Reform or Innovation: Common Sense Should Prevail

This week I ventured into the blogosphere in search for updates or any innovative idea that may contribute to the momentum of health care reform. Soon after Google’s announcement of its health initiative on February 28, I wrote about the benefits a national health information storage system will bring. I am delighted to find the post, “Health 2.0: Getting in PHR, Privacy and Deborah Peel issue off my chest,” written by Matthew Holt. He provided very sharp counter arguments to the allegations that such information would violate patient’s privacy. By separating myth from reality, he brings common sense back into discussion of such an important subject. According to Matthew, the real issue is not of violation of patient’s privacy, but is in the inefficient use of medical data that causes harm and wastage. I found another post, “Concierge Medicine from a Doctor’s Perspective” by David R. Donnersberger , MD, JD, very interesting. Though it is not a brand new topic, this business model appears to be gathering momentum. Under “boutique medicine” or “concierge care,” physicians ask patients to pay an annual retainer fee. In exchange, patients get greater access and personalized service. According to Darin Engelhardt, the Chief Financial Officer and General Counsel for MDVIP, a Florida based company that helps doctors transition to boutique practices, “95% of the company’s 40,000 patients renew their annual memberships each year. The business model appeals to over-worked and over-booked physicians. I wish to present my comments on these two posts for you below.

"HEALTH 2.0: Getting the PHR, Privacy and Deborah Peel issue off my chest"
Comment:
Thank you for drawing our attention to the right focus. As you wrote, “the biggest problem with the United State’s health care system and its use of technology is not privacy violations. It is the inefficient use of data causing harm (and costs and poor quality care).” You managed to introduce common sense back into the discussion; the setting up of national health care information adds no additional risk to patient’s privacy rights than what actually exists now. The information uploaded to the system is a mere copy, not the original. In fact, what is uploaded can be de-identified, thus offering patient privacy protection. Naturally, a well-designed system will preserve consumers’ right to decide who gets access to the data. Perhaps, consumers or patients may specifically block insurance companies, financial institutions, and employers from accessing the information. This will address the concern that these business entities may use the information to deny insurance coverage, loans, or employment, which creates whole new classes of people who are unemployable, uninsured, and dependent on the government, as Dr. Deborah Peel of Patient Privacy Right Foundation claimed. I believe consumers will appreciate that with Microsoft, Google, and Dossia getting into the business; the overall PHR industry privacy quality will improve. The Health Insurance Portability and Accountability Act, written before any PHR vendors came into business, is not updated but can be amended or modified to come up with a broader “covered party” definition, and to standardize patient privacy disclosure code for PHR vendors requiring the sale of data only in a de-identified format. We therefore should not use any loophole in HIPAA (logo shown to the left) to deny the value of a national health information system. A consumer will share personal information if there is a return or benefit. A borrower gives up his/her social security number in the loan application and allows a bank to access his/her credit report. We provide our medical history, together with the social security number and other personal data in the purchase of a health insurance policy. As a traveling person, I want my personal health information on a system that is secure, accurate, and readily available to those who need to take care of me, especially in times of an emergency. What good is my personal privacy will do for me if I no longer exist to give meaning to it.

"Concierge Medicine From A Doctor’s Perspective"
Comment:
Thank you for sharing this growing trend. I believe that our health care system is very vibrant, notwithstanding its shortcomings and challenges. Consumerism and capitalism play a big part in our health care system. Consumers want choices, and service-providers seek returns. Boutique medicine or concierge medicine (as shown in the image to the right) meets both expectations. I am not suggesting that financial reward is everything in our economic system, nor is the only deciding factor in a supply and demand equation. For a physician, a small client base means more time devoted to patient care and advocacy, along with continuing medical education and family life. While a care-giver may have to sacrifice financial gains, getting greater satisfaction from long-standing doctor-patient relationship offers a different kind of gratification, which an over-worked, over-booked physician will miss. A reduced patient load for physicians often translates into longer and same-day appointments, better coordination with specialists, and more emphasis on preventive care. Concierge care may potentially result in a two-tiered medical system based on wealth of the patients. Some decry concierge care as another step toward a medical system in which the rich get no-wait examinations and the poor sit for hours just to see a HMO doctor for 15 minutes. This is simply the nature of a free market. According to one comment on your blog, in Europe, where the universal health care system is long established, a significant percentage of people pay out-of-pocket to see specialists, avoid long waiting rooms, get MRIs, more appointments sooner, or see a doctor who is said to have better training or personality. While the concept sounds ideal, my concern is that physicians who choose to take part in this boutique medicine business model may not cancel all their contracts with third-party or government payers. As a result, doctors simply commercialize the doctor-patient relationship, and patients who pay the fixed annual fee in anticipation for premium services and attention will not get their bargains. Such business model is not widely available. According to the General Accounting Office, in 2004, there were just 146 concierge physicians in the U.S. My other concern is what will happen to the established doctor-patient relationship when one party has to relocate, especially for a patient who is very accustomed to a concierge care moves to a new region where such service is not available.

