Albert Einstein would have said if he had one hour to save the world, spent 55 minutes defining the problem and only five minutes to solve. Our health care system is much more complex than most people by offering solutions admit or recognize, and unless we focus most of our efforts on defining its problems and thoroughly understanding their causes, changes to are likely to worsen because they are better.
Although I have worked in the American health care system as a doctor since 1992 and has a value of seven years as CEO of primary health care, I do not consider myself qualified to thoroughly assess the viability of most of the suggestions I ear to improve our health care system. I think, however, I can at least contribute to the discussion by describing some of their problems, make reasonable assumptions to their causes, and outlining some general principles that should be applied 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 care spending is expected to reach $ 8160 per person per year by the end of 2009, compared to $ 356 per person per year was 1970. This increase was about 2.4% faster than GDP growth over the same period. Although GDP varies from year to year and is an imperfect means of assessing the rising costs of health care compared to other expenses from one year to another, we can conclude from these data in the last 40 years years, the percentage of our national income (individuals, businesses and government) has been devoted to health care has increased.
Despite what many people think, which may or may not be bad. Everything depends on two things: why health spending has increased compared to our GDP and the amount of value that we have been getting for every dollar you spend.
WHY HEALTH has become so expensive?
It is a difficult question to answer as many people believe. The rising cost of health care (on average 8.1% per year between 1970 and 2009, calculated from the data above) has exceeded the rise in inflation (4.4% on average during the same period), so we can not attribute the increase in the cost of inflation alone. The costs of health care are known to be closely linked to a country's GDP (the richest nation, we spend more on health care), but also the United States remains an outlier (Figure 3).
Is it spending on health care for people over 75 (five times what we spend on people aged between 25 and 34)? In a word, no. Studies show that this demographic trend explains only a small proportion of the growth in health spending.
Is it because of monstrous profits of health insurance companies are winning? Probably not. It is difficult to know for sure because all insurance companies listed and therefore balances available for public review. But Aetna, one of the largest insurance companies listed in North America, announced a profit quarter of 2009 seconds $ 346.7 million, which, if projected out, predicts an annual profit of 1.3 billion of the $ 19 million they provide. If we assume that the profit margin is the industry average (though false, it is unlikely to be several orders of magnitude different from the average), the total benefit to all health insurance private companies in the United States States, which said 202 million people (second paragraph) in 2007 would amount to about $ 13 billion per year. Total expenditure on health care in 2007 were $ 2.2 billion (see Table 1, page 3), which provides a health benefit private industry about 0.6% of total costs medical health care (although this analysis combines data from different years, maybe you can afford the numbers are probably different from any order of magnitude).
Is it due to fraud in health care? Estimates of losses due to fraud to a maximum of 10% of all health care spending, but it is difficult to find reliable data to support this thesis. Although the percentage of fraud is almost certainly not be detected, perhaps the best way to estimate how much money is lost to fraud is to observe how the government actually recovers. In 2006, it was $ 2.2 billion, only 0.1% of $ 2.1 billion (see Table 1, page 3) in total health care expenditures for that year.
Is it because pharmaceutical costs? In 2006, total spending on prescription drugs was about $ 216 billion (see Table 2, page 4). While this represents 10% of the $ 2.1 billion (see Table 1, page 3) in total health care spending for this year and should be considered significant, that is still a small percentage of total health expenditure.
To administrative costs? In 1999, the total administrative costs were estimated at $ 294 billion, up 25% compared to $ 1.2 billion (Table 1) of total health spending that year. This was a significant percentage in 1999 and it is difficult to imagine that decreased significantly since then.
