Commentary
Two Birds, One Stone
Cover the Uninsured by Fixing Medicare
Eliminating reimbursement for medical care that does not help patients is the solution to curbing health care costs.
By Victor M. Sandler, M.D.
As a nation, we are in a heap of trouble. Our medical system is a disaster—overly expensive and ineffective. On average, we spend two to three times more per capita on health care than other developed countries. Yet on measures of quality, we rank 22nd out of 23 among those same countries, according to the World Health Organization. Not only that, Medicare, our national insurer for the elderly and disabled, is facing more than $30 trillion in unfunded liabilities over the next 40 years. We have 50 million people who are uninsured in this country and millions more who are underinsured because employers have shifted a larger percentage of premium costs to them and increased deductibles and coinsurance payments, causing some to forgo medical treatment because of the expense.
The bad news is that we are on a path that is much too costly and clearly not sustainable. The good news is we can get off that path by cutting medical costs dramatically without negatively affecting quality. The way to start is by acknowledging the fact that we don’t have the best health care in the world, as former President George W. Bush and others have touted. What we have is the most health care in the world.
The Causes of Medical Waste
The factors that feed our obese medical system are manifold. But three are especially troublesome. First, there is an unfortunate ethos within American medicine and society at large called “heroic positivism.”1 Essentially, it is the idea that the more we do to and for our patients, the more they gain. The very act of intervening, whether it is performing a test or giving a treatment, connotes a benefit for the patient. This philosophy leads many doctors to perform, and many patients to submit to, unnecessary tests and overly aggressive treatments. This is particularly true in geriatrics, where there is a narrower margin of safety because patients are frail and have a short life expectancy, giving physicians less time to achieve positive outcomes. Many elderly patients would be far better off if we complied with the “do no harm” maxim and offered them more conservative, less risky interventions, or no intervention at all.
Second is our emphasis on procedures rather than prevention. Most specialty care physicians are in fee-for-service practice. They eat what they shoot. The more stents they place, the more hysterectomies they do, the more MRIs they read, the more they earn. Most doctors are not so mercenary as to ignore their patients’ best interests. However, the financial incentives clearly drive them to do more, not less, for their patients.
Third, and most insidious, is the conflict of interest that pervades health care in this country. Eighty percent of medical research and 70 percent of continuing medical education for physicians is paid for by drug and medical device companies.2 Sixty percent of medical school department chairs are paid consultants for these companies.3 Of physicians who author clinical practice guidelines, 80 percent are on the payroll of Big Pharma, and 59 percent have relationships with companies whose drugs were considered in the guidelines they authored.4 Far too many medical decisions are being shaped by this unholy marriage of physicians and corporate interests. The physician covenant must be with his or her patient. Yet, the influence of drug and device companies plays a role in nearly every clinical decision made in every doctor’s office and at every hospital bedside.
This results in unnecessary and unproven care. Evidence suggests that at least 30 percent of medical tests and treatments done in this country are unnecessary.5-7 Examples include the use of statin drugs to lower cholesterol in elderly people who don’t have coronary disease, PSA testing in elderly men, mammography in elderly women, coronary CT angiography, Pap smears in women who’ve had hysterectomies for benign disease, and chemotherapy in patients with advanced cancer who are debilitated and close to death.
The Solution
The drivers of health care cost inflation can be controlled not by rationing beneficial care but by eliminating ineffective care. There are a number of ways we can do this.
First, we can start cutting Medicare costs by eliminating ineffective care—that means not reimbursing for it. If research has not established that a test or treatment benefits a patient’s health, the government should not pay for it. We should base these determinations on evidence presented by nonbiased medical outcome research organizations such as the Cochrane Collaboration, which make such information available at no cost.
In 2006, the state of Minnesota created the Health Services Advisory Council (HSAC), whose mission is to write authorization guidelines designed to eliminate ineffective care and, thus, save the state money. The council and similar entities in other states could be charged with saving Medicare dollars as well. The federal government could provide states with an incentive to do this by sending 50 percent of the Medicare dollars saved back to them. The states could then use those tens of billions of dollars to cover the uninsured.
