When all the screaming going on the health crisis in the United States, many difficulties are likely to focus, let alone understand the problems for us in September. I realize dismayed tone of the debate (although I understand it --- people are afraid), and embarrassed that someone dared him sufficiently qualified to know the best way to improve the health care system because they only met when people who have spent their entire careers studying it (I do not mean the politicians) are not sure what to do with myself.
Albert Einstein is reputed to have said that if he had an hour to save the world who spent 55 minutes defining the problem and only five minutes to solve it. Our health care system is much more complex than most of those who are providing solutions to admit or recognize, and unless we focus most of our efforts in defining problems and in-depth understanding of the causes, changes are only likely to exacerbate them because they are better.
Even though I worked in the health care system in the United States as a doctor since 1992 and has seven years experience as executive director of primary health care, I do not feel qualified to properly evaluate the viability of most of the proposals I have heard to improve our health system. However, I think I can at least contribute to the debate by describing some of its problems, taking reasonable proposal to their causes, and outlines some general principles to use to try to solve them.
THE PROBLEM OF COST
No one disputes that health care spending in the United States has increased dramatically. According to the Centers for Medicare and Medicaid Services (CMS), health spending is projected to reach 8160 dollars per person per year by 2009 compared to $ 356 per person per year in 1970. This increase occurred at about 2.4% faster than the increase of GDP over the period. While this ratio varies from year to year and is an imperfect means to assess an increase in health spending relative to other expenses from one year to another, one can still conclude from these data over the past 40 year, a percentage of our national income (individuals, businesses and government), we have devoted to health has increased.
Despite what most people assume, it may or may not be evil. Everything depends on two things: why health care costs have increased relative to our GDP and how the value that we were done for each dollar we spend.
WHY HAS HEALTH CARE BECOME SO COSTLY?
It is a harder question to answer as many think. The increase in health spending (on average 8.1% per year from 1970 to 2009, calculated from data above) has outpaced the increase in inflation (averaging 4.4% over the same period) so we can attribute the increase in costs to inflation alone. Health spending is known to be closely linked to GDP of a country (the wealthiest nation, the increased spending on health care), but even the U.S. remains an outlier (Figure 3).
Is it because health care costs for people over 75 (five times what we spent on people aged 25 and 34)? In a word, no. Studies show that this demographic trend explains only a small percentage of health spending growth.
And monstrous profit health insurance companies are raking in? Probably not. And 'certainly difficult to know with certainty, because all insurance companies are publicly traded and therefore budgets are available for public review. Aetna, but one of the largest publicly traded companies health insurance in North America, reported second quarter 2009 profit of $ 346,700,000, which, if projected out, provides an annual profit of about 1.3 billion U.S. dollars is approximately 19 million people insured. If we assume the profit margin is on average in the industry (even if true, probably an order of magnitude different from the mean), The overall result for all private health insurers in America, which provided 202 million people (second point of the list) in 2007, would come to about $ 13 billion per year. Total health expenditure for 2007 was 2,200 billion (see Table 1 on page 3) which provides a private benefit to the health-care industry around 0.6% of total health expenditure (although this mixture analysis of data from different years, it might qualify as figures are not likely different by an order of magnitude).
Is it for health care fraud? The estimates of fraud losses range as high as 10% of total health spending, but it is difficult to find reliable data to support this thesis. Although a certain percentage of fraud is not detected, most certainly, maybe the best way of estimating how much money is lost to fraud is watching how the government actually collects. In 2006, was 2,200,000,000 dollars, only 0.1% of the 2.1 billion dollars (see Table 1 on page 3) in the total health care expenditures for that year.
Is it because of the cost of pharmaceuticals? In 2006, total spending on prescription drugs was about $ 216,000,000,000 (see Table 2, page 4). Although this amounted to 10% of the $ 2,100,000,000,000 (see Table 1 on page 3) in total spending on health care this year and should be considered significant, is only a small percentage of total health care costs.
Is this administration? In 1999, total administrative costs are estimated at 294 billion dollars, a full 25% U.S. $ 1.200 billion (Table 1) of total health spending this year. This was a significant percentage in 1999, and it is difficult to imagine that it reduces to a significant degree since then.
Eventually, however, what is likely to have contributed most to the growth of spending on health care in the United States two things:
1. Technological innovation.
2. Overuse of the second health care resources for patients and health workers themselves.
Technological innovation. The data show the increased costs of health care are mainly due to technological innovation is surprisingly difficult to obtain but estimates the contribution to increased health care costs attributable to the field of technology innovation, ranging from 40% to 65%. Although we have more empirical evidence in this regard, several examples illustrate the principle. Heart attacks were treated with aspirin and prayer. Now they are treated with medications to control the shock, pulmonary edema and arrhythmias, as well as thrombolytic therapy, cardiac catheterization with angioplasty or stenting, and bypass surgery. You need not be an economist for determining which scenario ends up being more expensive. We can learn to make these procedures more conducive to the same period of time (in the same way that we understand how to make computers cheaper), but because the price of the procedure to reduce the total amount used for each procedure, increases the number of procedures performed increases. Laparoscopic cholecystectomy is a 25% lower than the price of open cholecystectomy, but prices of both have increased by 60%. Because of technological development will be more widely used, they become more widely used, and what we are doing well the U.S. will available technology.
