Health Care Reform: The Urgency of SOMETHING

It was only a matter of time before my blood began boiling over the current health care debacle in Washington, D.C. The nihilism that ensued yesterday after the Democratic party lost its "supermajority" in the U.S. Senate was no doubt the catalytic event. So, with that brief preamble, I enter the murky waters.

As a stakeholder in the health care system - a future MD/PhD academic physician - I am deeply concerned about the current state of affairs in the system. The cost of delivering care is astronomical, with health care expenditures comprising ~16% of GDP, with no signs this number is going down anytime soon (by 2020, it will be close to ~20%). Despite the amount of treasure (personal, governmental) being devoted to health care, 15% of Americans have no health insurance. The largest government-run health insurance program - or more accurately, entitlement program - is Medicare. Estimates are that with no changes to the current system, Medicare will be insolvent by 2018. If future physicians think that this is no big deal, consider the fact that Medicare funds residency programs - it provides the salaries and other institutional support. So this is a big deal.

OK, those are some of the grim numbers. In short, we spend too much, we have no way to pay for health care if the status quo persists, and something must be done. Physicians don't wait for patients to go into multi-system organ failure (MSOF) before treating a patient with antibiotics, blood pressure support ("pressors"), ventilation assistance, and dialysis, etc, so why have we as a nation waited for the health care system to spiral into the shape it is currently in?

It's hard to say exactly why things have gotten so bad, and even more, it's hard to explain why the government has been so complacent. I think a big part of the problem is that bringing all of the players in the health care system - the doctors, the hospitals, the nurses, the technicians, the labor unions and employers who decide how to fund insurance policies, the insurance companies, the pharmaceutical companies, the diagnostic companies, the medical device manufacturers, the government, the patients, the lawyers - and having them agree on how to change the system and on which sacrifices they can accept is a massive (some think insurmountable) challenge. That is easier said than done, especially when said interest groups have varying degrees of influence ($) on Republican, Democratic, and Independent members of Congress.

I cannot say how exactly we should fix the economics of this broken system. I haven't looked at enough data, I don't understand all of the market forces at work, medical reimbursement practices; and I don't think most people in congress truly understand this either. And that's one of the first problems: the blowhards on both sides of the aisle in Washington use their opinions and empirical observations as a guide. Few (if any?) employ a rigorous treatment of the data. And that's the first place we need to start. As someone who has invested years of my life to learning how to design and execute good research, I think a first bold step would be to take the same hard look at medical care. That is, we need all of the pilot programs, evidence-based medicine approaches, properly placed incentives for good care, data sharing, electronic medical records, preventative measures - we need it all. These are the relatively cheap components of current proposals out there.

Whether - and how - to mandate insurance coverage for the whole citizenry of the United States is another question. The current proposals have done nothing to significantly change the costs of delivering care with respect to a mandate. They simply say that people should have coverage, the government will help if financially people have problems, and once covered, it's business as usual. So that's really not a good aspect of the current legislations.

Here's my take on health care reform: First, I want the death panels! So-called death panels - rather, having medicare reimburse physicians for having the difficult "goals of care" or "end of life" discussions is actually one of the best ideas that has been floated around, and it's one of the most politically polarizing elements of the reform legislation. And yet, it's one of the best damn ideas out there. Think about it: the bulk of medical care costs in a lifetime are incurred in the final months of a patient's life. Do a degree, this is unavoidable: if you get cancer and there's a chance to be cured, you'll try to treat it. But what if there is "no hope"? Or, more elegantly put, what if the realistic goals of care are palliative rather than curative? At that point, costs can be reduced dramatically (consider some of the data: http://www.reuters.com/article/idUSN06415881). But what's interesting is that when interventions are halted, usually suffering diminishes. The problem is that, all too often, doctors, hospitals, and providers in general either don't want to, don't know how to, or are financially incentivized not to have discussions about drawing down care and bringing people home. And so, more drugs are delivered, more treatments performed, more suffering ensues, all because who really wants to pull the plug on grandma? And sadly, most of the time, no one bothers to ask grandma what she thinks! And when they deem it time to ask grandma, she's already drugged up on sedatives/anti-anxiety/anti-psychotic drugs, in a hopeless ICU-induced delirium. At that point, few family members would be willing (and fairly so) to make executive decisions about where to go with care. Wouldn't it make good sense for patients - starting at a young age - to periodically have discussions with their doctors about end of life goals? Doctors ask whether patients sleep with men, women, or both; they ask whether it's cocaine, marijuana, heroin, meth, and/or all of the above; they ask about booze; they ask about depression; they ask about aches, pains; they ask about what concerns us the most. Why aren't they paid to have discussions about dying. After all, it's the one thing that will happen to every patient. And yet, this is the kind of stuff that has been maligned by opponents of health care reform legislation.

I want the pilot programs. The same kinds of government-funded and maintained programs that helped the agricultural industry in the U.S. become modernized could benefit health care immensely. And some of the privately- or state-funded programs already in existence prove this can work. Atul Gawande talks at length about this in a recent New Yorker piece. Note that he spends little, if any, time talking about public options versus mandates versus deals with pharmaceutical companies. He's talking about fundamentally changing how health care is delivered in the United States by empowering doctors and hospitals to make changes that benefit themselves, their patients, and the nation's finances as a whole. It will not happen overnight, but it can transform health care.

To make health care a truly sustainable and cost-controlled industry in the country will require more than just giving more people coverage in the same broken system. It will require innovative and progressive approaches to delivering care in the years to come. As examples, end of life discussions, in addition to numerous pilot programs embedded within current proposed legislation, offer some (of many) compelling ways to cut costs and do something rather than nothing when it comes to health care in the United States.

Stakes is high.