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Still BrokenUnderstanding the U.S. Health Care System
By STEPHEN M. DAVIDSON
Stanford University PressCopyright © 2010 Board of Trustees of the Leland Stanford Junior University
All right reserved.
Chapter OneThe Promise and Disappointment of U.S. Medical Care
FOLLOWING PUBLICATION of the influential Flexner Report on medical education in 1910, the United States built on a foundation of science a health care system that, by the end of the 20th century, was the envy of the world. A visible symbol of that accomplishment is the astonishing number of health-related Nobel Prizes won by American physicians and other scientists. Since 1950, of the 133 prize winners in medicine and physiology, well over half have been either Americans or scientists who trained or worked in the United States.
Indeed, modern medicine is one of the unnamed wonders of the contemporary world. But it is more than a collection of impressive intellectual achievements. It has made a huge difference in the lives of many ordinary people in the United States and throughout the world. New treatments developed over the past one hundred years cure previously fatal acute illnesses. Even when the impact has not been to improve mortality rates, patients often recover much more quickly and with much less disruption of their daily lives and reduction of household income than in earlier times. Moreover, many chronic conditions that once were tantamount to a death sentence can now be managed effectively so that people who have them can carry on relatively normal lives.
It is no exaggeration to say that new drugs, new medical devices, and new surgical procedures have changed the face of illness to the point that we no longer need to fear many diseases that once evoked only the grimmest of images for the future. Following are some examples.
From the time of the Black Death, which is estimated to have killed one-third of the population of 14th-century Europe, until the advent of antibiotics, there was no good antidote to the effects of deadly microbes. Before the development of antibiotics, infections were major killers. "[U]ntil 1936, pneumonia was the No. 1 cause of death in the United States, and amputation was sometimes the only cure for infected wounds." Penicillin, one of the first antibiotic drugs, discovered in 1928 by Sir Alexander Fleming, kills harmful bacteria that cause illness and infection in humans. In the early 1940s, two researchers discovered how to make it in powdered form and helped mass produce it in time to curtail the risk of infection leading to amputation of damaged limbs or even death on the front lines of World War II. After the war, penicillin and other antibiotics were used widely to fight infection in the civilian population, dramatically reducing the harmful effects of many infectious diseases and contributing to the upward kink in life expectancy in America in the latter half of the 20th century.
With people living longer, partly as a result of "wonder drugs" such as penicillin, illnesses associated with age have become increasingly important, leading to other new treatments. Among the most common-and most frightening-conditions that primarily afflict older Americans are cardiovascular events, including heart attacks (myocardial infarction) and strokes, both of which usually result from hardened or blocked arteries. Blood pressure measures how clear and flexible arteries are and is a direct assessment of their ability to handle the pressures of blood flow. Higher blood pressure indicates that a patient is having trouble maintaining adequate blood flow through arteries that probably are constricted. For that reason, doctors want to measure blood pressure frequently in patients at higher risk (say, above age fifty) and to lower it with medications in order to reduce the risk of heart attack.
Take Janet, a fifty-five-year-old female with high blood pressure unknowingly at risk of a heart attack. She experienced extreme fatigue and indigestion and, later, nausea and vomiting, and she felt faint. Janet went to the emergency room of a nearby hospital, and though she was almost sent home for not displaying a classic sign of a heart attack (chest pain), the attending physician decided to run more tests. An old technology, the electrocardiogram, showed no acute abnormalities, but the ER doctor's suspicions were raised when a serum troponin blood test suggested that Janet had microscopic amounts of heart muscle damage.
Partly because of the potential for false positive results from the blood test, a cardiologist was called in to make a more definitive diagnosis. Following an examination, the cardiologist suggested immediate catheterization. This technique involves inserting a thin plastic tube (catheter) into an artery or vein in an arm or leg and advancing it into the chambers of the heart or into the coronary arteries. In Janet's case, it revealed an important blocked artery that the cardiologist was able to treat by angioplasty, a procedure in which a balloon is used to open a blockage in a coronary artery narrowed by atherosclerosis. He placed a small hole in Janet's femoral artery (near her groin) where, after dye was injected to document the blockage, a thin wire was passed through the blockage. Then, a small balloon was passed over the wire into the blockage and inflated to open the artery. Next, a separate catheter was deployed, leaving behind a spring-loaded stent in the part of the artery that had been expanded by the balloon. The metal struts of the stent significantly reduce the chance that the now-dilated artery will close again.
