Words of wisdom
by Rhonda Mullen | Illustrations by Karen Blessen
It's broken, and it needs fixing. That much everyone can agree on when it comes to health care in the United States. Much of the conversation about reform centers on cost, but access and quality of care are key factors too.
Any serious discussion has to start with where we are now, and it's not good. The United States is spending $2 trillion a year (almost $8,000 per person). We spend more than any of the other top 20 developed nations, but our health outcomes scrape the bottom of the barrel compared with theirs. Medicare and Medicaid account for 23% of federal spending, almost 6% of GDP, but Americans receive only half the screening and preventive care recommended for each age group.
The challenges range from lack of universal coverage to unequal access to care. The U.S. system has fragmented and uncoordinated care with wide regional variations. Its payment incentives fail to reward for good outcomes. Vested interest groups vie for their share of the trillion-dollar health care pie.
In the midst of national debates on how to approach the challenges, Emory experts are adding their voices, testifying before Congress, drafting reform policies, and hosting meetings of the best minds to discuss reform. How would they fix the dysfunctional system?
Adam Atherly would start with Medicare. "Medicare is a time capsule of health insurance in the 1960s," he says. "Part B is almost straight from the Federal Employee Health Plan of 1965." That plan is built on a fee-for-service model with high cost-sharing through co-pays and deductibles, and it includes no stop loss or limits. Until recently, it included no prescription drug coverage.
Atherly, a health policy expert at Emory's Rollins School of Public Health (RSPH), believes "it makes sense to do a good job of running the programs we have already." Specifically he'd simplify the federal program, eliminating Parts A and B to make Medicare more user-friendly.
Atherly's research focuses on Medicare Advantage plans, supplemental policies that offer low co-pays for office visits, drug formularies, and low deductibles for hospital stays. Although these plans are politically controversial, they are not going away, he says.
Another tack, he suggests, is to give CMS (the agency that administers Medicare, Medicaid, and the Children's Health Insurance Program) more teeth. "Currently, it doesn't have enough money or power," he says. For one thing, doctors who lose their medical licenses due to fraud can simply move across state lines and set up a new practice, and CMS has to accept them as providers. For another, Medicare pays 50% to 100% more than private insurers for durable medical equipment. "Medicare is too easy to exploit," he says.
Some experts believe Medicaid has done a better job than Medicare. Research in Health Affairs reported that Medicaid was better run, more successful in making incremental changes (such as introducing prescription coverage without fanfare in the 1970s), and offered a more proactive benefit package, including services such as dental care.
"Given the constraints and burdens on Medicaid, it has done pretty darn
well. I'd give it a solid B," says Kathleen Adams, a health economist at the RSPH who has headed several large projects on Medicaid populations and policies at the national level.
"The states are laboratories for health care reform, and they bubble up ideas to the federal level," says Adams. The $87 billion in stimulus funds for Medicaid is an opportunity for states to maintain their efforts and for some of the successful state programs to perhaps be replicated elsewhere, she says. Vermont, for example, is allowing for more patient-oriented choices as well as developing a pay-for-performance system. By requiring mandatory health insurance, Massachusetts has come close to insuring 100% of its citizens. PeachCare in Georgia has expanded insurance access to more than 200,000 children.
Unfortunately, these separate efforts lead to fragmentation, says Adams. "We really have 50 Medicaid programs, not one."
In addition, categories that determine who is eligible for Medicaid are seriously flawed. Currently, Medicaid will cover a parent with dependent children, the elderly and disabled, and pregnant women and children at varying federal poverty levels. "This leads to people being in and then out of the health care system if their income or category changes," Adams says. "For example, we cover a woman once she's pregnant, but we won't give her any prenatal counseling or health care before or after she's pregnant."
A new Medicaid vehicle addresses this flaw and also allows states to use family planning waivers. Georgia, however, is not one of the states using the waiver-despite the fact that the state's Medicaid program pays for an estimated 50% of births here. "It's so sensible. Why not do it?" asks Adams. "With family planning, we could potentially reduce unintended pregnancies and have better birth outcomes."
Adams would like to see reform efforts eliminate Medicaid's categories and handle coverage for the uninsured with a mix of public and private funds and programs. More than anything, she'd like to see a uniform system across all states.
She also supports expansion of model programs, such as the Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA) for underserved women. BCCPTA has drawn more women into Medicaid earlier, potentially saving lives by detecting disease earlier and thereby saving money as well. "It is having a wow effect," Adams says.
She advocates rewarding programs that work, such as the SCHIP (State Children's Health Insurance Program) for low-income children who are ineligible for Medicaid but who are near-poor and cannot afford private insurance. Re-authorization of this program early this year shows how federal and state governments can work through Medicaid to expand coverage while allowing states flexibility in how to achieve this goal.
