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The Arnold Relman Challenge: US HealthCare Costs vs US HealthCare Outcomes

Reviewer and Curator: Larry H. Bernstein, MD, FCAP and

Curator: Aviva Lev-Ari, PhD, RN

 

 

 

 

 

 SOURCE

http://www.nybooks.com/contributors/arnold-relman/

 

This is a posting of Relman’s just published review of the new publication  by Elizabeth H. Bradley and Lauren A. Taylor, in the prestigious Public Affairs (AUGUST 14, 2014 ISSUE)

The American Health Care Paradox: Why Spending More Is Getting Us Less

The US spends much more per person on medical care than any other country. And yet,

• by commonly accepted measures of the quality of its national health system, it ranks only in the middle of the other advanced countries

belonging to the Organization for Economic Cooperation and Development (OECD).

Elizabeth Bradley and Lauren Taylor argue that

• this “American health care paradox” is resolved when expenditures on other social services that undoubtedly contribute to improved national and personal health are taken into account.

These expenditures include support for such services as housing, education, maternal and child care, disease prevention, nutrition, environmental safety, and unemployment benefits. They also involve subsidies for the very poor, the disabled, and the elderly.

• The US spends a much smaller percentage of its GDP on these programs than other OECD countries. Thus,

when these expenditures are added to what is spent for medical care, the total, expressed as a percentage of GDP, places our country in the middle of the other OECD countries.

That is consistent with the ranking of our health care system, and so the authors claim

• the “paradox” is resolved.

To increase the quality of our health care system to the level now achieved by France, Germany, Switzerland, and Sweden,

1. we would need not only to expand our investment in other social services, but also
2. to practice what Bradley and Taylor call “a more holistic approach” to the medical care of each patient.

That means more attention to preventing illness and to modifying patients’ behavior in ways that promote health.

Their argument has intuitive appeal, made even stronger by the warm endorsement given by Dr. Harvey Fineberg, outgoing president of the Institute of Medicine (IOM) of the National Academy of Sciences, in the foreword he has written for the book, and by recent reports from committees of the IOM. It is generally agreed that

• poor and disadvantaged populations, such as teenaged single mothers and their children, or
• unemployed, uneducated, and ill-housed minorities,

suffer relatively poor health.

So it might seem entirely reasonable to conclude with the authors

• that the answer to what ails our national health system lies in paying more attention to
• social welfare programs, preventive measures, and education.

Relman dissatisfied:

Their argument is made more attractive by their clear prose and by their many helpful descriptions and historical explanations of US health care policy. Nevertheless, it does not persuade me, and
I don’t believe it will satisfy many critics who look closely at the issues.

In the first place, Bradley and Taylor pay insufficient attention to the great value Americans place on

• the immediate diagnosis and treatment of personal illnesses and injuries, as compared with
• public measures to enhance national health such as disease prevention and nutrition.

In the US, prompt medical care is given

• far greater priority than improved public health, and
• it commands much greater resources.

Research on personal medical care is also given a high priority, but  (political reality)

• new large investments in social welfare programs are not a legislative or political necessity now or in the foreseeable future,
• so long as conservative Republican opposition to governmental spending of this sort persists.

Moreover, the long-range economic benefits of social welfare and preventive measures are generally misunderstood. For example,

• prevention of heart attacks in early life through exercise, better diet, and elimination of smoking would extend life into later decades.

That is certainly a desirable goal, but then the multiple

• incurable disabilities of old age and the need for long-term care after retirement begin to increase total health costs.

Second, the evidence presented by Bradley and Taylor to support their claim of resolving the American health care “paradox” is not as strong as their rhetoric implies. This is well illustrated by their Figure 1.3, which shows

• aggregate health care and social welfare spending in OECD countries for 2007, and

is supposed to demonstrate that when all costs are considered,

• the US is no longer as inferior to European countries as many have claimed.

The figure shows that American total expenditures place it just about

• in the middle of all the countries shown, in accord with the quality of its health care system.

Nevertheless, while total expenditures on health and social welfare in France, Sweden, Switzerland, and Germany exceed those in the US (which would be expected given their generally superior health systems), the figure shows

• total expenditures for Canada, New Zealand, and Australia to be well below those in the US, even though
• these countries are widely acknowledged to have better health systems than the US.
• Similarly, total expenditures in Norway are roughly equal to those in the US, although the Norwegian national health system is generally recognized to be of much higher quality.

Their Table 4.1 (see below) also illustrates this lack of congruence between health care outcomes such as

• infant mortality and life expectancy in selected countries and
• their ranking in total expenditures (as shown in Figure 1.3).

In short, total expenditures (social welfare plus medical care) do not seem to be as consistently related to health outcomes as Bradley and Taylor would have us believe. But they are certainly correct in arguing that in general, more attention to welfare programs would improve the quality of life in the US.