Keep in mind that Medicare serves as a template for most other medical insurance companies. The reimbursement decisions made by Medicare eventually would be replicated in the private market. Thus, the positive effects of these evidence-based authorization guidelines would be felt across the whole health care system, resulting in huge savings.
Second, we must urgently resurrect primary care, which is the foundation of an efficient health care system. The American College of Physicians warned in 2006 that “primary care, the back bone of the nation’s health care system, is in danger of collapse.” During the past decade, the number of graduates of U.S. medical schools entering primary care specialties (pediatrics, family medicine, internal medicine, and geriatric medicine) has dropped dramatically, as the number entering other more lucrative specialties has increased.8 This is happening at a most inopportune time, as members of the baby boom generation are entering their senior years and need the type of coordinated, whole-person care these physicians deliver more than ever.
A number of measures must be taken to increase the supply of primary care providers. Some of the options we might consider include defraying the cost of medical school, which now exceeds $100,000, for doctors who choose primary care specialties; mandating pay equity between primary care and specialty care physicians; and providing the staff and support that would give physicians more time for patient care and prevent burnout. One way to expand access to primary care is by increasing the supply of advanced practice nurses and physician assistants. The range of services these providers perform is often limited by state statute and reimbursement restrictions. Laws should be modified in order to maximize their potential as primary care providers.
Third, we need to eliminate ineffective care at the end of life, which is now poorly managed and excessive. The frail elderly and the terminally ill all too often receive unwanted and expensive medical care. Many patients might refuse some of this care if the true benefits (often nil) and burdens (often great) were accurately explained to them. We need to adopt tools such as POLST (the Physician Orders for Life-Sustaining Treatment paradigm), which is designed to ensure informed consent about the care people receive at the end of life. We also need to do a better job of integrating hospice and palliative medicine into our health care system. These services improve patients’ quality of life and decrease costs by discouraging undesired medical interventions.
Fourth, we need to encourage the development of integrated health care systems such as those of Kaiser Permanente in California, Intermountain Health in Utah, and Mayo Clinic. These systems save money—as much as 20 percent compared with the cost of other care—through improved care coordination, use of electronic medical record systems, and elimination of duplicate services.
Conclusion
The priority for health care reform must be cost containment. Eliminating medically ineffective or unproven care will accomplish this goal without sacrificing quality. We can kill two birds with one stone. The tens of billions of dollars saved by limiting Medicare reimbursement for unproven care will provide the resources we need to cover all of our citizens. Finally, we must continue to improve health care delivery by rewarding physicians who practice primary care, promoting better end-of-life care, emphasizing better care coordination, expanding the use of electronic medical records, and eliminating redundancy of services. By doing this, we can create a cost-effective, high-quality health care system that truly is the best in the world. MM
Victor Sandler is an internist and geriatrician. He also is bioethics committee co-chair for the University of Minnesota Medical Center, Fairview, medical director of Fairview Hospice, and a member of the State of Minnesota’s Health Service Advisory Council.
References
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2. Abramson J. Overdosed America: The Broken Promise of American Medicine. New York, NY: Harper Collins; 2004.
3. Campbell EG, Weissman JS, Ehringhaus S, Rao SR, Moy B, Feibelmann S, et al. Institutional academic-industry relationships. JAMA. 2007;298(15): 1779–86.
4. Choudry NK, Stelfox HT, Detsky AS. Relationships between authors of clinical practice guidelines and the pharmaceutical industry. JAMA. 2002;287(5):612-7.
5. McKinsey Global Institute. Accounting for the Cost of U.S. Health Care: A New Look at Why Americans Spend More. McKinsey and Co. December 2008.
6. Dartmouth Atlas Project. The Care of Patients with Severe Chronic Illness. Lebanon, NH: The Dartmouth Institute for Health Care and Clinical Practice; 2006.
7. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL., The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Int Med. 2003;138(4):288-98.
8. Bodenheimer T. Primary care—will it survive? New Engl J Med. 2006,355(9):861-4.