Guy Clifton
Now is the time to make the necessary reforms.
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Anne Casey lived in Houston, Tex., supporting herself by providing in-home care for the elderly and by making jewelry. My wife’s best friend, Phyllis, who was also a friend of Anne’s (not her real name) from high school, referred me to her. I came to enjoy sitting in her home studio on Saturday mornings, chatting and picking out materials from which she would create the most striking pieces of jewelry.

In 2007 a black lump appeared on Anne Casey’s neck; she had the fair Irish skin that is prone to cancers. She could not afford health insurance, so she paid cash for a dermatologist to biopsy the lesion. The doctor was notably concerned after seeing malignant cancer cells under the microscope and told her that she needed surgery right away, though he could not do it, since he was not a surgeon. Anne had a malignant melanoma, a potentially fatal skin cancer that is normally removed as rapidly as possible to prevent its spread throughout the body. The down payment alone for a hospital admission would have been $10,000—money Anne did not have.

Fearing for her life, Anne began the process of obtaining a “gold card” that would permit her to use the public hospital system in Houston. After four weeks of bureaucratic processing she received her card and, after four weeks more, a clinic appointment. The doctors who were to perform the surgery needed to determine the extent of the cancer through an M.R.I. scan. The problem: Ben Taub General Hospital, which had to serve the county’s 1.2 million uninsured, was the only public hospital with an M.R.I. scanner. Anne lay in the hospital for six days waiting for the study.

Phyllis, who each day was growing more anxious, called a radiologist friend, who agreed to perform the study free. Meanwhile, as Anne and Phyllis watched in horror and helplessness, the black growth on Anne’s neck grew larger every week. The M.R.I. was performed, but weeks passed without the anticipated call to come in for surgery. Phyllis, desperate to help her friend, called the doctor who had performed the biopsy and insisted that he telephone the doctors at the public hospital to expedite the process.

Four months after the diagnosis of her life-threatening cancer, Anne Casey finally underwent surgery to remove the malignant melanoma. Always gracious, she told me in early 2008 that she felt she received excellent care and was thankful for it. I thought too that she had been lucky, until I learned that Anne Casey died on Thanksgiving Day, 2008. I know the doctors had done the best they could with the limited resources available to them. It is ironic, however; had she been insured and had her surgery been delayed for four months for any preventable reason, the episode would have been classified as medical malpractice.

For 20 of the last 30 years that I have practiced neurosurgery, I have worked at the Texas Medical Center. It is a 700-acre complex of tightly packed medical facilities housing over 6,000 hospital beds, the largest concentration of medical resources in the world. Some of its hospitals have billions of dollars in reserves, with lobbies like fine hotels, complete with china cabinets, and valet and concierge services. Serving these hospitals is a mile-long row of gleaming professional office towers. Ben Taub General Hospital, on the other hand, where Anne was forced to seek treatment, lies in forlorn isolation in the back of Texas Medical Center and is the anchor for the care of the region’s uninsured, nearly one-third of the population. The facilities for the uninsured in Houston can be likened to a town of 30,000 with one operating room and one clinic. Houston is not unusual and Anne Casey’s story is not unique. Delayed diagnosis and treatment is the reason that 22,000 uninsured Americans die prematurely each year. Her story is a metaphor for the U.S. health care system.

Unbridled Consumerism

The goal of expanding insurance coverage is solidly obstructed by a fact well known in Washington, D.C.—soon the United States will not be able to afford its existing public programs. According to Thomas Saving, a Medicare trustee, in 2006 Medicare accounted for 11.6 percent of income tax spending. By 2020 the program will consume 21.2 percent; by 2030 over one-third of income tax revenue (at current-law taxes and premiums) will be spent on Medicare. Without action now we are less than a decade away from an unplanned health care reform conducted under duress with unpredictable results—a circumstance that is now familiar to Americans.

The good news is that there is plenty of money to work with, and these problems can be solved. Conservative estimates indicate that unnecessary medical services account for one-third of medical spending, or some $700 billion. In other words, the U.S. health care system could insure the uninsured seven times over with the amount of documented money wasted annually.

Unnecessary services come in three categories. The first and largest source of waste is the poor management of chronic diseases. If doctors in regions where spending for Medicare patients is high were to treat patients as doctors do in areas where Medicare spending is low, Medicare costs could be decreased by almost 30 percent—with improved quality. In higher spending regions, patients with chronic illnesses are hospitalized more often for longer stays, are more likely to end their days in a hospital rather than at home (regardless of their wishes) and are the recipients of more tests, consultations and minor procedures than in lower spending areas.

