14-Luglio-2009

In order to create an effective health care system for the USA, and improve systems in other countries, it is essential to understand two important traits of humans that makes meaningful reform difficult to achieve:
1. people are greedy and
2. people often act on the basis of emotion and not wisdom.
It is essential to recognize these qualities in humans in order not to rely exclusively on individuals who will stem to benefit or not benefit from changes and to avoid the traps of emotional reasoning.

Starting with this as a baseline, one realizes that true imperative reforms have to be made on the basis of informed decisions (and by that I generally mean through the use of scientific methodolgy examining large populations or groups) and these decisions must be made by individuals who are not stakeholders in the process. Input from stake-holders ( examples: insurance companies, hospitals, various specialty types of physicians, nurses, and the general public) is essential, but if change is expected to only occur if there is consensus from everyone, then this will certainly be permanently mired in disagreement. Groups generally oppose change if their perception is that this change will be against their (financial) self-interest, and generally this resistence is emotion-based rather than scientific-based reasoning. A profound example of this in the american system is the emotional uneasiness (that many stake-holders exploit) that universal health care coverage means socialism (which is not necessarily so bad), but that socialism means Stalinism (which is bad, and the USA will become the USSR). This last point seems ludicrous to most people who live in other countries of the world, and yet remarkably it is a very real concern in the USA.

It is starting with the baseline of understanding the foibles of the human condition that one can then look at making real change in the US health care system, and for members of other nations to visualize the weaknesses in their own systems. Many countries are not as different from the USA as they would like to believe, and there is a general tendency that everywhere eventually becomes the USA (not from an american imperialism methodology, but secondary to the global interconnectiveness of the modern era and the american system is perceived as having fun, not so much hard-work, and lots of money). It is therefore imperative that everyone pay attention to the elements of health care reform.

The US health care system is remarkable for the fact that atleast twice as much money is spent per capita than even the most expensive systems in other developed countries, and the US is the only developed nation in which there is not universal health care, and somewhere between 10-20% of the public is not covered (and no one seems to know what the actual proportion is). I will describe in point form the major problems with the US health care system, and offer the most reasonable recommendation for change, in decreasing order of importance.
1. Too many middle men not directly involved in health care. The problem with an extensive system of private insurance companies is that each comapny has to replicate its own work-force of middle men. Hence there is a large number of people employed who contribute nothing actually to health care itself. What is worse, since they are for-profit enterprises a sizable number of individuals and a sizable budget goes towards marketing, and what is worse, the most direct methods of achieving profit in a health care system are to subselect for healthy people, disallow sick people, deny claims for patients requesting services, and deny payments to health care providers (1). This one sentence, which is founded upon the essential human quality of greed, explains why health care should not be a for-profit enterprize. A whole industry is set up of individuals in companies who deny items, and health care providers who have coders, case managers, and others who try to get payment, both often employing startegies based upon creating illusions. My estimate is that approximately 10 times as many middle men are present in the USA health care system than in all other countries.

2. Too high salaries for senior management in insurance companies. Excessive payment to senior management is endemic in the entire US business system. The justification often is that only a particular person can perform the work required as a CEO, and therefore deserves appropriate compensation. This ofcourse is pure folley and fabrication, designed to maintain and increase the satus quo. Almost no one who functions as a manager is irreplaceable, and excessive compensation is never acceptable - both points well shown during the French Revolution. Among the largest insurance carriers, the CEOs receive annual financial compensation atleast $10 million USD with some individuals receiving considerably higher than that. Where does this money come from? Money is a zero sum game in a set business environemnt, so it comes from denying services to patients or denying payments to health care providers. Furthermore it is demoralizing to everyone in the USA, but especially to employees and other members of the health care system (for example physicians) to see such outlandish compensation, that is based upon one sole principle, greed. All CEOs and other similar managers should have salary caps of what the system is prepared to pay them, and this should certainly be the case for health care related companies. My recommendation would be a total annual compensation cap of $4million USD, and violation punishable with jail time. An atmosphere permissive to unbridled greed is essentially demoralizing and destructive to a society. Certain highly intelligent and highly motivated individuals cannot of themselves resist or reign in their greed, and that is one of the roles of government. Although my position may seem naive or even Stalinistic to some, none the less history has shown the importance of government containing the greed of those who seem unable to do so on their own.

