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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{ 7 comments }
The approach you outline adds to the murkiness of the issue. It requires a more direct approach may be more effective. Some 40 million plus are without insurance with 18,000 per year lose their life unnecessarily because of it. It is destroying business and is a large cause of bankruptcy(over 60%). Call it what you will but without some National Health Plan, the costs will soar at astronomical rates. The present private industry tries to cover as many health people as possible. They use a top heavy model to achieve this, hiring many people who are not directly helping their subscribers. It is time for Medicare For All. Nothing less will even approach solving the way we pay for health care.
“If you think health care is expensive now, wait until it’s free.”
PJ O’Rourke
After years of disarray, it wil be a hard battle. Reform needs to happen from the medical school up. More incentives to place people in primary care. A better reimbursement for the primary care. the ability to direct care to a more cost effective source – ie not the emergency room as the safety net. I, too, believe a unified medical record would eliminate much over spending of repeat test, evaluations and the cost of doing nothing. I have been practicing 8 years in the ER now…the system is broke. I just don’t know if the government has the tenasity to see reform through, or this will be another wash job!
“The nine most terrifying words in the English language are: ‘I’m from the Government and I’m here to help.’” – Ronald Wilson Reagan
The Executive Branch already has the authority and the ability to prove that it is up to the task of health care. Make the quality of care received at the IHS and the VA the envy of the rest of us. Proof is in the pudding. Until that happens, the rest is just words. Oh and Doc99, that is also the punch line for a sad but true Indian joke.
Any reform ought to respect those things that make America work: liberty, ownership, personal responsibility. No mandates, no coercion, no freedom from consequences for exercising that freedom. The out of control costs are due to too little personal accountability already. We also need to ditch the childish fantasy that there is a solution to every problem. I know what my obesity is doing to me and have a place to exercise, etc. I also buy individual insurance rated for that risk and so personally pay through the nose for the costs of that condition. I am still fat. Not every problem is going to be solved with the “right program.”
No matter what the government does people are still going to get sick and die. Being sick is still going to suck. People are still not going to like it. The ER is still going to be the repository of other unsolved social problems as it always has been. No matter how much “universal coverage” is written all over any bill and no matter how much money is sucked involuntarily out the pockets of the American people, there are still going to be people show up in need of care with no means, outside the “universal” system, and practicing medicine will, as it always has, mean sometimes not getting paid for our labor. Important that we retain the freedom to treat freely with those who can pay us. Likewise they should retain the freedom to insure or not insure as they see fit.
In Spain we have the best public Health Care in the world because we pay as workers,since the first day of work,to the Social Security as part of our salary.It works and there is no deficit to support Public Hospitals and Doctors.Please think it over our experience since years.
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