by Arthur Chernoff, MD
Prior to President Obama’s address to Congress on health reform, I asked myself, “What would I tell the President?”
First and foremost: go for it. All of it. Health care in America is too important, both economically and morally, to be left adrift in its current state. Its focus is wrong. It costs too much. And not everyone who needs it is able to have it.
Two rules that have served me well during 30 years of practice apply here. Rule #1. Make no assumptions. Rule #2. Always challenge authority. Accordingly, I challenge the very notion of health care reform. The word reform sends the wrong message to a public that by and large is happy with what they have and are afraid of losing it.
Reform is divisive; it implies that there is a wrong that needs reform. What is needed is not reform but transformation. Transformation is a process that can take place over time. Transformation invites cooperation among stakeholders; it is an evolutionary, adaptive process. We need to transform our notion of what health care is, how it should work, who should have it, and how its success is measured. We need to move to a system that focuses on improving the health of the individual and our communities. We need to learn to value knowledge-based care as much as the technology of care. We need to move from a system that values rescue care more than preventive care. We need to move from a system that is built to deny care to one that embraces those who are in need of care.
Universal health care must be a priority. The cost of not being inclusive is simply too high both on economic and moral grounds. Imagine if sanitation worked like health insurance: “I am sorry; you cannot have sewage or sanitation this year because you have a pre-existing condition.”
Single-payer health care would unify a disjointed system but it may not be feasible. This does not mean that the patchwork of private and government insurance that now exists can’t be brought to function as a unified system. This can be fostered by adopting unified standards for performance, processes and benchmarking just as other industries do.
Health care needs to function like a utility. It must be the same in Alaska as Alabama and it must be portable. And, like a utility, it has to be there when it is needed and it has to be easy to use.
Electronic medical records are a focal point for change. More important than having electronic medical records is to have electronic medical records that are fully integrated and compatible with each other. The Mayo Clinic record not only needs to be readable in the Cleveland Clinic, but in any clinic. Privacy is a concern. However, I worry more about gaining continuity of care in a population that is mobile and values choice. It has not gone unnoticed that fully integrated electronic medical records provide a key resource for the scientific tracking of treatments and their outcomes.
Research has received scant attention in the current debate; yet research is the heart of medical progress. We need research to power the transformation of care. Funding for basic science is critical to understanding normal biology and disease processes. There needs to be support for the research that brings discoveries made in the lab to the bedside. The process of medical care needs to be examined scientifically so that both doctors and patients learn what works and what does not.
Comparative research will determine which treatments are most efficient and which are wasteful, which medications are worth a premium price and which are not. Would cholesterol matter if no studies had been done to show that lowering it with statins prevents heart attack and stroke? Treatments need to be tested for their ability to improve our health and quality of life.
For the patient with a chronic disease, medical care is a marathon that is punctuated by sprints of acute care and races over the hurdles that the health care system imposes. In a transformed system, the health care industry would facilitate care and foster the resources to keep it coordinated and on track. Patients with chronic illnesses should have a passport to care rather than a requirement to get referrals for care.
There needs to be access for patient education, support for lifestyle modification as well as the prescribed medications and treatment. Chronic illness provides an opportunity to examine what limits effective care in the current system and why these limits need re-examination. A person at risk for diabetes may understand the need for exercise and healthy food choices but may live in a community where there is neither a place to exercise safely nor a market to buy affordable, healthy foods. Who bears responsibility? It is a health care problem that goes beyond insurance coverage and the affordability of medicines. It tests the limits of what we have traditionally called health care. It calls for a new order; one with broader vision and greater concern. It calls for a step away from acute care and a bold step toward preventive care.
It is clear why the current legislation runs to a thousand pages or more. Solving health care is complex. To do all of what I have outlined still would not meet the full measure of the health care transformation that we as a nation need; but it is a start.
So let us begin.
Arthur Chernoff is Chair of the Division of Endocrinology at Albert Einstein Medical Center.
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