader discussions on how we will make decisions in the most responsible way to improve the health of America. There will clearly be an ever-widening gap between what is possible and what is affordable. Methods will need to be developed to deal with the complex decisions of what should and should not be done, including consideration of broad concepts such as ethics and equity. We must also expand the horizon of cost-effectiveness analysis to include the implications of prevention and screening strategies as well as new diagnostic and therapeutic interventions, not only on the present disease but also on the potential health or disease for the remainder of the patient's life. Prevention may reduce the cost of the present disease (or eliminate it) but markedly increase the overall cost when a patient gets the next disease. Cost must then be placed in the context of effectiveness, as measured by extending years of healthy life. This is our goal, not saving money. On the other hand, in a world of limited resources, a reasoned approach to coverage policy must be developed beginning with evidence, including information on patient and societal preferences, ethical principles ultimately leading to the criteria for evidence-based benefits.
Physician shortages.
While predictions of the adequacy of healthcare workforce have been incorrect in the past (19), there are secular trends that are undeniable. The leading edge of the baby boomers is currently 58 years old and, in seven years, will be 65, when statistically, healthcare utilization will markedly increase (20). We have improved our care for patients with chronic disease, whether heart disease, diabetes, or cancer, thereby increasing the prevalence of patients with those diseases in the population. Finally, there will be the increased need for new subspecialties such as genetics. With this increase in demand, the supply of new physicians seven years from now is established: our first-year medical students will finish residency in 2009. With the increasing number of women in medical school and their absolutely appropriate need to work fewer hours, as well as the also appropriate desire for our graduating men to be with their families, the hours worked by our younger physicians (and perhaps some older physicians as well) are likely to decrease. Estimates have been made that between one-third and one-half of physicians over the age of 50 will retire by the end of the decade (21). The geographic maldistribution of physicians is likely to worsen as jobs become available in places currently considered to be saturated with physicians.
There are a number of possible approaches to this anticipated physician shortage. We physicians should do workforce studies such as those currently underway by the ACC. These studies should demonstrate the size and nature of possible shortages as well as their geographic distribution, so that the supply of all types of practitioners can be addressed appropriately. During times when there are more patients than we can handle appropriately as specialists, there will need to be a realignment of education of others in the healthcare system (e.g., generalists, nurse practitioners) to work in teams. The Academic Health Center will be particularly valuable, not only in teaching teamwork but also in creating novel information systems to connect teams into virtual integrated delivery systems across a region, which will allow patients to be cared for close to home, while decreasing the need for travel to the medical center by using telemedicine and e-mail for access to the latest advances. As the workforce issues become more apparent, the justification for stable funding for undergraduate medical education will be even clearer. As with most supply/demand problems, physicians in short supply will increasingly demand adequate payment, thus increasing—not decreasing—cost.
Malpractice.
One of the greatest areas of waste is in our malpractice system. Rates for malpractice insurance are now limiting access to care. We must have tort reform by limiting non-economic awards and by developing alternate approaches to lengthy trials (22). However, as physicians, we must also do our part: we must take an approach to medical errors that involve change in systems. Despite all these system changes, some physicians commit repeated errors. We need to identify those of our own who require remedial education or even limitation or discontinuation of practice. We owe that to our patients and to ourselves as professionals. Although it will be controversial, we must consider use of guidelines in liability. For example, if we decide we will not pay for class III(b), perhaps if a patient was harmed by a procedure in class III, the guideline could be used to support the claim. If the basis for suit could be narrowed to class III(b), perhaps the cost of "defensive medicine" could decrease.
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Physicians: attacking coverage, quality, and cost
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We must begin now: each of us should commit to working in at least one of these areas. In quality, we as physicians can have the greatest effect. We should rapidly adapt and adopt information systems that permit data collection and transmission; we should compare our own data to those of our colleagues without defensiveness; we should use these data to create and improve practice guidelines for physicians, other caretakers, and patients, and develop ways to incorporate these guidelines into our daily practice, whether by the reminder of improved payment or the reminder of best practice generated by a computer-based medical record. We must educate our patients and help them to be more accountable for their health; we can pilot model systems for individuals using patient and physician preventive care guidelines to improve wellness. Patients could have lower premiums, and physicians could be given incentives for following the guidelines. We must decrease cost by eliminating waste. We must pay attention to our practice guidelines and continue to improve and apply them. We must begin to work in teams and leverage the abilities of each team member to care for patients as the practitioner shortages worsen. We must support tort reform and improve our systems to reduce medical errors. Finally, we can provide medical input to achieve coverage for all. The ACC has endorsed a plan proposed by the American College of Physicians (23), and Senator Jeff Bingaman (D-NM) has introduced a bill that embodies many of these principles. We can begin now to help create state demonstration projects as suggested by the Institute of Medicine (24), piloting new systems of coverage as I have outlined for a complete safety net and for private insurance for individuals and similar businesses through mechanisms to spread risk such as "insurance exchanges" or approaches similar to FEHBP.