3. Medical Litigation. Conservatively, medical litigation contributes atleast 10% additional cost to the health care system in the USA. Realistically the true cost may be as high as 30%. Although the concept of medical litigation as a means to ensure that patients are not grossly mistreated by their health care providers, is an important one, this as well has become out of control in the USA (2). The driving forces behind nsustainable expences in medical litigation stem from a number of sources , including : i) excessive greed on the part of trial lawyers which has been amplified by the american system of contigency fees (contigency fees are the practice that in the USA plaintiff lawyers will not derive their financial compensation on an hourly salaried basis, but rather will share the risk of not receiving compensation by not charging the patient fees on an ongoing basis but rather will take a proportion of the settlement, often times in the 30 - 50% range), ii) the sense of entitlement of the american public including the concepts that any bad outcome must be compensated by damages, the american dream of a financial wind-fall, and the endemic adversarial societal relations, iii) decisions about fault and compensation are made by a jury system, where the members of the jury are not especially educated members of the society, and yet they are expected to reach sound judgments on complex health care issues, and iv) financial motivation on the part of medical experts to state what the lawyer needs them to say, rather than what the scientific truth is. Medical litigation should be made by medically trained individuals, either with medical or legal backgrounds, but preferentially a combination of both, and decisions should be made on the basis of scientific truths and evidence-based information, rather than on the basis of the showmanship of lawyers and the emotions of jurors. In contemplation of the american system, on the one hand, this has resulted in a relatively low incidence of patient mishandling and mistreatment compared to other countires (although charlatanism is always endemic in the human condition and the incidence of charlatanism is probably comparable), but on the other hand the cost associated with this is that medical litigation and expence is approximately 5 fold greater than in all other countries. Quite often, rather than ensuring good care of patients, it has resulted in services not being offered in various regions because the costs of the malpractice insurance are too high for a physician to make an income. A common medical service affected by this is high risk obstetric care. No other developed country has a system like the amercian system, and the inequities of the system must be paid attention to in order that others do not follow the US lead.

4. Excessive ordering of expensive medical tests. A sizable proportion of this, perhaps 80%, is due to defensive medical practice by physicians and health care institutions to attempt to stave off medical litigation. Controling point 3 above will certainly be the most important step to minimize excessive test-ordering. The remainder of this is the lack of training and knowledge on the part of physicians as to the costs of procedures and tests, and of their relative merits and utilities. One example, that I see commonly in my own practice, is that many physicians order ultrasound studies of the abdomen because it is an easy test to get done quickly and it is relatively cheap (about $600 USD compared to about $1200 for a CT study and $1400 for an MRI study). Yet very rarely does the imaging investigation stop with an ultrasound, and investigation goes on to get a CT or MRI or both. So although ultrasound is cheaper than the other two modalities, it most often ends up being just an additional charge that gets added up to the other imaging studies. It is beyond the scope of this current article, but MRI often is able to answer the question defintively, and also is a safe imaging modality (compared to CT). Most of the time, in the end it is cheaper to start with the most expensive but definitive test, rather than starting a cascade of many tests that add up to a much higher total bill. Health care providers are often uninformed of the costs or charges of lab tests, imaging studies and other procedures. On requisition forms and test results, the charges of the test should also be put on the form, in a similar fashion as the normal range of lab values is currently standard on lab forms. This should be mandated on a national basis. This way one does not have to try to recall what the charges are for an instiution for a certain test of procedure - it is right on the form, for the health care provider to consider whether the cost merits the potential, and likelihood, of the gain.

5. Polypharmacy. Much of polypharmacy stems from multiple root causes : i) defensive medical practice, ii) greed on the part of pharmaceutical companies, iii) greed on the part of health care dispensers of the medications, which may be physicians (for example oncologists with expensive pharmaceutical agents) and/o pharmacists, iii) pacification of patients, and iv) lack of adequate training of physicians to try to employ the simplest, most cost effective means of managing patients. It is beyond doubt that everywhere, but especially in the USA, that drugs are used excessively, and at times, additional drugs are employed to control the side-effects of other drugs the patient is on, and maybe the use of any of the drugs is dubious. In my estimation, there may be relatively few conditions that the use of certain drugs are clearly shown to have a substantial impact on outcome, as measured by patient benefit and especially long-term morbidity and mortality, often times short term surrogates are used as evidence for patient benefit, when in fact long term studies show little or marginal benefit. Few entities probably require the use of drugs, that simple exercise, diet, and attention to sleep cycle cannot control. On the important list of common entities where drugs are essential are : severe hypertension and insulin-dependent diabetes. Even more fraught with dubious value than the overprescription of developed-nation science-based medications are the use of wholistic or eastern culture therapies. These latter group usually rely on the placebo value of treatments, which can be very powerful in some, but generally do not work for the majority. This will be described later in evidence-based scientific inquiry. My general view of how health care is practiced is that 1/3 of patients get better, 1/3 stay the same, and 1/3 get worse. In order to use, or in the case of a national centralized health care system, to pay for, a treatment or medication there must be clear evidence that this equilbrium is shifted to the clear benefit of the patient. It is not unusual for some very expensive cancer drugs, and cancer drug regimens, that the benefit from the use of these drugs is measured in terms of days of prolonged life expectancy - which in my mind is not a sufficient benefit to justify a central system covering these costs. I would use as a measuring stick one year, there should be good evidence that patients benefit by one year of either better health or longevity. Recent medical history is littered by studies that show intial positive results from a medication or medication regimen, that follow-up studies show that there is no long term benefit. We must avoid the pitfall of relying on limited studies that examine limited outcomes or benefits.