The best predictor of whether an area will spend highly on Medicare is an abundance of hospital beds and specialists. In most market economies the supply of a product or a service increases only when the demand for it increases. In medicine, the opposite is true—regions with a large supply of medical facilities will see a rise in demand that keeps them full. It is not as if a cabal of doctors gather in a room and decide to deliver a lot of services. It is that doctors are paid by the volume and complexity of the services they render. In the absence of any accepted or measured standards of medical practice, they all simply provide whatever services are required to keep themselves busy at their craft. On measures of quality, however, including mortality rates, low spending areas tend to perform better. In other words, more health care is not necessarily better health care.

A second source of waste is inefficient hospital processes. According to the 2007 semiannual report of the National Surgical Quality Improvement Program, the incidence of complications of surgical procedures (adjusted for factors like age and medical condition) is three or four times as high in some hospitals as in others, and cost likely varies accordingly. Hospitals are not safe places either. A patient is at greater risk of being subject to a medical error in a hospital than he is of having his bag misplaced by an airline.

The third source is the too-frequent performance of major procedures that are beneficial in many, but by no means all, of the groups of patients who undergo them. In the course of doing research for my book Flatlined: Resuscitating American Medicine, I calculated that major procedures of doubtful or unproven indications account for about 6 percent of hospital spending. A good example is back fusion surgery. Over half of these procedures are performed for unproven indications. In other words, the procedure could just as well cause additional back pain as cure it.

Principles for Reform

We face a crisis because of our success in financing and inventing new treatments, which are often developed in the absence of rigorous evaluation; by the public’s view of medical care as a service to be consumed instead of managed; and by a fragmented system of medical care in which profits flow exclusively from the volume and complexity of the procedures and services provided. The power of modern technology has outgrown the system through which we deliver it and the methods by which we pay for it. The only way to reduce the cost of health care so as to improve its quality is to create an efficient health care system. The alternative to efficiency is price cutting and rationing of services, which will worsen quality. For the uninsured, eliminating waste from health care is a matter of justice; for the insured it is a matter of quality and affordability.

Substantial reform of the system requires universal participation, guided by three principles: 1) pay providers for the quality of their care rather than its quantity; 2) each person should have one primary care doctor as the first point of contact with the medical system; 3) benchmarks for high quality medical practice should be measured and reported.

Primary care doctors (internists, family doctors and pediatricians) are trained to manage patients with chronic illnesses, to provide early diagnosis and treatment of new conditions and to prevent illness. The fee-for-service system pays a doctor on the basis of the manual difficulty of a medical intervention. For example, Medicare pays a primary care doctor $50 for a half-hour visit at which a colonoscopy to detect colon cancer might be recommended. The gastroenterologist who performs the procedure in the same amount of time, however, is paid $500. The result is that primary care doctors must see 30-35 patients a day, virtually a health care assembly line, to earn an annual income of $120,000 to $180,000. This is one-third to one-fifth of what a specialist can make. Under these circumstances it is no wonder that Americans have only a 55 percent chance of receiving standard treatments, such as aspirin for heart trouble or vaccination to prevent pneumonia, when they go to a primary care doctor. The United States has a procedure-driven health care system. The role of primary care doctors must change, and their payment should reflect it.

No primary care payment or quality scheme can be successful unless patients are anchored themselves to one primary care doctor or clinic as their first point of contact with the medical system. The average Medicare patient sees seven doctors in four practices, none of whom are likely to know what the others are doing. The public must allow one clinic of each patient’s choice to manage the patient’s care and should expect that clinic to be available to the patients, to know them and to make judgments in their best interest.

Similarly, hospitals are paid their cost plus profit, even if their cost is for treatment of complications that could have been prevented by more attention to detail, training and use of systems to manage care better. A better way to pay hospitals and hospital-based physicians is a bundled fee based upon the patient’s condition on admission—not based on how sick they become by the time of discharge—and indexed to the cost of the most efficient hospitals and specialists, not the least efficient.

Finally, the only standards for medical practice are now at the extremes. To operate on the wrong limb, for instance, is a “never event” for which there is no excuse. Yet there are currently no agreed-upon standards for what constitutes excess testing, unnecessary hospitalizations and futile use of an intensive care unit, excess consultations, unnecessary surgery or unacceptable hospital complication rates. Doctors in Miami provide two-and-one-half times as many interventions for patients with the same diagnosis as do doctors in Minneapolis. Who has it right, the Miami doctors or the Minneapolis doctors? Is it acceptable that a patient does not know whether he lying in a hospital with a 4 percent rate of hospital-acquired pneumonia or one with a 12 percent rate? Are the two hospitals equally acceptable?