Public Trust Matters: Keeping the Big Pharmaceuticals In Line

In my previous post and following Google’s announcement to launch a personal medical record service, I raised the hope that the United States will eventually have a national health information storage system that will help deliver better care, lower costs, and reduce medical errors, in spite of some initial resistance. I believe such resistance can be overcome over-time since the American society has a good track record of embracing internet technology. Underlying that optimism is that public trust remains unshaken by the conduct of health care community – care providers, the pharmaceutical industry, and health insurance companies. Big, publicly-traded drug companies are powerful players in the health care community because of their financial resources as well as their control over the new drug supply. Unfortunately, they do have a questionable reputation through years of careless product launch, aggressive marketing tactics, and to a lesser extent – overcharging the public and the government. Although these companies are financial giants, they can be nudged into building better public confidence, as some of their perceived influence could be exaggerated.

The latest confidence-shaking incident involved Merck and Schering-Plough, who manufactured the drugs, Zetia and Vytorin, a combination of Zetia and Zocor, to treat high cholesterol. Worldwide, about five million people are now taking the drugs, according to a New York Times report. A two-year clinical trial that ended April 2006 raised questions about the medicine’s effectiveness and about the behavior of the pharmaceutical companies. The trial was meant to prove that Vytorin’s combination of Zetia and Zocor would reduce the growth of fatty plaque more than Zocor alone. Instead, the plaque actually grew almost twice as fast in patients taking the combination. Due to the drug’s significant contribution to their profitability, it aroused suspicions that the companies had deliberately delayed the release of data two years after the trial ended. The House Energy and Commerce Committee is investigating the delays.

Reflecting the general public suspicion about the drug companies' marketing activities, there are many articles written about their influential relationship with physicians. Part of the $671 million settlement, which Merck announced on February 8, 2008, was related to charges that it gave doctors freebies and gifts to induce them to prescribe its drug. As reported in the New England Journal of Medicine (November 2007), Eric Campbell, the co-author of the survey report, disclosed that over 90% of physicians take something from drug companies. The most common freebies are food and drug samples, which about 80 percent of physicians reported receiving, a smaller percentage (25-35 percent) of physicians reported receiving substantial payments in the form of reimbursement for professional travel, consulting, and servicing on speaker’s bureaus or advisory boards. According to Eric Campbell, "Although most physicians deny that receiving free lunches, subsidized trips, or other gifts from pharmaceutical companies has any effect on their practices....companies wouldn't spend $19 billion each year establishing and maintaining them [if this strategy didn't work]."

It is unrealistic to expect the big drug companies will not aggressively market their products, having invested a large sum of money on research and development. According to the Congressional General Accounting Office (GAO), the pharmaceutical industry spent about $30 billion on R&D, and about $20 billion on marketing and advertising. About half of the $20 billion is accounted for by the free medicine provided to doctors. The big drug companies maintain their relationship with the physicians through the large army of drug representatives, who are, by and large very intelligent and good at cultivating personal relationships. I believe such contacts or relationship is necessary and helpful, if it is limited to carry out informational programs. Today, a physician, especially a general practitioner under the network of a HMO, has limited time for a constant product update. I am not disputing that each physician should keep abreast of any new drugs launched, and our internet-delivery system can make such attempt an easy task. However, physician's continued learning can always be enhanced in a one-on-one “tutoring” session, when a drug representative visits. Due to complexity of new products, drug representatives could play an important role to disseminate results of this post marketing studies. It is also likely that through these calls, some of the beneficial drugs which are under-prescribed can be brought to the physicians’ attention. I believe such relationships can be beneficial to new drug developments. Many of the drugs currently on the market simply would not exist if it were not for such close relationships whereby physicians enroll patients in manufacturer’s clinical trials, and provide valuable advice on the drug development. Some think that such marketing call may result in a physician giving preferential treatment to the drug which the visiting drug representative promotes. In reality, and in our intense competitive environment, physicians do see other representatives from the other manufactures. Competition among manufactures itself will offset the effect exerted by the other drug representatives. Further physician’s prescriptions could be subject to the insurance company’s approval. An insurance company may request that the dispensing pharmacy to substitute a branded drug with a generic one whenever it is available. I do not see how giving physicians drug samples is an issue, since the samples are not for sale. Some physicians may use free drug samples to help low-income or uninsured patients, especially if the sample is of a new, expensive drug, which would treat patient’s condition. While the influence of the freebies on physician's behavior is real, it is limited.

