To accomplish great things we must not only act, but also dream, not only plan but also achieve. -Anatole France
Remember that time is money. -Benjamin Franklin
?Let?s fix health care.? When I speak with members of Congress or their staff, I like to start briefly and grand in scope. Then I listen. I watch their faces very closely. Only the politicians with the best ?poker faces? can avoid taking a deep breath and sighing. These policymakers do not become sullen because a young resident physician just issued them an idealistic imperative. These all-too-common reactions reflect a modern-day political reality-when it comes to policy making, health care is the 600-lb gorilla in the room, and it is gaining weight quickly.
Health care presents unique challenges to legislators. Health care problems, such as Medicare, the uninsured, medical liability, and quality improvement, interdigitate so tightly that ?quick fixes? rarely happen. Moreover, decisions in this arena often impact people at their most vulnerable and emotional moments, when nothing else in the world could possibly matter more.
Yet, I believe the enormous importance and the near indivisibility of the challenges in health care will fuel its salvation. Hope lives for the health of America.
Currently, 46 million Americans, including 8 million children, are uninsured.1 In the past 15 years, the percentage of those without insurance coverage has grown faster than the total US population. Low-income citizens, ethnic minorities, and the young remain more likely than others to be without health insurance.2 But compared with just 4 years ago, all income categories and races have seen growth in their uninsured populations. 1,3These are the patients we see every day in our emergency departments, offices, and hospital wards.
By historical comparison, Medicare patients have been well covered. The American elderly are nearly all insured, but Medicare is running out of money and cannot be sustained long-term. Even now, however, it is fraught with complicated coverage restrictions. A flawed reimbursement formula for physician services, based on the so-called Sustainable Growth Rate, does not keep up with the cost of delivering care. Although Medicare patients are insured, access to care for its enrollees is limited and may shrink in the near future.4
As Medicare sunsets, how will medical training be affected? Medicare now spends about $9 billion annually on graduate medical education, accounting for the majority of resident and fellow positions in the United States. As Medicare resources decrease and spending becomes increasingly scrutinized, will federal funding for physician training get pinched?
Even more urgent are the financial threats to undergraduate medical education. As discussed in our article in November 2005,5medical school loan debt has climbed to its highest level ever. The growing expense of attending medical school far exceeds inflation rates. Loan repayments are consuming an ever-larger percentage of young physician income. With the skyrocketing cost of educating and training physicians, how will America maintain a robust and diverse physician workforce comprised of the best and the brightest?
Despite outstanding medical training in the United States, flaws in our care delivery systems fail many of our patients.6 Rightly, the American Medical Association (AMA)?convened Physician Consortium for Quality Improvement and initiatives, such as the Institute for Healthcare Improvement?s 100,000 Lives Campaign, are making positive strides to improve effectiveness of care in our hospitals and offices. Many payers of health care services now hope to tie health care quality improvements to reimbursements.7 Although attractive in theory to some, such pay-for-performance programs have already proven very challenging to execute and could serve to divide the stakeholders who so desperately need to stick together.8
It goes without saying that physicians will always want to improve patient care. For care to improve, the truth must come out. Unfortunately, the ?exorbitant costs? of unnecessary lawsuits make divulging and analyzing adverse outcomes a dangerous business for some providers.9 Deep-rooted partisan divisions have made legislative fixes sparse. Clearly, quality of health care will suffer until leaders unite to overhaul our medical liability system.
The pathway of American medicine holds many potential roadblocks. We seem to be walking uphill, with no peak in sight.
We are faced with tough questions: as young physicians preparing to inherit the reins of this health care system, what will we do? Will we ever summit this treacherous hill?
The solution will depend on a few key principles:
? American health care is an intricately woven web of issues, spun by many stakeholders. Tugging on one thread strains all the others. We can no longer hope to repair individual health care issues in isolation. The entire web must be reconfigured.
? Partisan divisions, with myopic concern only for personal turf, will ultimately benefit no one. Providers, payers, legislators, and patients must work together. Each group must prepare to compromise. In the end, we can all win.
? Health care leaders must always remember how they would want their own families cared for. Advances in health care delivery must provide patients with choice and always honor the physician?patient relationship.
? Physicians must take the lead. For too long, the majority of physicians have sacrificed the tough, macrodecisions on health care to others. We do an excellent job of caring for the individuals in our examination rooms. Intuitively, physicians are most capable of securing the best care for all of America?s patients.
? Every time we avoid the roadblocks, our path lengthens, and more obstacles arise. Further delays will prove increasingly costly. Our work must begin now.
Please know that the AMA-Resident and Fellow Section intends to help lead this effort. At the annual meeting of the AMA in June 2006, we will formally promote Comprehensive Health System Reform to all the leaders in our Association.
We need your help. Please discuss these concerns with your colleagues, and read to learn more. Encourage your local health care leaders to support collaboration and comprehensive fixes. Finally, join our efforts, and send us ideas on how we can improve health care together to: rfs@ama-assn.org.
Joseph A. Craft, MD
Chair
American Medical Association
Resident and Fellow Section
jcraft11@yahoo.com
References
1. DeNavas-Walt C, Proctor B, Lee C. Income, poverty, and health insurance coverage in the United States: 2004. Current Population Reports, P60-229. Washington, DC: US Census Bureau; 2005.
2. Institute of Medicine. Coverage Matters: Insurance and Health Care. Washington, DC: National Academies Press; 2001.
3. Employee Benefit Research Institute. The relationship between income and health insurance; retirement annuity and employment-based pension income; and facts from EBRI: finances of employee benefits, 1960-2003. EBRI Notes. February 2005.
4. Report to the Congress: Medicare Payment Policy. Washington, DC: Medicare Payment Advisory Commission; March 1, 2006. Available at www.medpac.gov/publications/congressional_testimony/20060301_Testimony_ MedPAC_Mar06_Report.pdf .
5. Craft J. How to curb the cost of medical education. Resident & Staff Physician. 2005;51 (11):45-46.
6. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 1999.
7. Center for Medicare & Medicaid Services. Medicare ?pay for performance (P4P)? initiatives [press release]. Washington, DC: US Department of Health and Human Services; January 31, 2005. Available at www.cms.hhs.gov/apps/media/press/release.asp?Counter=1343.
8. Kerth S. Doctors claim UHC program pushes ?bare-bones? care. St Louis Business Journal. March 31, 2005. Available at http://stlouis.bizjournals.com/stlouis/stories/2005/ 03/14/story7.html.
9. Studdert DM, Mello MM, Gawande AA, et al. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med. 2006;354:2024-2033.