Kathleen Adams: State Medicaid programs are our labs for health care reform. They bubble up ideas to the federal level. Unfortunately, that is adding to the fragmentation in health care. What we really have is not one but 50 Medicaid programs. I ask my class: ‘Is that good?' By and large, within each state, I think Medicaid does a tremendous job, but is it right that the programs are so unequal?
Art Kellermann knows the statistics on the uninsured inside and out. Emory’s health policy dean and emergency medicine professor co-chaired the Institute of Medicine’s Committee on the Consequences of Uninsurance. At a recent lecture, Kellermann noted that at least 60 million Americans lack health insurance or live with an uninsured person. And the problem is rapidly worsening as millions of Americans lose their jobs and employment-based health coverage.
Why do the number of uninsured people matter? Typically, uninsured adults receive less timely and preventive care, fewer screening procedures, and inconsistent care for chronic diseases, Kellermann says. Because they are frequently denied care in other settings, they often seek treatment in emergency rooms, which charge substantially more for care than a typical office visit.
“Because we don’t cover everyone, uninsurance has consequences for everyone,” Kellermann says. “Communities struggle to recruit and retain doctors. Specialists are reluctant to take ER and trauma call because of payment issues, and hospitals are less likely to offer vital but unprofitable services.”
People who lack coverage are not all alike. They range from 20-somethings, who tend to be healthy but have entry-level jobs that don’t offer coverage, to workers in their 30s and 40s, who make too much to qualify for Medicaid but not enough to afford insurance for their families. Then there are those who are older and millions with a chronic illness that effectively renders them “uninsurable.”
No matter the bracket, the conclusion of Kellermann’s committee was definitive. The President, Congress, and leaders in the public and private sector urgently need to figure out how to achieve health insurance coverage for everyone. To make the coverage sustainable, the cost of health care must be stabilized.
Art Kellermann: A single payer system for health care is not going to fly in the United States. That's too radical an idea for us. We need something in the middle that combines public and private payers. Free enterprise will kill way too many people. We have to have a hybrid.
Primary care pulpit
When Emory primary care physician Kimberly Rask looks at a patient, she sees a human being, not a disease: “The person may have no health issues, or one disease, or 12. But our literature tends to focus on one disease at a time rather than the whole person.”
As director of the Emory Center on Health Outcomes and Quality at the RSPH, Rask wants to go beyond the debate on cost. “In the long run, achieving cost savings depends on how we organize our health care,” she says. “We need programs that provide the right care at the right time for the right condition.”
For Rask, that means evidence-based care. Far too often, care is based on ability to pay rather than evidence indicating that it is beneficial. Take MRIs, for example, she says. “An MRI won’t necessarily help a patient get better, but it is helpful if it helps inform and improve a treatment plan such as ruling out cancer or stroke. Often, for some conditions, such as an injured knee ligament, watchful waiting may be just as helpful and far less costly. However, trying to talk family members out of unnecessary treatment or even antibiotics can be challenging.”
Evidence-based care is a key ingredient to the concept of a “medical home.” The medical home (not a physical place) is an approach in which health care is continuous, coordinated, and comprehensive, with a partnership between patients and providers. Other ingredients include 24/7 access to care, team-based care with prominent roles for nurses, coordination across sites of care, predictive analytics to identify high-risk patients, and performance reporting.
But a medical home cannot become a reality until the United States addresses the current shortage of primary care physicians, Rask says, quoting statistics that fewer than 2% of medical school graduates are going into the field. Why the low number? “Internists are expected to see a patient every 15 minutes,” she says. “The way the system is set up, the internist is a paper manager, leading many to leave primary care and set up boutique practices, where they can spend more time with patients. The concept of the medical home could bring joy back into the field.”
Kimberly Rask: Health care is not just a money issue. In the United States, we think if you spend more, you get more. Not really. When we compare ourselves to other countries-Germany and the Netherlands, for example-we spend more, and we may get more technology, but we don't get better outcomes. The United States has the worst infant mortality rate of all the developed nations.
Controlling chronic conditions
In West Virginia, Emory's Ken Thorpe is helping chart an overhaul of the state's health care system. What the Woodruff Professor in health policy has found is that three-fourths of that state's health care spending is linked to chronic disease. If the state took on management of just obesity and chronic illness, Thorpe estimates it could save roughly $2.7 billion by 2018.