The health care community is doing a good job in constantly bringing this freebie issue alive for discussion. This is part of the effort in keeping the powerful drug companies in line with certain standard of ethics. Within the professional body, in limiting the undue inference, the American Medical Association has recommended physicians not to accept gifts over $100. The industry has always been working toward upgrading a set of codes of conduct. Even Congress, which is thought to be heavily influenced by lobbyists from big drug companies, introduced legislation last fall to make drug companies disclose how much they have spent on gifts to medical practitioners. For now, we may rely on people like Cynthia Fitzgerald (as pictured above) in the health care community to be a willing whistle blower as another form of deterrence. With all these efforts acting collectively, and despite all the happenings and discussions, I do not feel we have a fractured trust that will end our health care reform hope.

Click by Click: Joining the Health Provider and Consumers Together

This week, I again browsed the internet to get an update of health care development. I came across some quality resources that complement the websites and blogs I had previously listed in my link roll in hope of promoting a greater understanding of matters concerning health care. These additions meet the standards set by Webby Awards and IMSA criteria. Some sites may appear to serve the same purpose, but they differ in emphasis and breath. MerckMedicus was the first website that caught my attention, displaying highlights regarding medical news and consumer news. The visual design and fonts deliberately adopt a daily newspaper format to look like one, but unintentionally leads to congestion. The Medscape site also features latest news and displays prominently specialty spotlight but blended together well with effective pictures and graphics to encourage further navigation. Some may find the content too specialized for easy reading. The Over-My-Med-body blog uses an eye-catching skeleton to stir emotion and draw interactions. I was not surprised to discover lively postings commenting on a wide spectrum of health care issues intellectually and basing on real-life experiences. If its content is better organized around a singular or related issue, overall experience will be enhanced. The ScienceRoll blog uses a combination of video presentation and simulation to generate interest and comments. Its blogroll leads me into an extensive network of medical communities. However, my arrival to a particular community could have a shortcut if the Blogroll were to be repositioned in the front. Despite facing a dull visual design, I somehow stumbled upon the ORlive site, which I later felt irresistible following through a virtual operating room experience that was guided by a step-by-step professional narration. While ORlive site is very limited n its functionality, Quality Health site seeks to achieve maximum interactivity by offering quizzes, forums, question and answers, and videos in a somewhat crowded visual design. Dlife site cannot be misunderstood for other sites with a rolling advertisement flashing out messages at the center with surrounding graphics pointing to other useful information and "Blogabetes" (as pictured above), a blog for diabetics to discuss their personal experiences, Notwithstanding that of other written messages, the font is too small for ease of reading. Similarly, American Academy of Pediatrics website is very distinctive, strategically displaying faces of infant and young children. The content is well organized to help parents access straight into a subject of immediate interest, which includes health and development issues involving children of different age groups. Visual design could be more creative or artistic to enhance weak experience. HealthAffairs gives the impression that it is a no-nonsense blog with an editorial format and authority which is reflected in a subtitle – “The Policy Journal of the Health Sphere”. The font and content uphold that image. I find the postings intellectually stimulating and current. However, a more contemporary visual design may make it less intimidating. Moving along with a serious mood, I had expected the Medical Library Association site to be as stiff as the HealthAffairs Blog. It turns out that it has a good artistic visual design incorporating elements of fun, art, and creativity. I did find useful information for health consumers though the site appears to primarily serve the professionals. After all, click by click, I found my search enjoyable and rewarding.