Physicians, coverage, quality, and cost are intertwined as a caduceus. Let's work with our patients to improve their health—one at a time—by improving systems of care. Together we can make real progress.
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References
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- U.S. Census Bureau 2002. "Health insurance coverage: 2001" Online. Available at http://www.census.gov/prod/2002pubs/p60-220.pdf. Accessed January 2, 2003
- Gilmer T, Kronick R. Calm before the storm: expected increases in the number of uninsured Americans. Health Affairs. 2001;20:207–210[Free Full Text]
- Pilote L, Racine N, Hlatky MA. Differences in treatment of myocardial infarction in the United States and Canada: a comparison of two university hospitals. Arch Intern Med. 1994;154:1990–1996
- American College of Cardiology. "Principles For Health System Reform" Online. Available at http://acc.org./advocacy/advoc_issue/health-reform.htm.\. Accessed January 2, 2003
- Lambrew JL, Garson A, Jr. Small but significant steps to help the uninsured. New York, NY: The Commonwealth Fund, 2002: Publication #585
- Garson A Jr. The U.S. healthcare system 2010: problems, principles and potential solutions. J Am Coll Cardiol. 2000;35:1048–1052[Free Full Text]
- Davis K, Schoen C, Doty M, Tunney K. Medicare versus private insurance: rhetoric and reality. Commonwealth Fund 2002;584:1–5
- Ku L, Cohen Ross D. Staying covered: the importance of retaining health insurance for low income families. Commonwealth Fund 2002;586:1–5
- Singer SJ, Garber AM, Enthoven AC. Near-universal coverage through health plan competition: an insurance exchange approach. Meyer JA, Wicks EK. Covering America: Real Remedies for the Uninsured. Washington, DC: Economic and Social Research Institute; 2001. p. 155–171
- Broder JM. Problem of lost benefits is reaching into the middle class. New York Times, November 25, 2002, Page 1
- Institute of Medicine, Committee on Quality of Healthcare in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. p. 39–60
- Guadagnoli E, Landrum MB, Peterson EA, Gahart MT, Ryan TJ, McNeil BJ. Appropriateness of coronary angiography after myocardial infarction among Medicare beneficiaries: managed care versus fee for service. N Engl J Med. 2000;343:1460–1466[Abstract/Free Full Text]
- Fisher ES, Wennberg JE, Stukel TA, et al. Associations among hospital capacity, utilization, and mortality of US Medicare beneficiaries, controlling for sociodemographic factors. Health Serv Res. 2000;34:1351–1362[Medline]
- American Heart Association. AHA healthcare quality improvement program recognized by U.S. Department of Health and Human Services. Am Heart Assn News 2002;1. 2/28/02
- Zipes DP, DiMarco JP, Gillette PC, Garson A Jr. Guidelines for clinical intracardiac electrophysiologic and catheter ablation procedures: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 1995;26:555–573[CrossRef][Medline]
- Institute of Medicine Committee on Enhancing Federal Healthcare Quality Programs. Leadership by example: coordination of government roles in improving health care quality. Washington, DC: National Academies Press, 2001:1–24
- Judd A. The worried well. ABC World News Tonight, October 29, 2002
- Frolich JB, Karavite D, Eagle KA. American College of Cardiology/American Heart Association preoperative assessment guidelines to reduce resource utilization before aortic surgery. J Vasc Surg. 2002;36:758–763[Medline]
- Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Affairs. 2002;21:35–45
- Meyer JA, Wicks EK. Covering America: Real Remedies for the Uninsured. Washington, DC: Economic and Social Research Institute; 2001.
- Greene J. Physicians enticed into early retirement. Am Med News 2000;July 24:1
- Sage WM. Principles, pragmatism and medical injury. JAMA. 2001;286:226–228[Free Full Text]
- Healthcare affordability, responsibility and equity act of 2003: S.1030. Available at http://www.acponline.org/hpp/healthcare_act.pdf. Accessed January 2, 2003
- Institute of Medicine Committee on Demonstrations to Improve the Healthcare System. Chapter 5: State health insurance coverage demonstrations. Washington, DC: National Academies Press, 2002
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Abstract
Coverage