This time it really is different – at least as it pertains to health care. We have heard this many times: in 1965, with the creation of Medicare and Medicaid, in the 1980s, with the development and proliferation of health maintenance organizations (HMOs) and again, in 1989, with payment reform and development of the resource- based relative value system.
Here is why it really is different this time. We are in the midst of the largest worldwide economic shift since World War II. Immediately after that war, our national debt reached 118 percent of our gross domestic product, by far the largest debt in modern times. At the same time, U.S. health care expenditures accounted for only 4.2 percent of GDP.
As we entered the 1980s, our debt had shrunk to 35 percent of GDP, or rather, GDP had exploded relative to debt. Fast-forward to 2012, and we have a very different picture. U.S. debt has again reached levels that equal GDP, with continued deficit spending by the federal government. Health care spending now accounts for 17.6 percent of GDP and is rising. Economic growth is stagnant. The federal government spends more on health care than any other single program, accounting for 21 percent of total expenditures.
At the state level, Maine spends $2.5 billion, or 32 percent of the state’s budget, on our Medicaid program (MaineCare). Expenditures of this magnitude leave no room for creation of new federal or state programs or expansion of existing programs.
U.S. spending on health care far exceeds that of any other nation – $7,600 per person. Norway is second at $5,000 per citizen, but that only represents 9 percent of their GDP. France, whose health care system consistently ranks as one of the best in the world, spends $3,700 per citizen.
One could argue that spending money on health care is a worthy endeavor, except the United States consistently finds itself low in the rankings of quality of care compared to other developed nations. In 1999, the Institute of Medicine published “Crossing the Quality Chasm,” which reported that between 50,000 to 100,000 deaths occurred annually in the U.S. due solely to medical error. A follow-up 2010 study showed no change.
The United States has a value problem with its health care – we are spending far too much for a mediocre product.
What can be done? President Obama’s health care reform legislation, the Patient Protection and Affordable Care Act, uses accountable care organizations (ACOs) as its model for care delivery. At the heart of these ACOs are the primary care physicians who must transform their practices into patient-centered medical homes. The idea is that primary care will increase their responsibility and role in all aspects of patients’ health, with fewer referrals to specialists, fewer hospital admissions, and at the same time improving overall health at a reduced cost: A very tall order.
The results of this new paradigm in large national studies is mixed; quality has improved but savings are less than expected.
But now the Supreme Court has put into question the president’s entire health reform plan. What is the significance for us? Under the health reform law, many states were required to expand their Medicaid programs, albeit inadequately funded, and now will want to contract to pre-reform levels. Maine, being an outlier to start, was not required to expand MaineCare, as it already exceeded the minimum thresholds established by the health care law.
The bottom line is that regardless of the Supreme Court decision, our health care system remains too expensive and of mediocre quality. The private sector spends nearly 70 percent of total health care dollars and private enterprises are the ones that will now lead the call for change. Employers in this state can no longer tolerate annual double-digit insurance premium increases.
Physicians must now spearhead health care reform. If we do not, health systems and others, with less direct knowledge and experience in patient care, will do it for us. As well intentioned as the hospitals and health systems may be, they need our leadership; in fact, they want our leadership.
We must work, in concert with health system administrators, to construct meaningful, common sense reform. Patient care must move from that of individual physician decision-making to that of health care teams. These teams must include health system/hospital personnel, nurses, other health care practitioners, and most importantly, doctors, working in very close coordination to develop rational approaches to each and every aspect of patient care.
These teams must determine what will work best in their communities, based upon patient characteristics, system resources and health care expertise. It is time for us, as physicians, working with our hospital partners, to transform health care into a system that we can be proud of, but more importantly, one that our patients deserve and can afford.
– Special to The Press Herald