Ultimately, however, which probably contributed as much to the increase in health spending in the United States two things:
1. Technological innovation.
2. Overuse of health care resources for patients and health professionals themselves.
Technological innovation. The data show that the rising costs of health care are mainly due to technological innovation is surprisingly difficult to obtain, but estimates of the contribution to the increase in health care costs due to the range of technological innovation between 40% and 65% (Table 2, page 8). Although most of the time only empirical data, several examples illustrate this principle. Heart attacks are usually treated with aspirin and prayer. Now, they are treated with drugs to control shock, pulmonary edema and arrhythmias, as well as thrombolytic therapy, cardiac catheterization with angioplasty or stenting and CABG. You do not need to be an economist to understand that the scenario ends up being more expensive. We can learn to make these procedures less expensive over time (in the same way that we have found a way to make computers cheaper) but as the cost per procedure decreases the total amount spent on each procedure increases because the number of procedures performed increases. Laparoscopic cholecystectomy is 25% lower than the price of an open cholecystectomy, but both have increased by 60%. Technological advances become more widely available, which are more widely used, and the only thing we major in the United States, have made the technology available.
Overuse of health care resources for patients and health professionals themselves. We can easily be defined as the excessive use of unnecessary use of health care resources. What is not so easy to recognize. Each year, from October to February, most patients who come to the emergency clinic at my hospital are, in my opinion, doing so unnecessarily. What will they come? Colds. I can offer support, assured that nothing is really wrong, and tips on over-the-counter remedies --- but none of these things will make you better faster (although I am often able to reduce their level of concern). In addition, patients have difficulty believing that the key to achieving a correct diagnosis is in the collection of the history and careful physical examination rather than technology-based test (not that it n is not only important --- lesser extent than most patients think). How patient-centered system of exploitation costs of health care is difficult to determine because most have only anecdotal evidence as above.
In addition, doctors often disagree among themselves on what constitutes an unnecessary health. In his excellent article, "The Dilemma of cost," says Atul Gawande regional variation in the exploitation of resources in health care by doctors best accounts regional variation in Medicare spending per person. He goes on to say that if doctors might be motivated to control excessive use of high-cost areas of the country, it would save enough money to keep Medicare solvent for 50 years.
A reasonable approach. To do this, however, we need to understand why doctors are overutilizing health resources in the first place:
1. Judgement in cases varies in the literature is vague and unhelpful. When faced with diagnostic dilemmas or diseases for which conventional treatments have not been established, a change in practice still occurs. If a primary care physician suspects that the patient suffers from an ulcer, is itself empirically treat or refer to a gastroenterologist for an endoscopy? If certain "red flags" of symptoms, most doctors refer. If not, some and some not in accordance with their training and the exercise of judgment intangible assets.
2. Inexperience or lack of judgment. More experienced physicians tend to rely on history and physical examination rather than physicians with less experience and hence order fewer tests and less expensive. Studies suggest that primary care physicians to spend less money on tests and procedures than their subspecialties, but similar results, sometimes even better.
3. The fear of being sued. This is particularly common in ER settings, but extends to almost all areas of medicine.
4. Patients tend to require more rather than fewer tests. As previously mentioned. And physicians often have difficulty refusing requests from patients for many reasons (for example, want to please, the fear of losing diagnostic justice, etc.).
5. In many environments, excessive use makes doctors more money. There is no reliable incentive for doctors to limit their spending unless its capitation payment or receive a fixed salary.
Gawande article implies that there is a certain level of utilization of health care resources is optimal: using too little and you get errors and missed diagnoses, overfishing and excess money is spent without improving the results, Paradoxically, which sometimes leads to results that are actually worse (probably as a result of complications of all tests and treatments extra).
How can we encourage physicians to use judgment consistently order the exact number of tests and treatments for each patient --- the "sweet spot" --- in order to obtain the best results with the least risk of complications? It is not easy. No, fortunately or unfortunately, an art for the use of health resources good. Some doctors are more suited to this than others. Some are more diligent in keeping current. Some care more about their patients. An explosion of studies on tests and medical treatment occurred in recent decades to help physicians choose the most effective, safer and cheaper, even to practice medicine, but the spread of proof based medicine is a tricky business. That beta-blockers, for example, have been shown to improve survival after a heart attack does not mean that every physician knows or gives them. The data clearly show that many do not. What are the drivers of the information from the medical literature in medical practice is a subject worthy of an entire post in itself. Make things happen consistently proved extremely difficult.