The Emergence of a Health Information System: A White Elephant?

Health care is an important issue in the United States, as 47 million Americans are without health insurance coverage, and spending is projected to rise to $4 trillion or 20% of GDP by 2016. In a report prepared for the Commonwealth Fund Commission on High Performance Health System, the authors recommended four key areas of policy adoption that will simultaneously improve health care access, quality, and overall health of the population. The top priority is to produce and use better information for health care decision-making. This means having a national health information storage system or network of systems that can be updated regularly, efficiently, and be accessible at the point of care. Such a system holds the promises of delivering better care, lowering costs, and reducing medical errors. It also tends to benefit stakeholders, such as providers, payers, and the hospital systems.

On February 28, Google unveiled its plan to launch a personal medical record service, at a health care conference in Florida. Under this plan, a password-protected Web service (as shown to the left) stores health records on Google computers, with a medical service directory that lets users input doctor’s records, drug history, and test results. Currently, Google is reported to be in the process of signing deals with hospitals and companies including medical tester Quest Diagnostics Inc, Health Insurer Aetna Inc, Walgreens and Wal-Mart Inc pharmacies. Google’s announcement is a significant addition to the prevailing health care reform momentum. Google’s biggest rival, Microsoft, has a similar service (as pictured below) offered under its Health Vault services. Other start-ups in the field include Revolution Health, a company backed by former AOL Chairman Steve Case. The U.S. government has ambitious plans to put in place a national network to share health data with all relevant parties by 2014. With the involvement of market participants like Google and Microsoft, the nation may reach the finishing line sooner than the United Kingdom.

In 2002, the United Kingdom embarked on a similar program to computerize patient’s health records and to make them available at the point of care by doctors. The program was reported in the U.K. Parliament to be the largest IT work in the U.K., involving a budget of £2.3b (about US $4.66 billion) over a three year period. The budget was later increased to £12.4bn extended over 10 years. Edward Leigh, the chairman of the Commons Public Accounts Committee issued a report in April 2007 saying, “This is the biggest IT project in the world and it is turning into the biggest disaster.” Unlike in the U.K., the U.S commercial enterprises have taken charge of the enormous project. According to Deloitte Touche Tohmatsu, there are currently more than 160 Health Information Exchanges (HIEs) in the U.S. that are either up and running or under development. Supporting the development is a large pool of technology-savvy individuals working in businesses like IBM, Oracle, Siemens, AG, and other small business concerns. They provide technical solutions such as the digitalization of records, adapting facsimile technology to feed information electronically, reducing individual identity to no more than a bar-code, and other functions that deliver the promises of patient-controlled and privacy protection that the system makes. Perhaps due to the lack of awareness of these technological advancement or possibility, patient privacy issue continues to show up in public discussion.

The World Privacy Forum raised the issue in February 2008 in its article entitled, “Why many PHRs Threaten Privacy.” The World Privacy Forum is a non-profit public interest research and consumer education group which was founded in 2003. I find the discussion rather restrained and limited to the technical loopholes which exist in the current version of the Health Insurance Portability and Accountability Act (HIPAA). HIPAA is a federal rule that establishes a baseline for health privacy in the United States, and was enacted in 1995 long before many smaller Personal Health Record (PHR) players came into business. HIPAA must be amended to close such technical loopholes in order to add credibility or integrity to such a health information system. In reality, such a system adds no additional risk to patient privacy than what already exists. Robert Gellman, the author of the above-mentioned article said, “The PHR record is a copy but not the only copy.” The health information about consumers held by their physicians, health plans, dentists, laboratories, pharmacies remains exactly where it was before it entered the PHR.

Looking at the Microsoft Health Vault website, one gets a sense that it is sensitive to patients’ privacy rights. The website highlights its privacy commitment policy on the top right (see image above). In the same manner, and in announcing the launch of Google’s Health service, its CEO Eric Schmidt seemed to understand the patients’ desire to have full control; the individuals’ right to privacy; and the security issue that goes with it. He began his key note speech on the subject of privacy and security before he talked about the platform, portability, and other features in the system. It is reasonable to assume that both Google and Microsoft have the financial resources to educate and convert new users. After looking into the world of E-bay, E-trade, Amazon.com, and internet banking, where consumers willingly provide their personal information and transact electronically at the point of consumption or need, I can confidently expect the emerging health information system to be eventually widely accepted. According to the New York Times, 20% of the U.S. patient population has their records computerized rather than on paper. This pool of patients provides a good foundation upon which to build a national health information system.