Overuse of health care resources for patients and health workers themselves. We can easily identify over-consumption of unnecessary health care resources. What is not so easy to recognize. Each year from October to February the majority of patients coming to the clinic for emergency care at my hospital is in my opinion to do so unnecessarily. What goes into a? Colds. I can offer support, reassurance that nothing is really wrong, and advice on the counter remedies---But none of these things will make them better more quickly (although I have often managed to reduce their concern). In addition, patients have difficulty believing the key to achieving a correct diagnosis is the history collection and a thorough physical examination rather than technology-based test (not that it is not important --- a little less than most patients think). Exactly how patient-oriented health care costs of overfishing is difficult to define, as we have mostly only anecdotal evidence as above.
In addition, physicians often disagree among themselves about what it means to need care unnecessary. His excellent article Cost, enigma Atul Gawande second regional variations overuse of health care resources for the best doctors representing regional variations in Medicare spending per person. He also claims that if doctors could be motivated to curb the overuse of high cost of land, you save enough money to keep Medicare solvent for 50 years.
A reasonable strategy. For that to happen, we must understand why doctors are overutilizing health resources in the first game:
1. Sentences vary if the medical literature is vague or useless. Faced with problems of diagnosis or disease for which conventional treatments have not been established, the change always happens in practice. If the GP suspected a patient of his wound, not perform or refer empirically gastroenterologist for endoscopy? If certain red flag symptoms, most doctors ask. Otherwise, some people and not, depending on the training and intellectual reflection.
2. Inexperience or poor reviews. Medical experts tend to rely more on the history and health experts that the doctor less and requires less and less expensive tests. Studies have shown that primary care physicians less money tests and procedures than their sub-specialty, receive the same, and sometimes even better results.
3. The fear of being sued. This is particularly common for emergency settings, but extends to almost every medical field.
4. Patients tend to need more testing, not less. As indicated above. And doctors often find it difficult to refuse requests from patients for many reasons (eg, wanting to please, for fear of missing a diagnosis and be sued, etc.).
5. In many places, over exploitation doctors make more money. There are no incentives for doctors to limit their spending reliable unless they are paid by capitation they receive a fair wage.
Gawande article suggests that there is some degree of utilization of health-care resources, which is best: using too little and you get errors and missed diagnosis and use too much excess money is spent without improving results, paradoxically, sometimes resulting performance is worse (probably due to complications of all additional tests and therapies).
How can we encourage doctors to use consistently good decision to order the appropriate number of tests and treatments for each patient --- the sweet spot--- to get the best results with the least risk of complications? Not easily. There are, fortunately or unfortunately, an art of using health care resources appropriately. Some doctors are better than others. Some are more a duty to stay informed. Some are more concerned about their patients. An explosion of studies of medical tests and treatment has taken place in recent decades to help guide physicians in choosing the safest forms of more efficient and cheaper, even to practice medicine, but the spread of evidence-based medicine is a delicate matter. Just because beta-blockers, for example, has been shown to improve survival after a heart attack does not know any doctor or supplier. The data clearly show that many did not. How information is transmitted from the medical literature into medical practice is an issue worthy of a whole line for itself. Take consistent action has been extremely difficult.
Short, most of the increase in health spending appears to come from technological innovation associated with its overuse of doctors who work in systems that motivate them to practice more medicine instead of more effective drugs, and patients require the first, he thinks that gives the latter.
Even if we could snap our fingers and magically eliminate all currently-used, health care in America remain among the most expensive in the world, forces us to ask for the following ---
WHAT VALUE ARE WE GETTING FOR THE DOLLARS WE SPEND?
According to the article in the New England Journal of Medicine called the costs of health care for working families --- effects on the reform of health spending growth can be defined more affordable until the rising share of income devoted to health are not reduces the standard of living. When the absolute growth in revenue can not maintain the absolute increase in health expenditure, health, growth may be paid only by discarding the consumption of goods and services related to healthcare. When this is not never been acceptable situation? Only when the additional cost of purchasing health care equal to or greater than the value of incremental update. For example, if you were told that in the near future we would spend 60% of income on health care, but the result you want to enjoy a 30% chance to live up to the age of 250, maybe you think that 60% of small price to pay.
This, apparently, is that the debate on health care spending should be around. Certainly, we must work on ways to eliminate overfishing. But the real issue is not the absolute amount of money is very dedicated to health care. The real question is what are we getting for the money we spend is worth it and we have to resign?