6. Excessive health care expenditure on the terminally ill. Approximately 50% of the health care budget is spent on the final 6 months of life. This point clearly has strong ethical and emotional implications as far as denying health care. Ultimately I think that if one can examine the question from a national perspective, it is clearly better to invest national health care dollars into prevention and early treatment of disease in physically essentially well people to forgo more costly and pervasive health care disease in years to come (for example obesity avoidance) than it is to pay for an ICU stay of a month for a patient with advanced metastatic cancer. These decisaions to limit health care have been developed by a number of national health care programs, many of which are based on limited services using defined age criteria. This should also include defined life or wellness functional evaluations. It may be necessary to develop a nation-wide health care board adjudication system that is based on fair and globally applied criteria , whose membership should include senior health care and judicial members. It may be that a reasonable cut-of for many expensive procedures from what a national program would cover whould be an age of 65 years. This is older than many national programs have employed.

7. Emphasis on evidence-based outcomes for health care delivery. Many procedures are performed in which there is no acceptable scientific evidence that the procedures work in a sufficient number of cases to merit scientific acceptability. Use for example, of chiropractic manipulations for anything other than back conditions, and probably also only acute back conditions, appears questionable. A further problem with evidence-based m,edicine is that little of what is termed evidence-based actually is evidence-based - mainly because the proxies that are used for evidence are usaully of a short termn nature or only examine a portion of the clincial picture, rather than long-term and evalauting thte totality of the patient condition. Experience has shown that limited perspective evidence-based studies ultimately oftne are shown to have litle to no merit. We have to train ourselves to look at the whole picture and for longer terms - and in particular we have to become better informed of the natural history of many diseases that we treat, as the treamtent may be not only more expensive, but also worse than the disease itself.

I have laid out 7 points that form the basis of health care reform in the USA, but also to a large extent are important subjects and are insufficiently adddressed in many national health care policies. The next point, is a subject that although present in the US health care system, is more of a concern in other countries with national health care programs. Although the opposition to national health care in the USA point to this as the reason why a national program would be disastrous, it is a short-coming not of a national program but by how almost all programs are run. This point is therefore not a problem of the US health care system as it is, but forewarns of circumstances that should be avoided in developing a national program.

8. Politicians determine how health care will be run including what services will be offered. American opponents of nationalized health care point to the Canadian system and offer how services are denied in Canada and how waiting times can be inordinate for life-saving procedures. The problem is not with a national heal care system per se, it is that the people who are making decisions are not knowledgeable individuals in health care matters. When polticians make decisions on health care, the results are that what is politically expedient gets done, which may actually have little to do with good health care practice, and more to do with politicians remaining in power or getting re-elected. Health care decisions should be made by bureaucrats who are not elected individuals or subject to other political forces, and who are well informed in population-based, evidence-based, and recent technology-based medical knowledge. They must have access to a team of consultants they employ who are experts in all the different aspects of modern health care. The decision-making bureaucrat should not be a health care stake-holder. The reason that government often does not run efficiently is that there are generally no structured incentives (financial compensation) to excellent work. Successful effort should not be viewed on the pure basis of saving money, buit on the basis of the overall wellness of the population, and the keeping current with health care practices and technology. A national health care system works extremely well if decisions are made by well-informed intelligent individuals who are not part of a political cycle of elections. Structured performance incentives and accountability are important factors that must be addressed.

References: 1.Porter ME. A strategy for health care reform - towards a value based system. N Eng J Med 2009; 361(2): 109-112. 2.Mello MM, Brennan TA. The role of medical liability reform in federal health care reform. N Eng J Med 2009; 361(1): 1-3.

Dr Richard Semelka is an internationally known expert in Radiology, one of the leading authors in the medical literatue, and the foremost world expert in cancer imaging of the abdomen with MRI and safety in imaging.
Dr Semelka has practiced medicine for 18 years in the USA, is originally Canadian and trained in medicine in Canada and worked in Canada for two years, he has worked in the health care environment in Australia for 6 weeks and in Germany for 6 months, and maintains close working relations with medical experts all over the world. Dr Semelka's background reflects the major points that he has raised in his article - it is imperative to be well-informed of the entire health care environment if one is to make decisions on health care improvements, so that one can act on the basis of knowledge and information rather than on the basis of emotions and suppositions.