After her procedure, Janet was placed on aspirin and clopidogrel, an oral antiplatelet agent used in the treatment of coronary artery disease, both of which help to prevent her arteries from becoming blocked again by "sticky" blood platelets. Her physician told her that she had chronically high blood pressure, hypertension, which likely led to her fatigue and feeling faint as well as to the risk of a heart attack. He prescribed a statin drug to lower her cholesterol, another risk factor associated with constricted arteries, and an Angiotensin-Converting-Enzyme (ACE) inhibitor to stabilize the internal environment of her arteries.
Higher-resolution imaging, better drugs, minimally invasive catheterization procedures, and advanced devices are all facets of the modern practice of medicine that benefited Janet. Her condition was caught relatively early and as a result, she recovered fairly quickly from her procedures and resumed her normal life sooner than she would have even a generation ago. It is no exaggeration to say that her life was saved by what not so long ago was the cutting edge of medical research and clinical progress.
Janet's story tells of a modern medical success. For another example, consider the story of Bill, a patient who was held by medical care at the brink of life for months, though ultimately he succumbed to his disease.
Following CT scans and biopsies, Bill was diagnosed with metastatic kidney cancer. After standard drug treatment and chemotherapy, Bill underwent a radical nephrectomy to remove his right kidney and right adrenal gland, along with four lymph nodes infected by cancerous cell growths. The pain after surgery was hard to control, and heavy narcotics were necessary to keep it at bay. For some time, the surgery and medication gave Bill a life that resembled the years before he was diagnosed.
Unfortunately, Bill's cancer resurfaced and was spreading to other organs. Liver surgery was necessary only months after his nephrectomy. The surgery was deemed successful, but Bill's doctors told him that his cancer had metastasized too much, and surgery was no longer a viable option. He was given six months. Bill's family was devastated, though solace was found in the fact that the newest drugs, procedures, and therapies had all been used to help extend Bill's life for almost three years. Although for many cancer patients, full remission is a happy ending to their bouts with cancer, for Bill and his family, it was enough that his life was extended beyond what many could have dreamed possible just a generation ago.
The Importance of Primary Care
The value of modern medicine is not demonstrated only by dramatic tales of surgery and specialty care, which occur many times every day with patients like Bill and Janet. Ordinary primary care also provides enormous, measurable benefits to the people who are able to access it. Barbara Starfield, a distinguished physician-researcher at Johns Hopkins University Medical School, has taught us a lot about primary care. As she defines it, it is the gateway to the wonders of modern medicine. Indeed, in its ideal form, it embodies much of what we want our medical care system to be.
First among primary care's four defining characteristics is first-contact care. It is the entry point into the larger system of care, which "implies accessibility to and use of services for each new problem or new episode of a problem for which people seek health care." A well-functioning primary care practice must not only be accessible but also seem accessible to patients who want to use it. The way we can know how well a medical care system is doing on that score is by measuring how services are actually used.
Longitudinality, which implies the presence of a single "regular source of care and its use over time," is the second component of primary care. The third characteristic, comprehensiveness, means that practitioners and facilities must be able to provide or arrange for all types of needed services, even those not available efficiently on site. Finally, the fourth element is coordination or integration, by which Starfield means some form of continuity connecting one episode with another. It can be provided directly by specific primary care physicians and other clinicians, or through the use of accessible medical records, or both. While primary care in this conceptualization would, almost by definition, ensure that people would be able to get their health care needs taken care of to the extent that science and the art of medical practice make that possible, the reality is somewhat less positive-at least in the United States. We will learn much more about that in the next three chapters.
The Disappointment of Medical Care in the United States
So although in theory the explosion of private and public-sector health insurance in the 1960s brought access to the benefits of American medicine to almost everyone, it turns out that many people in the United States do not have easy or regular access to primary care in Starfield's terms-even when they are able to visit a physician in an examining room. In fact, the situation has become so bad in some places and for some groups that now, early in the 21st century, we are in real danger of destroying the impressive achievements that help to define the American medical care system. Among the key objectives of this book are identifying some of the obstacles to achieving real primary care and then planning ways to overcome them.