In the end, America’s health care problems are collectively owned by the public and by providers, and they can therefore be solved only by a collective effort. If we address the problem of medical consumerism now, we can fund the uninsured, improve the quality of everyone’s health care and reduce its cost. We can also redeem ourselves for what we have permitted to happen to people like Anne Casey.

Guy Clifton, M.D., holds the Runnells Distinguished Chair in Neurosurgery at the University of Texas Health Science Center, Houston. He is the author of Flatlined: Resuscitating American Medicine. Flatlined: Resus

Comments

Christopher Mulcahy | 8/27/2009 - 4:30pm

I know God’s will and I demand government health care now.  I certainly don’t want to stop eating double cheeseburgers, so don’t mess with my diet.  Don’t tell me to exercise, either—this is America.  All those magazines about fish oil and CoQ10 just clutter my livingroom, so get them out.  No, I’m not a doctor, don’t plan to be one, and don’t like to read about medical procedures and costs.  That’s for the government, don’t you know? But when I want medical care I want to go to the doctor right now, and then go to the hospital if necessary, and have top quality drugs and procedures.  And don’t forget, one of my best friends is an attorney, so don’t even think about messing with the court system, because if the doctors or hospitals make a mistake don’t think I won’t collect, and collect big.  This is America!  I know my rights, and Obama does too.  That’s why we all voted for him, and he better deliver.

Christopher Mulcahy | 8/27/2009 - 4:30pm

I know God’s will and I demand government health care now.  I certainly don’t want to stop eating double cheeseburgers, so don’t mess with my diet.  Don’t tell me to exercise, either—this is America.  All those magazines about fish oil and CoQ10 just clutter my livingroom, so get them out.  No, I’m not a doctor, don’t plan to be one, and don’t like to read about medical procedures and costs.  That’s for the government, don’t you know? But when I want medical care I want to go to the doctor right now, and then go to the hospital if necessary, and have top quality drugs and procedures.  And don’t forget, one of my best friends is an attorney, so don’t even think about messing with the court system, because if the doctors or hospitals make a mistake don’t think I won’t collect, and collect big.  This is America!  I know my rights, and Obama does too.  That’s why we all voted for him, and he better deliver.