My final reason for skepticism is the authors’ dependence on personal interviews with

• a selected and limited number of sources for much of their original data on attitudes about health care.

Bradley, the senior author, is a professor of public health at Yale; Taylor was trained in public health and medical ethics. They would therefore be expected to use

• the methods of descriptive social science in developing their arguments.

They state that they conducted interviews with “more than eighty health and social policy experts, researchers, practitioners, and consumers.” Anyone who has been involved in such interviews knows how variably the results can be interpreted. Bradley and Taylor were commendably diligent in recording and transcribing their interviews, but

1. they took a relatively small sample, and
2. much of it was limited to Scandinavian countries,
3. which are very different from the US, for example

• in their levels of taxation and their guarantees of medical care and public welfare generally.

As a result, the reader can never be quite sure how comprehensive and balanced a picture this book presents of the American health system, when compared with other OECD countries.

Nevertheless, it is hard to deny two basic and fairly obvious points the authors want to make.

First, inadequate social services in the US contribute to our poor national health.

Second, adding welfare expenditures to those of medical care does help to some extent to resolve the American “paradox” of high medical expenditures and relatively poor health outcomes. But the resolution

• is not as complete or convincing as claimed, and
• there is no evidence that expanding welfare programs,

as Bradley and Taylor argue,

• would more effectively improve national health than directly reforming the payment and organization of medical services.

In fact, the evidence suggests the contrary. The US currently

1. wastes vastly more resources on a dysfunctional medical care system than it would ever consider spending on social welfare, so
2. the likelihood of bettering national health through major expansion of welfare programs is remote.

As difficult as it may be, trying to reform the medical system is a better bet;

• this would free up resources that could be used to improve other social services.

In addition, most Americans will inevitably become ill or injured at some time in their lives, no matter how adequate the US social services, and for them at that time,

• a good medical care system is essential. Therefore, it makes sense to consider

how reforming the payment and organization of medical care could reduce the heavy burden of

• unnecessary waste, fraud, and bureaucratic overhead on our medical care system.

This looks like the best way to begin to resolve this book’s “paradox.”

There is widespread and growing recognition that the best way of improving the delivery of medical service and reducing its costs would be

• a shift away from fee-for-service payment for medical care after it is received
• to prepayment for comprehensive care.

The Affordable Care Act (ACA) attempts to move in this direction by establishing “accountable care organizations” that are paid

1. small bonuses for bettering the treatment of Medicare patients (as defined by government guidelines). However,
2. these organizations work mainly through private insurance plans, which, despite these intentions,
3. still pay for the more expensive special procedures and services by fee-for-service.

The ACA is therefore not likely to control national health expenditures in the long term. Government actuaries and budget officers

• predict that these expenditures will continue to rise at an unsustainable rate unless there is major reform.

To achieve better quality at lower costs, I believe we will have to progress beyond the ACA, and

• the needed reforms will require more participation by the medical profession.

Physicians will have to join medical groups that accept a single payment for comprehensive care and

• are willing to be paid mainly by salaries rather than the fees they bill and collect.

Although insurance companies will lobby hard to maintain their power, such a system does not need private insurance plans; it would be much better without them. Vast overhead expenditures would be saved if payment were to come from a single tax-supported agency. That’s why single-payer plans are getting increasing attention these days.

Recent changes in the medical care system have created forces that

• both favor and inhibit the development of a single-payer arrangement.

Physicians who would formerly have started practicing solo or in small partnerships are rapidly becoming employees of large groups

• in order to avoid the daunting economic risks of managing their own practices. Unfortunately,
• most of these large groups are owned by hospitals that are primarily interested in furthering their own financial goals.

They use their physician employees to generate

• more admissions and greater use of hospital-based procedures.

They want to defend the status quo and their own income, rather than press for reform.

An awakening interest in political affairs and a recent trend toward a preference for Democratic political candidates suggest that

• the medical profession may soon wish to turn national health policy in a different direction.
  (this is a period of transition between generations)

No large-scale health reform is likely without broad support by physicians, so

• their political awakening may be the most important factor in bringing about major change.

A united profession could influence the views of its patients, and this in turn could

• influence legislators even more than the money of an army of lobbyists.
  (army of lobbyists is supported by an exhorbitant wealth disproportion unknown in history, or at least since reconstruction)

Legislators need votes most of all, and patients are the voters they need.
(assumes that patients are a homogeneous group; and thee is no difference between rural and municipalities)

Another recent change that may favor the arrival of single-payer health care is

• the rapid increase in the number of women in active medical practice.

They will soon equal or outnumber men. Women physicians seem to be more interested in the

• social services that are available in multispecialty medical group practices,
• among them adequate child care and parental leaves.
• They want to share practice responsibilities, and
• they tend to have more liberal political views than most men.