Qualities of a Good Website: Presentation, Content, Interactivity, and Usefulness

This week, I continued to probe the Web for updates on health-related issues. I selected ten websites and blogs and listed them at the linkroll on the right as my primary resource pool. Here is my evaluation of each blog based on the Webby Awards and Illinois Mathematics and Science Academy (IMSA) criterion.

The Physician’s First Watch website’s primary strength is in its rich and current content targeting visitors who primarily want to be alerted on the latest medical news or development. Visual representation and functionality take the back seat. Whereas WebMD site takes a different route – it offers interactivity (employing polls, message boards, and quizzes, and video presentations). It is a good website for advice and information, but not opinion. Its structure and navigation is user friendly. WebMD is one of the sites a visitor will bookmark for future references. On the other end of interactivity is the Health Care Renewal blog. It looks like a blog for medical professionals. The opinion expressed is strong with links to support its view or opinion. Interaction and visual representation are given low priority. Its structure and navigation is elementary. Similar in structure, The Health Care Blog discusses the latest health care developments. Its content is technically-oriented; the language is concise. Though weak in visual design and interactivity, the blogger occasionally adds sound clips to enhance overall experience. The opinion expressed is strong, but is balanced with views promoted by others through the links attached. Popularly recognized, the Wall Street Journal's Health blog adopts its proprietary newspaper format. The blog's journalistic language style and creative photos (as shown on the left) draw attention. It caters to the general population; hence structure and navigation are made simple. Its blog timing and usefulness exceeded my expectation. In the same manner, the National Institutes of Health (NIH) website caught my attention with attractive visual representation. Highlighting the recent hot topics in its “In the News” board enhances its usefulness, and its added functionalities like NIH Radio, Podcasts, and slide shows improve visitors' overall experience. However, interactivity seems lacking. Moving from the strength of visual presentation, Mayo Clinic’s website impresses visitors with a broad range of services highlighted on a tool bar. It entertains visitor’s emergency situation with a “Find It Fast” panel. Navigation is easy, and its interactivity is facilitated by quizzes or submission of personal questions. Podcast, links to blogs, and video shows enhance visitor’s overall experience. Catering to the medical professionals, Merck Manuals Medical Library site is plain looking. Its content covers a broad range of topics as a library would. Interactivity is obviously absent. Navigation is user-friendly. Multi-media are provided for better illustration in some subjects. No website in my link roll provides such extensive interactivity as the Wrong Diagnosis website. It provides a forum for visitors to enquire about a medical condition or write about one’s related experience. Visual design incorporates the listing of top-10 diseases to draw attention. A video center is built in to explain various diseases, making overall experience rewarding. As expected, Discovery Health’s website provides content that everyone in the modern society craves for, covering the latest news or information on health, healthy living, diseases, and delivers them with animation, graphics, and video presentations. It offers quizzes to promote interaction, and creates a forum for its community. Its easy navigation is vital to such functionalities. Positioning itself differently, Best Health’s website combines health, surgery procedure and drug information in its content using animation and video presentation to promote understanding. Its blog influence is wide, allowing visitors to tap into other resource centers for extended research through an easy navigation.

Need More than a Universal Health Care System: Grassroot Participation Is Important

Like many in the United States, I am interested in the health care issues we face. In TIME magazine’s latest poll among the under-30 voters, the main concern for 62% of the respondents is the ability to afford health care coverage. In our current economic environment, employment does not guarantee access to health care. I visited the Blogosphere to update myself on the latest thoughts and developments in our health care issue this week. The first post I found, “Health Insurance Can’t Be Optional,” was published by Louise Norris, a co-owner of a health insurance brokerage company, Insurance Shoppers Inc., in Broomfield, Colorado. She discussed the implementation of a universal health care coverage in Massachusetts and favored a mandatory subscription. In the second post, “A Modest Proposal For Reforming the Health Insurance Industry" Winston Apple, author of the book Edutopia: A Manifesto for the Reform of Public Education, promotes an idea of catastrophic health insurance as a means to expand coverage and reduce health care costs. I offer my comments on the author's blogs as well as below.

