“For every human problem, there is a neat, simple solution; and it is always wrong.”
— H. L. Mencken

t is tempting when viewing a crisis of the proportions we are facing in American medicine to come up with an all-encompassing, definitive solution; as the quote above suggests, this is neither likely nor simple. The last to suggest such a comprehensive overhaul was the Clinton administration, and the hue and cry raised by legitimate as well as illegitimate interests was of such magnitude that it is unlikely we will see another such proposal—unless the entire system falls apart.

Rather what I intend to suggest is a series of steps, many of which can be implemented first at the local level, which if successful could form the basis for more far-reaching health care reform. The problems can be broken down into several large categories: 1) the uninsured: 44 million and growing; 2) a system that pays for treatment of disease, not its prevention; 3) a public that demands far more than the system can afford without evidence that it will benefit them; 4) a physician workforce that, for the most part, acquiesces; 5) expenditures that cannot be justified of perhaps as much as 30 percent of the total health care dollar; and 6) a “for profit” system, best characterized by the pharmaceutical industry, which does not consistently respond to the public good—and in the case of drug costs and availability, may work against it.

What to do? Several colleagues and I have helped define a model of “personal care” that would be implemented by the insurance companies and would allow the patient and the physician enough time and easy access to get to know each other. We hypothesize that this model would develop a degree of trust and mutual satisfaction that is largely missing from our current system. In this model, prevention would be emphasized and paid for, unnecessary testing would be reduced, and evidence-based medicine would be mutually understood and practiced. Patients rarely want all the tests we order, but they are unsure of the alternatives; doctors order tests in part because they don’t have time to observe whether a particular problem will “go away” or define itself into something more easily diagnosed and treated. No less a debt-ridden entity than the National Health Service of the United Kingdom is paying personal physicians up to $70,000 (U.S.) per year to do the “right” thing and prevent more serious and expensive illness. We believe such a system would go a long way toward addressing the cost, satisfaction, and outcome crises we face.

What about the medical profession’s role in reform? Should every patient have the “right” to pick his or her own doctor? Yes, if that physician measures up. I don’t believe we have done enough to police ourselves and to help those physicians who are behind and are capable of improving. We need to demand that we all practice based on scientific evidence and to identify and remove personal gain from physician decision making. Do I believe this occurs? Yes, not always consciously, but frequently enough to account for some of the 30 percent of wasted medical expenditure either by our own charges or by the studies, procedures, or hospitalizations we order. Efforts are under way to change this; more needs to be done. Physician outcomes need to be transparent and oriented in science and patient safety.

What about the patient’s insistence on “everything”? Health care insurers are beginning to structure health plans that allow patients to make choices in return for economic gain or penalty. At the University of Miami, our new health plans designed by Humana give us a choice of what we want to be easily available and at what out-of-pocket cost. Additional tools such as “The Personal Nurse Program,” prediction of severity of illness, and a carefully crafted drug benefit put more decision making and more support in the patient’s hands. For example, if a serious test is really needed and recommended by your doctor, then paying a co-insurance amount might be different than if the physician’s advice is, “I don’t think we need that study right now; let’s wait and see.” In this latter case we might be more reluctant to pay or push if the doctor we trust says it isn’t needed; this would likely work in enough cases to show a definite benefit in health care expense.

What about wellness, prevention, and behavior change? Incentives to both patient (lower premium, cash back) and physician (pay for performance) are already in place in some pilot studies being done by Medicare and large employers known as the Leapfrog Group under a program titled Bridges to Excellence. The incentives in the United Kingdom program have the same goals. If it can be done elsewhere, why not here and in fact everywhere? Once the pilot studies are complete, I would hope that this approach would be incorporated into the program suggested above, including a cash incentive for patients to participate in wellness programs.

rying to deal with “big Pharma” is most likely impossible at the local level. How can any one group of patients and physicians compel the drug industry to ensure that enough doses of influenza vaccine are being safely made, to make “orphan drugs” (those with little profit potential) available when needed to treat severely ill patients, and to deal with the inequities of pricing like those between the U.S. and Canada (the same drug in the same bottle costing 60 to 100 percent more in the U.S.)? This is one of two problems that I feel must be addressed by governmental oversight and, if necessary, control. Locally, we can do something about our own drug costs. In an overwhelming majority of instances, generic drugs are perfectly appropriate in preference to the more (sometimes outrageously) expensive brand-name products. Our new health plan rewards us for choosing generics; always ask your doctor or pharmacist if a generic equivalent exists, and use it.

The last, most vexing problem is the uninsured. Why should we be concerned? I think for several reasons: first, the quality of a society is judged by how it treats its least fortunate; what is happening in our country does us no credit. For a more concrete reason, look at what is happening at Jackson Memorial Hospital. Even with county and sales tax support, Jackson lacks the ability to develop a plan for prevention that in the end would save all taxpayers money. A few hundred dollars a year spent in the identification and treatment of hypertension, for example, would prevent the $40,000+ per year cost associated with treating the kidney failure resulting from untreated hypertension. There are many examples. Exactly what kind of system should be in place for this large, heterogeneous group of Americans is too complex to describe or envision. But some expansion of our current Medicaid program with incentives for wellness must be our goal; only governmental entities have the ability to make this happen and only we, the public, have the influence to say this is important. Maybe if we can save enough using some of the strategies outlined above, this will be possible.

What I have attempted to outline is one person’s view of an approach to our ever-present and growing health care crisis. Some of the solutions suggested are already in place at the University of Miami. Others are being piloted and tested now. The only thing worse than trying new approaches to this problem is not trying at all.

Laurence B. Gardner, M.D., is professor and chair of the Department of Medicine and vice dean of the School of Medicine.
University of Miami Medicine Online
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