Sunday, April 26, 2009
Getting more care into health care
Elizabeth Strother
Recent columns
- For those who have too little
- Time to gather mountain views
- Our blind spot on roads
- Following the money trail
From the RoundTable blog
The trouble with the U.S. health care system is we have no system.
None that is rational.
We see the evidence piecemeal, in countless stories, from one about a recent spaghetti-supper fundraiser at The Roanoker to help a couple pay for their cancer drugs, to last year's report about the nonprofit Carilion Clinic's grinding efficiency in taking patients to court to collect unpaid bills.
The stories might make us angry -- at hospitals, doctors, insurers, even sick people for the desperate straits they're in. Pick your preferred villain.
If we're angry, it might be because the stories make us scared. They should.
They warn of a health care system, and I use the term loosely, that we can't sustain. The proof is in the growing numbers not just of uninsured but of underinsured people, from working poor to solidly middle class, who are one serious health problem away from financial ruin.
Carilion CEO Ed Murphy met with the editorial board last week to share a presentation made to Sen. Mark Warner to explain the urgency. The arguments have been made many times, frequently on these pages. Murphy laid out data.
Numbers from the Congressional Budget Office showed growth in health care spending on a steadily upward trajectory.
Graphs compared America's average per capita spending and total spending as a percentage of GDP to those of other Western industrialized nations. Rapidly widening gaps from 1980 through 2004 left the U.S. way out front.
That could be good, or at least not all bad, if we had the health results to show for it.
We don't.
A chart compared deaths per 100,000 people from conditions considered "amenable to health care" in 1997-98 and in 2002-03. All 19 countries measured showed declines in the mortality rate. The U.S. had only a slight drop and the dubious distinction of being worst.
We spend more for lesser results. What can we do about it?
The answer, Murphy thinks, lies partly in a finding by the Dartmouth Center for Health Policy Research that as much as 30 percent of all health care spending is on services of no value for patients. None. In a later e-mail to me, he cited as examples unnecessary diagnostic imaging studies, particularly CT scans and MRIs; laboratory blood testing; even hospitalizations, which can be harmful.
There's a reason for the waste.
"We live in a paradoxical situation, where the payment system is set up as a transaction system," Murphy said. "No one pays us to [help you] be well. ... We are incentivized to do more and more stuff to you."
He thinks the health care system needs to reimburse outcomes instead of just volumes.
"Or, we can continue on our current path -- de facto rationing. ... When we increase people's out-of-pocket, they self-ration, and not necessarily in a good way."
We see that in recent news stories about people who lost health insurance along with jobs, and tried to cut back on medicines for chronic health conditions. The serious ill effects cost far more to treat.
Murphy agrees the nation needs universal health coverage, but says we can't afford it without a system to contain costs, one less focused on medical transactions. "A lot of things that contribute to good primary care, they don't fit well in transactions" -- things like nursing care that can help elderly people maintain their health.
The chairman of Carilion's board of directors, James Hartley, outlined an integrated system in which a hospital and physicians would be assigned a population and a set of group benchmarks. "Instead of a fee for procedures, pay for maintenance of health."
It'd fit well with Carilion's clinic model. The public battering that has taken shouldn't automatically make the idea suspect. Actually, it sounds like good sense. And, Murphy insisted, "You could have competing organizations in the same community and still have competent, accountable organizations competing for patients."
Carilion has grown into a regional giant, and Murphy acknowledged the public perception is mixed. "We long have had the image of having this financial model that's all about money. The model the last several years has been all negative financially."
The clinic adjusted its charity care policy since last September's story about aggressive collections efforts, though this hardly has silenced critics if that was the intent.
Murphy thinks the criticism is something of a red herring that draws attention away from the larger demands of health care reform.
People need health care that's affordable and accessible to all.
Getting it will depend on the politics in Washington, Hartley said. "If we don't do something this summer, it will be much harder. I see some real momentum."
Let's not blow it.
Strother is a member of The Roanoke Times editorial board.