In summary, then, most of the increase in health care spending seems to have made technological innovation and its excessive use of doctors working in systems that drive them to practice medicine instead of more s improve medicine and patients who require the old way of thinking that you get later.
But even if I could snap my fingers and magically remove all excessive use today, health care in the United States remains one of the most expensive in the world, which raises the question below ---
WHAT VALUE're get the dollars we spend?
According to an article published in the New England Journal of Medicine entitled The burden of health care costs for working families --- Implications for reform, the growth of health spending "may be defined as affordable to the extent increase the percentage of income spent on health care will not reduce the standard of living. When absolute increases in income can not keep pace with absolute increases in health spending, the growth of health may be paid only by the sacrifice of consumption of goods and services related to health care. "When it is still an acceptable state of affairs? Only when the marginal cost of health care is an incremental value equal to or greater. If, for example, they were told that in the near future that would devote 60 % of their income on health care, but would enjoy as a result of, say, 30% chance of living to age 250 maybe he found that 60% of a small price to pay.
This is, I believe, that the debate on health care spending really needs to be around. Certainly, we need to work on ways to eliminate overfishing. But the real question is not how much money is too absolute to devote to health care. The real question is what do we do for the price we paid and that is what we need to give up?
Those alarmed by the idea that health care costs rise, the authorities may decide to ration health care do not realize that we are already rationing at least part of it. It does not seem as if we were because we are rationing first-come, first-served basis --- leaving at least partly to luck and not politics, it is uneasy to define and apply. So why not our father 90 years old in Illinois can not have the liver as just a girl of 14 years, Alaska was facing (or any Once my father was in the first line and then get the girl of 14 years does not work). As most of us are not comfortable with the idea of rationing health care based on criteria such as age or utility to society, such as technological innovation continues to drive spending health, which could have ultimately make critical judgments about medical innovations that deserve our society sacrificing access to other goods and services (unless we are stupid enough to repeat the fundamental error to believe that we can keep forever borrow money without having to pay).
So what do we do with the value? It varies. The risk of dying from a heart attack was reduced by 66% since 1950, as a result of technological innovation. Because the ranks of cardiovascular disease as the leading cause of death in the United States seems a high ranking on the scale of values, and it benefits a large proportion of the population in a major way. As a result of advances in pharmacology, now we can treat depression, anxiety, psychosis and even much better than anyone could have imagined even as recently as mid-1980 (when it was released on Prozac). Clearly, then, a certain increase in health care costs have been enormous value not want to abandon.
But how can we decide if we get good value innovation? Scientific studies show that innovation (whether a new test or treatment) actually provides a clinically meaningful benefit (Aricept is a good example of a drug that works, but does not provide patients dementia clinical benefit --- Big higher scores on tests of cognitive ability everything on it, but probably not much more functional and much better able to remember their children compared to when they are not). But comparative effectiveness studies are extremely costly, take a long time to complete, and can never be perfectly applied to individual patients, all of which means that the doctor must always apply good judgment for all medical problems patient.
Who is the best judge of the value to society of the benefits of innovation --- that is to decide whether the benefits of an innovation worth the cost? I would say that the group has finally paid off: the American public. As the public's views could be reconciled and then effectively communicate to policy makers efficiently enough to influence current policy, however, goes well beyond the scope of this post (and maybe someone's imagination).
The problem of access
A significant proportion of the population is uninsured or underinsured, limiting or eliminating their access to medical care. As a result, this group is the way of the smaller (and cheaper) ------ Resistance emergency rooms has greatly affected the ability of physicians to emergency represent our country really care emergency timely. In addition, polls show a shortage of primary care physicians regarding the demand for their services. In my opinion, this imbalance between supply and demand explains most of the patients in the poor of our customers every day of long waiting times for appointments, long waiting in doctors once their day appointment arrives, then spent short periods with doctors in the exam rooms, followed by difficulties in achieving their physicians between office visits and ultimately, delays in obtaining test results. This imbalance is likely to be partially offset by the overuse of health care for patients under.