Paul Glover | 8/4/2009 - 1:58pm
We have created a health co-op in Ithaca NY http://www.ithacahealth.org whose 800 members pay $100/YEAR to be covered for 12 categories of everyday emergency, and to own their own free clinic.
Bring together 50 million uninsured Amercans to demand Medicare for All, and to create their own nonprofit health systems, and something will happen. http://www.healthdemocracy.org
Donna | 6/14/2009 - 11:37pm
Universal health-care will destroy the quality of health-care for all in America. An aspirin for heart trouble? You call that quality? A vaccination for pneumonia? Quality health-care? I'm 43; 30 yrs ago, did we have a health-care problem? Why don't you outline what gov.t interference has done to increase costs (Medicare, Medicaid) and what malpractice insurance has done to increase costs. There is any easy way to reduce costs - tort reform for one. Why on earth should Americans trust the gov.t to run their health care system when Medicare and Medicaid are in complete shambles? And why would ANYBODY put themselves through the grind and sacrifice of medical school just to work for the gov.t? Explain how the best and brightest minds in our country will want to work for the gov.t when they don't want to now! No one becomes the best they can be working for the government - all they expect is mediocrity and 9 to 5 ers who punch in and punch out - Raise your hand if that's the kind of quality health-care we really want to accept in America!! There's a much better way, and it utilizes the free market system. Get the gov.t interference out, reduce stupid lawsuits, and watch what happens!
William Ulwelling, MD | 6/14/2009 - 7:01pm
Dr. Clifton’s article, "Healing Healthcare," begins with the tragic story of Anne- "a metaphor for the US healthcare system"- who died needlessly because of her lack of health insurance. He notes that Anne is one of the 22,000 people who die each year in America because they don't have health insurance. These deaths constitute a Twin-Towers-magnitude disaster that occurs each month in our country while our politicians dither—fearful of offending powerful vested interests resisting change in the status quo. Unfortunately, the health care reforms outlined in the rest of Dr. Clifton's article would not necessarily cause any reduction in the ranks of the uninsured. The efficiency and cost-savings measures he describes would indeed result in significant savings. But what would prevent the insurance companies from using these savings, not to reduce the roles of the uninsured, but rather to deliver greater dividends to their shareholders? What would prevent the CEOs of the three largest medical insurance companies from pushing to use this money not to reduce the roles of the uninsured, but rather to increase their annual compensation packages from eight figures to nine figures? Only a single-payer universal healthcare system offers America a timely and affordable answer to the tragedy of Anne and the other 46 million uninsured. William Ulwelling, MD, MPH 3407 La Sala del Oeste NE Albuquerque, NM 87111 505/550-2260
johnmayer | 6/8/2009 - 6:45am
If you are uninsured and does not have insurance, you should check out the website http://UninsuredAmerica.blogspot.com - John Mayer, California
JohnMayer | 6/8/2009 - 2:02am
If you are uninsured and does not have insurance, you should check out the website http://UninsuredAmerica.blogspot.com - John Mayer, California
Bridget Reidy MD | 6/3/2009 - 10:40pm
I agree entirely with the facts, but see a different solution. One problem with the solutions most conservatives suggest is that they do not take culture into account. It is not just that docs vary their practice by region, but patients do as well. I am currently doing a temporary job as primary care for a rural area and my patients don't seek care unless they absolutely need it by anyone's definition. My suburban buddies are still getting pressured to treat sinusitis and sore throats by their patients, who will go elsewhere if they don't get what they want. When I was making housecalls to the frailest and most expensive Medicare patients, despite spending many hours over the long term earning their trust they would not believe me when I said "the ER can't help you", and they were sick enough that no matter what they showed up their with they usually got admitted, and then transfered to a long and expensive rehab stay because nobody knew they were already back to their best possible functioning. Now I'm a palliative medicine consult I can say "The ER can't help you" to patients I barely know and they believe me! There is no problem finding money in the system to cover everyone. Take away the insurance companies and there's plenty left. The only really good way they'll have to make extra under the compromise systems that are being discussed now is to obstruct the care of the sick and expensive so they'll choose someone else. Pitty Americans value choice so much. If we had a Canadian style system we could get twice the care they get for the money we spend now and choose our doctors, we'd just have to let the government choose what's covered. If Medicare covered all you can bet the voters, journalists, and courts would make it better. I long for freer and more transparent markets, but it doesn't work in health care. Government is best for roads, defense, and designing and implementing the studies we have to do to find out when medical care is useless or harmful.
Ted J. McGoron | 6/2/2009 - 10:16am
Insuring anything does not lower the cost of it. It just spreads the cost around so that everyone pays for it. Or, as in the case of life insurance, it allows one to pay for the cost of his inevitable demise in easy payments ahead of time. Some types of insurance, such as casualty insurance, allow fortunate (or careful) individuals to help pay for the cost of the accidents of those less fortunate (or stupid). Health insurance is in a field of its own, one in which everyone will eventually have to pay. There is no way to reduce the cost of health insurance unless you find a way to reduce the actual cost of the care. In fact if the government runs it you will only increase the cost of both the care and of the management, especially if the government is the current one, the one with its hand in your pocket, although I must admit the one ahead of it was only deficient in volume. It seemed to have the same idea of spending more than it had available to spend.
Ted J. McGoron | 6/1/2009 - 5:30pm
In the first place you are talking about the government being in charge of this, a government with a bad track record for managing big systems like Social Security. Will we wind up in a situation like Canada, or England, where everyone waits too long? Why doesn't the government do something about outreageous lawsuits that make it impossible for doctors to work without such big insurane policies, the costs of which are passed on the the patients. And don't forget the nuns who used to run so many hospitals. God bless them. They didn't care about money or prestige, just making people well. After Vatican II the beautiful nuns we knew were replaced by new ones who wanted to be priests. So they got rid of their habits and their ideals. Now the few that are left are on their own, doing the Lord knows what, and the hospitals are run by people who, most of all, need to make money. By the way, it is "Each of whom is" not "each of whom are".
Deacon Mike Evans | 6/1/2009 - 4:45pm
I would like to add some additional 'principles' to the article by Guy Clifton. 1. Everybody gets insured, no exceptions, no exclusions. 2. Everybody gets access to a primary care physician without having to go and beg for one. 3. A standard rate or fee is established for all the most common procedures at which doctors and hospitals are reimbursed. The rate for each of these procedures is annually reviewed and modified based on new technology and changes in costs. 4. Drugs are prescribed as needed for actual treatment. The first 90 days are fully covered as routine. The costs for next 90 days are determined based on the need for continued treatment at no cost or for a potential minimal co-pay. This would form a Medicare like floor to all medical costs and coverages. Additional premium coverage could be purchased from private insurers as desired.