This major demographic shift in the physician population, as well as its political movement toward more progressive policies, might put the profession in the forefront of health reform instead of the sidelines where it has usually been.

Without leadership by physicians, it is unlikely that we will see any major change in the system for payment and organization of medical care within the next decade or two. And

1. without such change, the future of the American health system is bleak;
2. either market forces or intrusive government regulations (or both)
3. will control how physicians practice their profession.

Financial responsibility for health care coverage will increasingly fall on individuals, because

• ‘neither government nor business employers will be able to afford the rising costs.

The greatest opportunities for reducing unnecessary costs and improving the quality of the American health system are to be found in

• reforming the payment and organization of medical care
• rather than in expanding social welfare programs.

Although these programs are of enormous importance for many reasons not only related to health, and well worth expanding, they cannot substitute for improving the effectiveness and efficiency of medical care for the sick and injured. That is where we are likely to see the most hopeful future development.

Epicrisis:

In my reading of Arnold Relman, I find that there is validity and unrealistic assumptions in his criticism.  It will take a generational change in the profession, which is currently avolving and making some of the changes he notes.

1. There is at least two generations of physicians who entered the profession in the post WWII era, when the Flexner model was in full force, and exemplified by William Osler, the Oslerian model..

Over a century ago, the Quaker merchant Johns Hopkins did more than provide in his will for the construction of a university, a hospital and a medical school.  He provided a vision of a unique university-based health center, one with a vital mission: to create a learning, training and caring environment where the quest for new knowledge would continuously yield more effective and compassionate care for all. Today, after a century of progress that even its founder could not have envisioned, the quest for new knowledge leading to better health care remains the defining mission of Johns Hopkins Medicine.

The original faculty of The Johns Hopkins University School of Medicine, including such pioneers of modern medicine as William H. Welch, William S. Halsted, William Osler and Howard A. Kelly, created a revolutionary new medical curriculum that integrated a rigorous program of basic science education with intensive clinical mentoring. With the opening of The Johns Hopkins Hospital in 1889, followed four years later by the School of Medicine, these founding physicians ushered in a new era in medical education marked by rigid entrance requirements for students, a vastly upgraded curriculum with emphasis on the scientific method, the incorporation of bedside teaching and laboratory research as part of the instruction, and integration of the School of Medicine with the Hospital through joint appointments. 

Notable faculty have included:  John Jacob Abel – Pharmacologist, John Shaw Billings – Civil War surgeon, pioneering leader in hygiene, Alfred Blalock – Developed field of cardiac surgery, Max Brödel – Acclaimed medical illustrator, William R. Brody – Radiologist, President of the Salk Institute, former President of Johns Hopkins University, Ben Carson – Pediatric Neurosurgeon, awarded the Presidential Medal of Freedom, Denton Cooley – Renowned Cardiovascular surgeon, Harvey Cushing – Father of modern neurosurgery, Catherine Clarke Fenselau – Biochemist and mass spectrometrist,  William Halsted – Father of modern surgery, Leo Kanner – Father of child psychiatry, Albert L. Lehninger – Biochemist, Victor McKusick – Developed field of medical genetics, William Osler – Father of modern medicine, Wilder Penfield – Pioneer of epilepsy neurosurgery; developed the cortical homunculus, Peter Pronovost – Anesthesiologst, MacArthur Fellow, Julie A. Freischlag, M.D., the director of the Department of Surgery

2. The large inroads in genetics, genomics and the Human Genome Project attests to the incredible growth in the knowledge base required from which physicians make decisions.  But despite the huge competition for entry, a shortage of primary care physicians, and a brain drain for less developed countries, the multicultural profession has had to adjust to a multicultural society into which it has to be integrated.  As much as a half century ago, candidates competed for entry on the basis of correlation with their undergraduate performance in organic chemistry.

3.  A half century ago, the poor could obtain emergency room care as a primary root of admission, which was likely late in the progression of the illness. This was not then, and is not now an acceptable system.

4. When Medicare came in, physicians accepted it as a reliable source for patients.  The same had to be true for hospitals.

5. Managed care began with the building of the Golden Gate Bridge, finished early, and supported by physicians employed by Henry Kaiser. This became a model taken seriously by Eastman Kodak and IBM.

6. It appears be be difficult to predict what will be in place a decade from now.  The Republican party is in default mode, and the Supreme Court has appointments that have not earned a lifetime appointment.

7.  I can’t see how the reorganizing of medicine, even with NPs and PAs can deal with the healthcare burden without attending to..

• children in broken families
• a substantial population in prison confinement
• dealing with white collar corruption
• supporting a minimum standard of living
• an improvement in education at a very young age (with parental involvement)
• a population that is more than 70% literate

8. There is a young physician population that has a dream and life style that is larger than the ALL MEDICINE and early to rise, late to bed than I have seen for so many years, and compassion has become important, as we don’t have all the answers, or all of the control.