GUIDELINES FOR SOLUTIONS
As the authors Freaknomics Steven Levitt and Stephen Dubner state "If morality represents how people would like the world to work, then economics represents how it actually does work." Capitalism is based on the principle of self-interest, a system that creates incentives to produce behavior that benefits both suppliers and consumers, and thus society as a whole. But when incentives suddenly, people start to behave to continue their profit, often at the expense of others, or even on their own in the future. All changes to our health care system (and there's always more than one way to skin a cat), we must be sure to align the incentives for behavior that results in each part of the system contributes to durability rather than its ruin.
Here is a summary of what I think the best advice I've found to deal with the problems I described above:
1. Change the way insurance companies think about doing business. The insurance companies have the same goal as any other business: maximize profits. And if a health insurance company and marketed in their 401k portfolio, you want to maximize the benefits, too. Unfortunately, the best way for them to do is to refuse service to customers who pay for themselves. It is more difficult for them to spread risk (the function of any insurance company) compared to say a car insurance company, because many more people make claims insurance claims car insurance. It would seem, therefore, from the point of view of the consumer, the model of private health insurance is fundamentally flawed. We must create a disincentive for insurance companies to deny health claims (or, conversely, an additional incentive to get paid). Allow and encourage competition among states aross sure that at least partially attack the forces of the free market to reduce insurance premiums, and open new markets for local insurance companies, benefiting both consumers and insurers. With its customers, now armed with the power of the utmost importance to look elsewhere, the health insurance companies would be an opportunity to see the quality with which it provides service to their clients (for example, payment of compensation) as a way to maintain and develop their business. For this to work, monopolies or quasi-monopolies should be dissolved or at least discouraged. Even if this is the case, however, the government still probably have to tighten regulation of the health insurance industry to ensure some flagrant abuses happening now stop (for example, companies Insurance should not be allowed to stratify consumers into subgroups according to age and risk premiums based on average higher group of diseases and health of older consumers, and end up being penalized for their age rather than their behavior). Karl Denninger suggests some interesting ideas in a post on his blog about requiring insurance companies to offer similar rates to businesses and individuals, as well as creating an obligation "open enrollment" period in which participants could only participate or not a system in a base year. Whether individuals can buy insurance only in case of illness, which eliminates the problem of adverse selection leading insurance companies refuse to pay for pre-existing conditions. I would add that, although the rates of reimbursement to providers of health care are determined in the future (again, a whole post in itself), all health insurance plans , whether public or private, must reimburse health care providers in a percentage equal to eliminate the existence of certain "good" and "bad" which is currently responsible for encouraging hospitals and doctors to limit or to refuse service to the poor and who may be responsible is the same for the elderly in the future (Medicare reimburses only slightly better than Medicaid). Finally, regarding the idea of insurance "public option" open all, I fear that if it is significantly cheaper than private options, while providing almost the same benefits as the rush across the country to the ground, which the private insurance industry and we forcing everyone to subsidize another health care with higher taxes and fewer options, but at the same time, if the cost to the consumer of a "public option" is comparable to private options, even those that it is supposed to help you not be able to afford.
2. Motivate people to participate in healthy lifestyles that have been shown to prevent disease. Disease prevention probably saves money, although some have argued that living longer increases the chances of developing diseases that would not have happened otherwise, so that the overall consumption of health care more money ( that even if this is true, the more years of life would be considered by most valuable enough to justify the extra cost. After all, the purpose of health care is to improve the quality and quantity of life, not save money for the company. putting the cart before horse No). However, the idea of avoiding a potentially bad result at some point in the future is only weakly psychological motivation that explains why so many people have so much trouble getting themselves to exercise, eat well, lose weight , stop smoking, etc. The idea of a financial reward desirable behavior and / or financially punishing undesirable behaviors is highly controversial. Although I am concerned about this strategy may adopt policies that affect fundamental freedoms if it is done too far, I'm not against creative thinking about how they could strengthen the forces of motivation to help people to achieve the objectives of health outcome. After all, most obese people want to lose weight. Most smokers want to quit. They could be more effective if they could find a more powerful motivation.