"Health Insurance Cannot Be Optional"
Comment:
Massachusetts initiated a new universal health insurance system using a combination of incentives and penalties to get citizens to sign on (see image on the right of Mitt Romney signing Massachusetts Universal Health Care law). Massachusetts residents who are uninsured as of December 31, 2007 will lose their personal exemption – worth $219, when they file taxes in the spring. If they continue to lack health insurance into 2008, they will be taxed 50% of the price of the least expensive health insurance plan available. According to a report in the Wall Street Journal in February 7, 2008, only half of the previously uninsured currently enrolled; and no less than 20% did not qualify for subsidies and were granted exemptions because the costs were too much of a hardship (note the per capital money income of Massachusetts is reported as $25,952 for 2006). One lesson we could learn from here is that, in spite of government intervention, the cost of health care coverage in the U.S. could still be unaffordable. In the real world, it is difficult for us to acquire something that is not affordable. On the other hand, I would agree that health care coverage cannot be universal without a mandate, which may result in garnishing someone’s wage for failing to obtain health insurance coverage. Using the liability auto insurance as a parallel to present the logic of a mandatory health care insurance coverage for every U.S. citizen may not gain broad support because U.S. citizens have a choice of not owing an automobile.

The issue of affordability arises from the fact that everything has a price. Massachusetts’ mandatory health care insurance is costing the government about $158 million today, and is projected to reach $1.35 billion by 2011. On the other hand, Massachusetts is expected to incur a $1.2 billion budget deficit in 2008. To balance the budget in 2011, some other areas of government services, e.g. education may have to face deep cuts, or the tax needs to be raised. The current economic slow down will not help increase government revenue without new taxes. I believe health care reform in the U.S. will take a gradual approach, and it is going to be built upon the system we already have. In a few years' time, we will learn from the Massachusetts experience, what are the facts and myths of a universal health care system - its promises, the cost of delivering the promises, and the effect on people providing the health care services.

"A Modest Proposal For Reforming The Health Insurance Industry"
Comment:
The catastrophic illness plans are interesting, but may not contribute much to solving the problem of providing coverage to those currently uninsured. The product idea is not new, insurance companies do offer "high-deductibles" to cater to individuals who have affordability problems. If it is not mandatory, not all car owners may buy liability insurance. Our "health care" crisis is not just a health insurance crisis. In reality, health insurance companies are becoming the popular whipping boys. They are blamed for inefficiency, and bureaucracy, and being profit-minded (Blue Cross/Blue Shield are not-for-profit) at the expense of patients' well-being. We are not sure if we can safely remove the roles of insurance companies from our system without creating another form of crisis. Substituting the insurance companies with a government body may not be a better solution, as seen in the public transportation system or our public education system.

The aging population, the availability of more expensive advanced technology that treats diseases that were terminal previously, and even economic growth all contributed to our rising health care expenses as a nation. In the book entitled "The Fattening of America," by Eric A Finkelstein and Laurie Zuckerman, as shown on the left, it was reported that over two-thirds of Americans are overweight or obese. Over the past three decades, the number of obese Americans has more than doubled, across the socioeconomic spectrum, and for all racial and ethnic groups, most dramatically, for America's children. According to Eric, America's growing waistline is a by-product of our economic and technological success. It has been estimated that the annual cost of overweight and obesity in the U.S. is $122.9 billion, a sum that is comparable to the economic costs of cigarette smoking.

All health care crises have to be tackled on all fronts, and as you pointed out, reform could involve a grassroot movement. You suggested that we should band together to limit the role of insurers with or without help from the government. On the positive note, grassroot organizations have already started to direct the effort in discouraging smoking, addressing obesity, and adopting a healthy lifestyle. These are sure steps in bringing health care burden under better control in the long run.