The national picture mirrors those numbers. By Thorpe's calculations, if Medicare focused on managing obesity and chronic diseases, the program could save between $66 billion and $177 billion in just one year. Testifying before Congress, Thorpe, chair of the department of health policy and management at the RSPH, reported that 75% of national health spending is for chronic conditions such as diabetes and hypertension. Rising rates of obesity, which have doubled for adults and tripled for children since 1980, account for 20% to 25% of the overall rise in spending. And right now, less than 1% of national health spending is directed to avoiding health problems rather than fixing them.
Thorpe argues that even modest investments in prevention can yield surprising savings in public and private sectors alike. For example, work site health promotion programs have helped U.S. companies reduce both medical costs and absenteeism. A health management program at Citibank showed an ROI of $4.70 for every $1 in cost. A similar program at Johnson & Johnson reduced health risks such as high cholesterol, cigarette smoking, and high blood pressure, saving the company $8.8 million annually.
Kenneth Thorpe: Two recent studies have shown that seniors aged 65 to 70 who are normal weight, with no chronic diseases, spend 15% to 40% less over their lifetime than do obese adults with chronic diseases. If we applied those potential savings to Medicare for just this year, that would represent between $66 billion and $177 billion.
Arguing for basics
Years ago, when William Bornstein was a medical resident, he tried to impress his teachers by pursuing unusual diagnoses. "I'd come up with all the weird tests to order for a rare condition, and I got positive reinforcement for that," he says. "What would have been more impressive but less dramatic would have been to recommend something basic, like suggesting everyone get a flu shot."
Bornstein's story illustrates both a strength and weakness in America's health care system. A focus on innovation and discovery has contributed real breakthroughs, like cimetidine (Tagamet) for reduction of stomach acid and sequencing of the human genome. Along the way, however, argues Bornstein, we have lost sight of important fundamentals.
"We have focused on the rocket science instead and have left out the basic blocking and tackling, and now we need to rebalance," says Bornstein, who is chief quality officer for Emory Healthcare. "If we just gave regular immunizations, we'd have had more impact on saving lives than we've had with some groundbreaking discoveries. The epiphany is that we need to excel at both-the brilliant and the routine. As an academic medical center, we also need to lead the way in discovering and teaching new ways to deliver care more reliably and effectively."
Michael Johns and Ken Brigham: Appropriate management of chronic diseases decreases complications and hospitalizations, improves health, and enhances quality of life. But hospitalizations are what get paid for. The system rewards disease care, not health care.
The IT of health
"I can put my ATM card in any bank machine in the world and withdraw cash, but I can't go across town and access my health care record," says Art Kellermann. He's onto something that President Obama has identified as one of the crucial tools to lower health costs: health information technology. The United States will invest $10 billion each year for the next five years to move the country to adopt standards-based electronic health information systems.
The Blue Ridge Academic Health Group-comprising health care experts from universities and organizations such as the Burroughs Wellcome Fund, Association of American Medical Colleges, Emory, and others-took on informatics at its annual meeting in 2008. Useful technologies they identified included electronic health records, computer-assisted clinical decision supports, and genomic data warehouses that "promise efficiency, automation, effectiveness, transparency, decision-support, personalization, portability, and consumer empowerment." Their conclusion: these technologies can improve quality and safety, and health centers need to embrace and learn to use them.
At Emory, leaders are taking the promise of health IT seriously. The Emory electronic medical record has been used throughout Emory Healthcare for almost five years. Patients can create their own personal
electronic health record on Emory Healthcare's website. A Center for Comprehensive Informatics was created recently to empower more precise and scientifically informed decision-making in patient care. And Emory and Georgia Tech are launching a new joint department of Biomedical Informatics to train new leaders in this expanding discipline.
A mandate for reform
Every 15 years or so, health care reform catapults to the top of the U.S. political agenda. The past three presidents all took steps to enact significant reforms, but these efforts fell short. "Because of the economy, the likelihood that some reforms will come to fruition is higher than it has ever been," says Thorpe, who served as deputy assistant secretary for health policy under President Clinton.
Kim Rask sees glimmers of hope at the grass roots level, where she is interacting with communities and studying plans put forth in places like Findley, Ohio. There, private employers and health insurance companies are banding together to standardize health care benefits for patients with chronic diseases (for example, requiring no co-pays for diabetic supplies). In addition, they are encouraging use of primary care physicians as coordinators of care.
Kellermann believes the public mandate from the 2008 election will help carry reforms through. "Voters want something done. The No. 1 priority was to make health care affordable, and the No. 2 was to expand coverage to the uninsured. Eight out of 10 voters called for a major overhaul and fundamental reform. We know we can do better than this."
Just the facts
"Transforming Health Care through Prospective Medicine: The First Step," by Michael Johns and Kenneth Brigham, Academic Medicine, August 2008, p. 706.