U.S. Health Care System - Reflections on Commonwealth Fund Report

I’m leery of think-tank pronouncements. The latest report of the Commonwealth Fund, a New York City think tank, Bending the Curve: Options for Achieving and Improving Value in Health Spending, is such a pronouncement.

Here are the words expressing four highlights of the report in bold print of the Commonwealth Fund press release with my reflections in italics.


1. Information Technology: With an initial increase in investment, $88 billion could be saved by accelerating health care providers' adoption of health information technology that would allow them to share all patient health information with the other health care providers involved in the patient's care.


The operative words here are “could” and “accelerate.” Health IT could save $88 billion and could improve care. But will it? Present evidence indicates EMRs don’t ensure quality and are no better than paper-based systems (Linder, J.A., Electronic Health Records Use and the Quality of Ambulatory Care in the United States, Arch Int Med, 2007: volume 167, pages 1400- 1405). After 5 years of electronic records being promoted as the Holy Grail, only 5% of hospitals, 10-15% of practitioners have EMRs, and less than 5% of patients own patient health records (PHRs). Why the hold up? Well, for clinicians, it’s a combination of excessive expense, practice disruption, lack of return on investment, suspicion data will be used against them, clinical clumsiness trying to use EMRS during patient exams. Besides, where’s the money coming from, roughly $100 billion, it would take to install system integrating IT systems for the nation’s 5000 hospitals, 750.000 doctors, and 300 million patients?


2. Center for Medical Effectiveness and Health Care Decision-Making: Investing in the knowledge needed to improve health care decision-making; incorporating information about relative clinical and cost effectiveness into insurance benefit design; and including incentives for providers, payers and consumers to use this information. An estimated $368 billion could be saved by all payers over ten years.

Among policy wonks, the view persists computer-guided artificial intelligence can mimic clinical care, interpret nuances of patient-doctor interaction, dictate tests or procedures to perform, predict their relative effectiveness, and substitute and augment clinical judgment. That these functions can save money is unproven. In Minnesota, a state dedicated to creating a statewide record system by 2015, health costs are out of control- in a state of 3.8 million, 1.1 million Minnesotans expect to pay 10% of their pre-tax income for health benefits next year, and for a quarter of residents, the cost will be 25% of pretax income
(“Healthcare Takes a Hefty Bite out of Minnesotan’s Income,” Star Tribune, December 20, 2007)

3. Public Health - Reducing Tobacco Use: Increasing federal taxes on tobacco products by $2 per pack of cigarettes, with revenues to support national and state tobacco programs, could yield an estimated $191 billion savings over 10 years, shared by all payers.


Over the last 50 years, cigarette use has dropped from 50% to 20% thanks to public awareness of tobacco hazards. Further strategies such as a $2 a pack tax, raising premiums on tobacco users, outlawing use in public and private places, not employing smokers, and making smokers persona non grata in the media, may further reduce smoking use. These may be good things to do. But keep in mind that America is a democracy, not a nanny or a police state, where freedom and choice and even bad behavior reign. Behavioral intervention by government has limits in a democracy.
3. Strengthen Primary Care and Care Coordination: Improving Medicare reimbursements to primary care physician practices to support enhanced primary care services, such as care coordination, care management, and easy access to care. Such a "medical home" approach could result in net health system savings of $194 billion over 10 years if all Medicare fee-for-service beneficiaries were enrolled. Estimated national savings would be larger if this approach were adopted by all payers.


This will be hard to do. Barriers are significant and hidden in plain sight. Medical students are no fools, and they can plainly see primary care departments have a second rate status in academic medical centers and specialists have twice to the income of primary care physicians, Besides, the present RBRVS payment system favors sub-specialists, managed care gatekeeper systems have failed, and Medicare data indicates chronically ill Americans see 6 to 8 specialists each year in addition to primary care doctors. Because of lack of incentives embedded in the American medical education system and the preference of our culture or specialists, the primary care supply is likely to continue to dwindle.