3. Decrease the overuse of health care resources by doctors. I agree with Gawande that finding ways to get doctors to stop overutilizing health care resources is a worthy goal to control costs significantly, which will require a willingness to experiment, and it will take time. In addition, I agree that focusing solely on who pays for health care (public or private) do not address the problem adequately. But how can we encourage doctors, whose feathers are responsible for most of the money spent on 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 doctors must follow in order to control costs seems absurd. These organizations have neither the training nor the concern for the well-being of patients to trust such judgments. Why doctors more if we use their knowledge of nuanced approaches to complex situations? While working on a free system of incentives that compete with their duty to their patients, they are in the best position to make decisions about what tests and treatments are worth examining a patient, as care is taken to avoid excessive paternalism confidence (refusing to get a head CT headache could be overconfidently paternalistic, refusing to offer chemotherapy for a cold is not). So maybe we should eliminate financial incentives to doctors worry about anything other than the well-being of their patients, ie, doctors' salaries must be disconnected from the number of surgeries performed and the number tests to order, and instead should be determined by market forces. This model already exists in academic health centers, which seemed to promote shoddy care when doctors feel they are fairly compensated. Physicians need to earn a living to compensate for years of training and massive amounts of debt that have accumulated, but no financial incentive to practice medicine should be allowed to join the good life.
4. Decrease the overuse of health care resources for patients. This, it seems, requires at least three interventions:
* Provision of adequate resources to the problems of law (so that patients do not go to the emergency room for a cold, for example, but rather to their primary care physician). This would require hitting the "sweet spot" in terms of the number of primary care physicians, the best access control frontline, not health spending as in the old HMO model, but sorting and treatment. There should also be a recalculation of reimbursement levels for primary care services in relation to specialized services to encourage more medical students choosing primary care (to reverse the alarming trend that we have seen for the last decade) .
* A massive effort to improve the health literacy of the general population to improve their ability to triage its own complaints (so patients do not really go anywhere MRI cold or request their return when doctors trust tell them that it's just a strain). It could be better with a series of educational programs (although, as a person in the private sector's interest to fund these programs, you can actually be one of the few things that the government should only --- we would of study and compare different teaching programs and methods to see which, if any, to reduce the unnecessary use without affecting patient outcomes and health outcomes savings above their cost).
* Redesigned insurance plans for patients more financially responsible for their health care options. We can not have people going bankrupt because of illness, or that people under-use of health care resources (avoid the emergency room when they have chest pain, for example), but we can not continue to support a system where patients are actually motivated to excessive use of resources, such as the "pre-payment for all" model done.
CONCLUSION
Given the enormous complexity of the health care system, no single article could solve all the problems that need fixing. Important issues not covered in this article are the challenges associated with rising drug costs, direct marketing to the consumption of drugs, care at the end of his life, the rising cost of cloud liability insurance The lack of cost transparency that allows hospitals to charge uninsured more than the insured paradoxically for the same care, extension of health care coverage for those who have not, the efficiency to reduce the administrative costs of implementation of electronic medical records to reduce medical errors, the financial burden on companies that are required to provide their employees with health insurance and tort reform. All are deeply interdependent, standing as the proverbial house of cards. To attend touches everyone, I run through the health care reform without careful contemplation risk of unintended consequences and potentially devastating. Rate it must come, but if we do not give you time to reflect on the problems clearly and intelligently and implement solutions to a certain extent, we may destroy this house of cards rather than build.