U.S. medical care: A critique with proposals for change
Posted by medconsumers on September 14, 2012
It has taken a long time to sink in. The United States does not have the best medical care in the world. We are spending far more than other industrialized countries and showing poorer outcomes. And if that’s not bad enough, at least one-third — $750 billion — of our medical care spending in 2009 went to unnecessary services, excessive administrative costs, fraud, and other problems, according to a new report from the Institute of Medicine.
This report, entitled “Best Care at Lower Cost,” clearly presents the situation as dire and unsustainable: “America’s health care system has become far too complex and costly to continue business as usual. Pervasive inefficiencies, an inability to manage a rapidly deepening clinical knowledge base, and a reward system poorly focused on key patient needs, all hinder improvements in the safety and quality of care and threaten the nation’s economic stability and global competitiveness.”
The report draws on a large body of existing research that documents the health care system’s failures from the patients’ perspective. The result is lots of sobering statistics that serve as impetus for change. The rate of health care related injury, for example, is illustrated with this statistic: “One-third of all hospitalized patients are harmed by their care.” Similar back-up statistics appear with this list of italicized recommendations for improving the quality, efficiency, and cost of care:
-Use information technology [e.g., digital transfer of test results and medical records] more effectively: 20% of patients said their test results or medical records were not transferred from one place to another in time for an appointment; 25% said their health care provider has had to re-order a test to get accurate information for diagnosis.
-Improve transparency [e.g., hospitals and provider should make the cost of treatment publicly available]: 63% percent of patients do not know the cost of their care until they get the bill; 10% never find out the cost of their care.
-Promote teamwork and communication among health care providers: 50% of adults report problems with care coordination, notification of test results, and communication among their doctors. Less than half of all patients receive clear information on the benefits and trade-offs of treatments for their conditions. Less than half are satisfied with their level of control in medical decision-making.
The IOM report was compiled by a panel of experts, which includes my colleague Arthur A. Levin, MPH, the director of the Center for Medical Consumers, who has long been involved with patient safety issues. It takes broad view of the different ways people receive health care in the current U.S. system from small groups of physicians to large integrated delivery systems, each with different strengths and weaknesses. How can we learn from the good and the bad of these different systems? This is the crucial question taken on by the report’s authors.
Though written in the style of a health policy wonk, the chapter entitled “Creating a new culture of care” is worth reading. Like it or not our health care system is going to change—no matter who is president after election day. It makes sense to start giving some thought to how you want to adapt. Unhappy with health care that is fragmented and diffusely organized? This chapter describes large pioneering, integrated health care delivery systems (e.g., Mayo Clinic, the VA system, Kaiser Permanente).
These systems have many characteristics in common, such as use of electronic medical records, incentives for providers to adopt “best practices,” physicians on salary (my personal favorite), and bundled payments. An example of the “new culture” of care delivered by these systems: Readmission to the hospital would be regarded as a failure (as opposed to more income for the hospital), and the relevant staff members would come together to see how it could have been avoided. “A culture of teamwork is fundamental to building a learning organization and ensuring a continuity of care that yields better outcomes for patients.”
Nothing like these systems is available in my neck of the woods, but I have hope for the Accountable Care Organizations, which are already up and running in some areas of the country. ACOs are pilot projects funded by the Affordable Care Act signed into law two years ago by President Obama. ACOs are described recently by the N.Y. Times as “collections of medical providers who band together under one business umbrella. The organization can include primary care doctors, specialists, social workers, pharmacists and nurses. The difference is in how these providers are paid: Instead of an insurance company or the government reimbursing each provider for each service provided to each patient, the ACO is paid simply to care for a group of patients.” read more
You can read the 360-page IOM report online for free. This excellent interview from ProPublica is not part of the IOM report, but is definitely worth reading: Why Patient Harm Is One of the Leading Causes of Death in America
Maryann Napoli, Center for Medical Consumers©