The people are frightened by the idea that the policies of health care may decide to rising costs of health care rationing not know that we are already rationing of at least some of them. It does not seem fair that if we are since the rationing on a first come, first served --- is at least partially randomly instead of politics, who feel uncomfortable with the definition and implementation. Therefore, we are not realize why our 90-year-old father of Illinois may not have the liver, it is because a 14-year Alaska received the first line (or perhaps our father been at the forefront and that is that while the young 14 years is not working). Like most of us are still uncomfortable with the notion of rationing health care based on criteria such as age or the benefit to society, such as technological innovation continues to drive up health care costs, we may well at some point of critical judgments about the medical innovations worth sacrificing our whole society access to goods and services (unless we are so foolish as to repeat the critical error to think that we can keep borrowing money, still without ever having to repay).
So what do we value? Varies. The risk of dying from a heart attack was reduced by 66% since 1950 due to technological innovation. Because the ranks of cardiovascular disease as the leading cause of death in the United States seems high on the scale of values because it has a huge proportion of the population significantly. As a result of advances in pharmacology, we can now treat depression, anxiety, psychosis and even better than anyone could imagine, even as recently as the mid-1980s (when Prozac was first published). Clearly then, some increases in the costs of health care have taken a tremendous value, not going to resign.
But how can we decide if we are getting good value for innovations? Scientific studies show that innovation (whether a further examination or treatment) has brought significant advantages clinically (Aricept is a good example of a medication that works, but is of little clinical benefit for patients with dementia --- Rated on tests of cognitive ability all about it, but probably not significantly more functional and better able to recall their children compared to when they are not). But comparative studies on the effectiveness extremely expensive, it takes time to complete, and never can be perfectly applied to each patient, this means that some providers of health care has always apply common sense in all medical problems patients.
Who is best placed to assess the value to society of the benefit of an innovation --- that is, to determine whether the benefits of innovation outweigh the costs? I would say that the group pays in the end: the American public. How public opinion could be reconciled and communicate effectively with policymakers effective enough to influence actual policy, however, lies well beyond the scope of this position (and perhaps a person's imagination).
THE PROBLEM OF ACCESS
A significant proportion of the population is uninsured or underinsured, limiting or eliminating their access to health care. Therefore, this group is the path of least (and resistance to the cheapest rooms) --- --- emergency has weakened considerably the capacity of the ER doctors in our country to realize the attention timely emergency. In addition, surveys suggest a looming shortage of primary care physicians compared with the demand for their services. In my view, this imbalance between supply and demand explains most of the patients bad customer service compared to our system every day: long waiting periods for medical appointments, long waiting times in doctor's offices after of his appointment the day comes, then the short term with doctors within the examination rooms, followed by difficulties in reaching their physicians between office visits, and finally delays in obtaining test results. This imbalance would probably be only partially mitigated by the exploitation of lower health care by patients.
GUIDELINES FOR SOLUTIONS
As the authors Steven Levitt and Stephen Dubner Freaknomics state, If morality represents how people would like the world at work, then economics represents how it actually works. Capitalism is based on the principle of their own interests, a system that encourages conduct that society benefits from performance of suppliers and consumers, and therefore as a whole. However, when the incentives to break down, people start to behave in order to continue to benefit often at the expense of others or even their own travel expenses. Whatever changes we make to our health care system (and there are always more than one way to skin a cat), be sure to align the incentives for the behavior that results in each part of the system contributes to its sustainability rather than its destruction.
Here is a summary of what I think the best recommendations I have met to resolve the problems I described above:
1. Insurance Companies Changing the mindset to do business. Insurers have the same goals as any other business: maximizing profits. And if a health insurance exchange-listed portfolio in your 401k, you want to maximize their profits too. Unfortunately, the best way for them to do is to refuse their services to customers who pay most for them. It is harder for them to spread risk (the function of an insurance company), compared to say a car insurance company, because many more people make claims that Medicare claims auto insurance. Therefore, it seems, viewed from the perspective of consumers, private health insurance model is fundamentally flawed. We must create a disincentive for insurers to deny health claims (or the reverse, an additional incentive for them to pay). Allow and encourage competition aross public insurance, at least partially participate in the free market forces to lower insurance premiums, as well as open new markets for local insurance companies for the benefit of consumers and beneficiaries . With customers now armed with the power so important to go elsewhere, the health insurance companies could get to see the quality with which they can provide services to their clients (for example, payment of claims) a means of keeping and develop their businesses. For this to work, monopolies or near monopolies must be dissolved or at least discouraged. Even if it works, however, the government will probably still have to tighten regulation of the sector of health insurance for certain egregious violations happening now stop (for example, insurance companies should not be allowed to stratify consumers into subgroups according to age and increased premiums based on risk group of disease highest average higher, because the health of older consumers, and eventually penalized for their age rather than their behavior). Karl Denninger suggests some interesting ideas in a post on his blog about asking insurance companies to offer similar speeds to businesses and individuals, as well as creating an obligation to open enrollment period during which the participants could not accept or plan on an annual basis. This will avoid people to take out insurance when they fell ill, which eliminates the problem of adverse selection that is driven insurance companies to deny payment of pre-existing conditions. I would add that, regardless of reimbursement rates to providers of health care established in the future (again, a whole line for itself), all health insurance plans, public or private, must reimburse therapists with the same percentage to eliminate the existence of good and evil insurance that is currently responsible for motivating hospitals and physicians to restrict or even deny service to the poor, who may be responsible for same place for the elderly in the future (Medicare pays only slightly better than Medicaid). Finally, as regards the notion of public model of insurance plan is open to all, I am afraid that if it is significantly cheaper than private options simultaneously with compensation of approximately equal throughout the country will rush to it en mass, driving private insurance companies and force us to stop all support each others health with higher taxes and fewer options, but at the same time, if the cost to consumers a public model is comparable to private opportunities, even those it is intended as an aid, will not be able to afford it.