Consider this: an uninsured thirty-eight-year-old Texas woman with insulin-dependent diabetes "mixed occasional doctor visits with clumsy efforts to self-manage [her condition] ..., getting sicker all the while." Because $120 physician visits were usually beyond her reach, she visited her doctor only occasionally, her health deteriorated, and this married mother of four was forced to give up her job. (Neither her job nor her husband's job as a truck driver provided them with insurance.) One result was that she was "rushed almost monthly" to a hospital emergency room, eventually totaling weeks in intensive care and causing the hospital to provide almost $200,000 of uncompensated care. The hospital "solved" its financial problem by offering her regular, outpatient care at no charge-so that it would not need to absorb the much higher costs associated with emergency and inpatient care. As a result, the woman's diabetes is now managed effectively, and the hospital cut "nearly in half" its bad debt related to her care. The New York Times quoted one close observer of the health care system who called the hospital "visionary" for taking this action, but who also likened it to "sticking fingers in the dikes" while noting that finding ways to avoid the uninsured is the more common approach taken by community hospitals. Hospitals that do provide uncompensated care to uninsured people pass on as much of that cost as they can to those who do pay, contributing to the rise in insurance rates that, in turn, causes some employers or their employees to drop insurance.
In this one example, we find evidence of most of the critical issues afflicting the health care system: although scientific advances make it possible for patients with any number of chronic conditions, including diabetes, to manage their health and carry on most normal activities, the growing numbers of people with those illnesses need care regularly to keep their conditions under control. Yet many of them have no insurance to pay for that care, and because they tend to get less care than they need, the quality of their interactions with the medical care system declines and so do their benefits. For them, it is almost as if the scientific breakthroughs never occurred.
However, it is not just that people do not get the routine care they need. Because hospitals and other providers of care are unpaid for some of what they do, they increasingly lack the funds to maintain their facilities, equipment, and skills or to invest in the innovations for which American medicine is justly renowned. In addition, they often perform under great pressure, generated not just by the clinical implications of treating serious illness but also by inadequate systems for managing care and insufficient or outmoded resources of various kinds. These too often combine to produce rushed interactions with patients and inadequate attention to detail. As a result, many professionals and health care organizations do not perform up to their potential, avoidable errors occur, and instead of being helped, patients sometimes are made worse off by the care they receive.
The Importance of Health Insurance
The bottom line is that failure to solve these interrelated problems perpetuates the vicious cycle. Central to the solution is the simple statement that everyone needs to have comprehensive health insurance. There are three key reasons: first is the obvious one that it provides financial access to the care they need and thus removes what is arguably the main barrier to access to that care. Second, universal health insurance coverage means that the individuals and institutions responsible for their care-whether doctors, nurses, hospitals, or others-will be paid for every patient they treat. As a result, they will have the funds they need not only to provide good service to individual patients but also to upgrade their resources continually. And third, the combination means that per capita expenditures will be lower than if we continue to tolerate high-and growing-rates of uninsurance.
People without insurance get sicker because they don't get the care they need. Many eventually require emergency services and hospitalization, which might have been avoided if they took care of their condition earlier. And much of the care they get goes uncompensated, causing hospitals to raise their rates, insurers to raise premiums, employers and employees to drop coverage, and medical institutions to decline service.
The tendency for many Americans who can recite health-care-related problems they have experienced personally or that they know about from others is to want to correct each error and ensure that that particular problem does not occur again. That is our tradition-to tackle problems, one at a time, taking small steps, moving forward incrementally until the sum of an extended period of steady progress is large enough to be noticed and measured.
As I will show in the pages that follow, however, that approach is no longer adequate to the scale of the problems we face. A more dramatic strategy is needed to accomplish the goal of saving the medical care system so that we can rely on it to take care of us when we need it.
Because it is no longer enough to approach the problems one by one, we need not only to understand their causes but also to have a good idea of what we would like the reformed system to look like at the end of the improvement process. I will get to the causes in due course, but we can begin to define a well-functioning system here.
Excerpted from Still Broken by STEPHEN M. DAVIDSON Copyright © 2010 by Board of Trustees of the Leland Stanford Junior University. Excerpted by permission.
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Table of Contents
ContentsList of Tables and Figures....................xi
1. The Promise and Disappointment of U.S. Medical Care....................3
2. How Much We Spend....................15
3. What We Get for What We Spend....................34
4. Trouble in the Delivery Subsystem....................49
5. Why the Problems Need to Be Solved and the Goals of Reform....................71
6. What Caused These Problems, and How Can We Attack Them?....................94
7. Competition and the Market or the Public Sector?....................120
8. Elements of a Solution for Increasing Access to Health Care, Improving Quality of Care, and Containing Health Care Expenditures....................152
9. A Short History of Health Care Reform Efforts....................181
10. The Politics of Reform: Elements of a Strategy to Break the Logjam....................206
11. Strategy and Compromise....................227