Sunday, July 8, 2007

Obstacles to Health Reform -What’s Standing in the Way of A Perfect Health System?

To hear the presidential candidates tell it, the only things standing in the way of a perfect health system are improved quality, more prevention, better information systems, lower costs, and universal access.

There may be another reason – lack of patient compliance and better health habits. I pointed out these factors in the following July 6 letter to the editor of the New York Times.

To the Editor:

In her superb piece “2008 Candidates Vow to Overhaul U.S. Health Care, “ reporter Robin Toner gets it exactly right. The debate is about the role of government versus the private market in providing affordable and available care.

What she didn’t address were three realities: 1) In 42 years of existence, Medicare and Medicaid cost inflation rates have paralleled those of the private sector; 2) government already pays for nearly 50 % of health care; 3) the health of nations depends more on a nation’s culture than its health system. About 85% of health outcomes depend on the culture and 15% of the health system (Sagan L , 1987, The Health of Nations, The Cause of Sickness and Well-Being, Basic Books, and Satcher, D, and Pamies, R ,2006, Multicultural Medicine and Health Differences, McGraw-Hill).

In other words, in a multicultural nation like the U.S., neither a government-run or market-driven system is likely to reduce costs or influence outcomes. Government may relieve financial anxiety about costs, and the market may produce more choices, but neither is likely to dramatically improve our health, which is more a function of bad diets, lack of exercise, inactivity, obesity, stress management, self-care, accidents, and domestic violence and mayhem in the streets.

A recent survey of physician executives reinforces my point.

Obstacles, Percent of Physician Executives Feeling the Following Obstacles Are Major Issues

Patient compliance and awareness of healthy habits, 93%

Lack of resources or money, 90%

Clinician communications and culture, 88%

Physician resistance to evidence-based care, 87%

Insurance company practices, 80%

Federal government policies, 80%

Source: 2007Quality of Care Survey, American College of Physician Executives

And as far as electronic information systems guaranteeing quality, it isn’t necessarily so. In a survey of 50 family physician practices – 13 with EMRs, 37 without, these were the results

Measure, Percent of Practices with Favorable Quality Outcomes

• Processes of Care (3 of 5 guidelines met), with EMRs , 35.0%, without EMRs 53.8%

• Treatment (all guidelines met), with EMRs, 35.3%, without EMRs, 46.6%

• Outcome targets (2 of 3 guidelines met), with EMRs, 29.0%, without EMRs, 43.7%

• Outcome targets (all guidelines met), with EMRs, 3.9%, without EMRs, 10.7%

Source: “Electronic Medical Records and Diabetes Quality of Care, Annals of Family Medicine, May/June, 2007

Oh, well, everybody has some bad habits, nobody’s perfect, even when they are fully wired.

1 comment:

Richard L. Reece, MD said...

I agree with Dr. Dach that we ought to "humanize" medicine. The question is "how"? The government and health plans cover 250 million Americans, and each have their "agents" to assure payment. In this complex environment, Customer relationship firms have sprung up to fill the gap. Perhaps the most sensible approach is that of Susan Keane Baker, who in her book Managing Patient Expectations, tells doctors how to train themselves and their staff to identify and soften those 15 "moments of truth" by which patients judge doctors. Compassion is necessary, but it is not enough.

Richard L. Reece, MD