2. Motivating people to adopt better lifestyle habits that have been shown to prevent the disease. Disease Prevention saves money, no doubt, though some have claimed that increases the probability of life of developing diseases that would otherwise not take place, what more dollars overall consumption of health care (although even if true, these extra years of life is considered by most large enough to justify the additional cost. After all, the main purpose is to improve healthcare quality and quantity of life, not save the company money. In order not to the cart before the horse). However, the idea of preventing a fairly bad in the future is not clearly motivated psychologically, which explains why so many people have worked so hard to exercise, eat well, lose weight, stop smoking, etc. The idea financially rewarding desirable behavior and / or financial punish unwanted behavior is highly controversial. Although I fear that this type of risk strategy for the implementation of policies that could undermine fundamental freedoms if taken too far, I am not against to think creatively about how we can harness the forces strong motivation to help people achieve health goals that they want to achieve. After all, most obese people to loose weight. Most smokers want to quit smoking. They may be more effective if they could find more powerful motivation.
3. Eight overutilization of healthcare resources for physicians. I agree that Gawande ways to get doctors to stop overutilizing resources for health is an important objective, which is significantly control costs because it requires a willingness to experiment, and that takes time. I also believe that focusing only on who pays for our health care (public or private sector) fails to address adequately. But exactly how do we motivate doctors, whose pencils are responsible for most of the money for health care in this country to focus on what is truly best for their patients? The idea that external agencies --- if insurance companies or government panels --- could be used to establish standards of care physicians must take to control costs ridiculous. These organizations have no training or concern for the welfare of patients rely on to make these decisions. Otherwise, why are we so doctors do not use their expertise to nuanced approaches to complex situations? So working on a system of incentives that compete with their duty to their patients, they remain in the best position to make decisions about what kinds of tests and treatments are worth in a given patient, provided they are taken to avoid excess Trusted paternalism (refusing to get a CT scan of the head of a headache could be confidently paternalistic, refusing to offer chemotherapy for a cold is not). So we can eliminate any financial incentive doctors have anything but the welfare of their patients, which means that doctors' salaries must be disconnected from the number of surgeries performed and the number of tests available, and where should instead be set by market forces. This model already exists in academic and health care appears not to promote the poor quality of care when doctors feel fairly rewarded. Physicians should make a good living to compensate for years of training and massive amounts of debt accumulated, but no financial incentive to practice more medicine should be allowed to join the good life.
4. Decrease overuse of health resources for patients. I think this is requires at least three phases:
* Provide adequate resources for legal problems (such that patients do not go to the ER for colds, for example, but rather to their primary care physician). This would affect the sweet spot with respect to the number of primary care physicians better control of access to primary care, not an expenditure of health care as in the old model HMO, but triage and treatment. It would also require a recalculation of the reimbursement levels for primary care services with respect to specialized services to encourage medical students to go into primary care (to reverse the alarming trend, we have seen the last decade.)
* A enormous task to bring literacy to public health, improve their ability to classification problems (such as patients themselves do not go anywhere or take a cold MRIs on my back, when the doctor says that trust is position). This can best be achieved through a series of training programs (also because no one's interests for the private sector to fund these programs, could be one of the few things the government should --- we only investigate and compare the training programs and methodologies that can reduce unnecessary use without worsening of the patient, results and lead to savings in health care more than pays).
* Restructuring of insurance schemes for patients in an even more financially responsible choices of health care. We can not have people in bankruptcy due to illness, and do not want people to underutilized healthcare (avoiding the emergency room when they have chest pain, for example), but can not continue supporting a system that patients are actually motivated to use more resources than the current pre-pay for all models do it.