Reforming the American Health Care System: Build on What We Already Have

Unlike previous years, youth participation in this year’s presidential election is very strong. TIME magazine in its February 11, 2008 issue listed "fear factors" in the polls conducted among the under-30 voters. At the top of the list, 62% of the respondents were concerned about not being able to afford health care; which was an even bigger concern than not being able to find a stable, well-paying job (ranked third at 58%). Their concern can be understood against the background that 47 million Americans, or 11% of the population, were without health insurance in 2005 (see chart to the left). According to the Henry J Kaiser Family Foundation Employee Health Benefit 2006 Annual Survey, a third of firms in the United States did not offer health care coverage. Due to high insurance premiums, many small employers cannot afford to provide health benefits. Employment is no longer a guarantee of health care coverage. Reforming the U.S health care system involves both expanding the coverage and controlling the growth rate of expenditures, which will result in better affordability. This efficiency can be achieved by improving every aspect of the health care chain and requires collaboration among the stakeholders in the system.

Although many people presently expect Congress to establish a cost effective health care system for all workers and their families, regardless of existing health, income level, or employment status, like other developed nations (as shown in the map on the right), this idea is not new. In his State of the Union address on January 5, 1949, President Harry Truman called for a nation-wide “system of prepaid medical insurance which will enable every American to afford good medical care.” More than fifty years later, we have yet to see the proposal become a reality. It has a lot to do with our culture, which embraces consumerism and capitalism. Within such a culture, patients want choices, and care providers look for returns. We allow market forces to allocate resources. Therefore, it is not surprising if the U.S. has a higher per capital number of health care professionals and high tech equipments.

Any universal coverage does come with a heavy price tag. According to the February 7, 2008 report in the Wall Street Journal, Massachusetts’ mandatory health insurance is costing the government about $155 million a year, and is projected to reach $1.35 billion by 2011. On the other hand, Massachusetts is expected to incur a $1.2 billion budget deficit in 2008. To balance the budget in 2011, some other areas of government services, e.g. education, may have to face deep cuts, or raise taxes. Moreover, we must realize that the universal health care system has shortcomings. It does not guarantee the quality service and access to a needed health care specialist in a timely manner. The bureaucratic inefficiency does exist in a universal health care system as it is in a Health Maintenance Organization (HMO) set-up. The U.K and Canada started their Universal health care system in 1948 and 1984 respectively. In the Commonwealth Fund 1998 International Health Policy Survey, 10% of the public in Canada and the UK said they did not get needed care in the past year, comparing to 14% in U.S. respondents. In the same survey, 47% of the Canadian respondents said it was very difficult for themselves or family members to see a specialist or consultant, comparing to 40% of U.S. respondents. In addition, market feedback continues to show significant percentage of people in Europe pay out-of-pocket to see specialists, avoid long waiting rooms, get MRIs, or see a doctor who is said to have a better training or personality.

There is no lack of proposals as to how to improve our health system. Preventive policies can lower expenditures. A report published by Commonwealth Fund in December 2007 examined 15 federal policy options that have the potential to lower health spending relative to projected trends. They include policies that would use better information for health care decision-making (which I separately address in another post), promote health and enhance disease prevention, align financial incentives with quality and efficiency, and correct price signals in the market. According to the authors of the report, “combining [these] policies would capture the synergistic benefits of individual changes.” The savings could amount to $1.5 trillion in national health expenditures over 10 years, while also improving value in terms of access, quality, and health care outcome. In the U.S., substantial costs to the health system are related to care of chronic diseases, such as diabetes or heart disease. Reducing tobacco use and prevention of obesity would potentially save the system $191 billion and $283 billion respectively over 10 years. Individuals taking wellness programs and living a healthy lifestyle would help lower the rate of growth in treatment expenditure. However, resetting the price signals is a delicate task in light of the shortage in primary-care doctors and the potential shortage of general surgeons as the population grows, according to the recent AMA data. Complicating the challenge is another growing trend that the quality-of-life issues are changing younger doctors’ attitudes towards practice options (which I discussed in my post under Reform or Innovation: Common Sense Should Prevail). Under these conditions, any radical reforming approach may create more new problems than it intends to solve initially. There is no magic bullet to fully address rising costs and inefficiency in the system; every stakeholder has to play a part to improve through gradual innovation.

After the election year rhetoric settles down, the government can build on the existing health care system. The sooner we address these challenges, the earlier we will see the benefit. Funding our long-term health care needs, by raising taxes will not . Any reform will lead to consumers directly feeling the pinch in their wallets, each time they utilize the system. Hopefully, this may lead to individuals assuming a bigger responsibility in pursuing healthy lifestyles and making choices for preventive treatment or care. Government assistance should always be the last resort for those who fall through the cracks of the system.